의료보험수가에 관한 사적 고찰

Abstract

우리나라에서는 진료비지불방식으로 진료행위별 수가제를 택하고 있다. 진료행위별 수가제는 진료비가 진료내용의 종류 및 빈도에 의해서 결정되는 진료비 지급반식으로 환자에게 제공되는 의료서비스의 경제적 가치 즉 원가를 기존으로하여 수가가 결정되도록 함으로써 의료제공자와 진료비 부담자 모두에게 경제적으로 공평을 기하고자 하는데 있다. 1989년 전국의료보험 확대실시와 더불어 국민의 생활수준과 의식수준의 향상으로 보건의료수요는 급증하고 있으며 인주의 고령화, 의학기술의 발달, 의료장비의 고급화, 의료행위별 수가제등으로 국민의료비의 증가가 가속화됨에 따라 보험재정에 압박을 가해오는 실정이다. 또한 현행 의료보험 수가체계에서 환자의 간호에 소요되는 간호비용은 진료비의 주요 구성요소임에도 불구하고 의료보험수가 제정시에는 지불단위로서 인정되지 않았다가 1988년부터 간호관리료의 명목으로 입원료중 환자관리료에 포함되어 비현실적인 금액으로 책정되어 있다. 본 연구는 선진국의 의료보험수가체제의 발달과정을 재조명하여 우리나라의 의료보험수가체제의 발전적 방향을 모색하고 의료보험수가체계에 적합한 간호수가 선정방법을 모색하기 위해 시도되었다. 연구방법은 문헌고찰을 통하여, 의료보험제도의 전개과정과 사회, 경제체제와 역서적, 문화적 특성에 따라 상이한 선진국의 의료보험수가체계를 파악하고, 우리나라의 의료보험수가체계 및 문제점, 우리나라와 진료비체계가 유사한 일본과 미국의 간호수가의 결정요인과 방법을 문헌고찰을 통해 분석해보았다. 연구결과는 다음과 같다. 1. 진료행위별 수가제를 택하고 있는 우리나라 수가체계의 문제점은 진료행위별 수가제에 의한 진료건당 진료비의 고액화추세, 보험재정의 악화, 의료기관에 대한 진료비지급의 지연등의 문제가 발생하고 있다. 또한 수가산정체계의 기본인 기준수가의 적정성에 관련된 문제점은 기준수가의 원가보상에 대한 적정성, 상대적 수가수준의 불균형, 기술료에 대한 보상의 미흡함, 수가인상율이 물가인상율에 못미친다는 점등이다. 의료인에게 익숙해져 온 이 제도의 근간을 바꾼다는 것은 힘든 문제이나 의료보험의 제도적 대응장치로 진료비 산정방식의 개선방안을 모색해보면 첫째, 진료수가를 원가산정을 근거로 책정하며, 상대수가간 격차를 조정한다. 둘째, 부분적 포괄수가제 도입으로 총의료비를 억제한다. 셋째, 대체 의료 서비스(Alternative Medical Service)제도의 도입, 확대가 필요하다. 넷째, 다른 진료비 지불방식으로 전환하기 위한 연구 및 시범사업이 필요하다. 2. 현행 간호수가의 문제점은 원가산정방법에 근거한 간호수가산정이 아니라는 점, 보험급여되지 않은 간호수가가 일반수가로 환자에게 부과되어 과다한 의료비 지출을 도모한다는 점, 비현실적인 간호수가로 인한 간호인력이 병원비용절감의 대상에 되므로 양질의 간호제공에 저해요인이 된다는 점 등을 들 수 있다. 우리나라와 의료보험체계가 비슷한 일본은 입원환자와 간호사수의 비율에 의해 차등화된 1일당 간호료를 책장하고 있어 환자의 질병상태에 따른 간호인력의 적정수 배치를 하고 있다. 미국의 간호수가는 DRG 도입이후 상대적 간호강도와 환자분류체계에 따라 차등화하여 산정하고 있으며 간호원가를 기초로 하고있다. 이러한 간호수가산정은 간호부서를 수익부서로 인식 시키는 계기가 되며 간호자원의 효율적인 관리를 도모하고 있다. 이상의 연구결과를 통하여 볼 때 간호수가는 간호원가산정방법에 의해 산정되어야 하며, 간호원가산정방법은 환자분류체계에 의해 산정하는 것이 바람직하다고 볼 수 있다. 간호원가에 근거한 간호수가의 책정은 간호단위의 투입요소와 산출요소간의 분석을 통한 간호자원관리와 병원관리의 합리화를 도모하여 의료제공자인 간호사의 입장에서는 양질의 간호 제공을 환자회복및 건강관리에 기여할 수 있으며, 의료수혜자인 환자의 입장에서는 진료비 절감효과와 질 높은 간호서비스를 제공받을 수 있을 것으로 본다. 본 연구를 통한 제언은 1. 진료비 산정방식에 부분적 포괄수가제도입, 원가에 근거한 수가산정방법, 대체 의료 서비스제도의 도입에 관한 반복연구가 필요하다. 2. 간호수가산정을 위한 원가계산에 관한 연구가 진료과목별, 간호단위별, 의료기관종별에 따른 환자의 간호요구도를 고려한 연구와 전국의 단일화하여 지역의 특성을 고려한 연구가 이루어져야 겠다. 3. 간호수가는 체계적인 이론과 기술을 습득하여 훈련된 고급전문인력인 간호사의 행위에 적합하게 단독으로 책정되어야 하겠다.;Our country is choosing the system of the fee-for-service reimbursement as the medical insurance system. The fee-for-service system aims at trying to be fair economically to all the medical treatment offerer and the person to bear the medical care expenses, on the basis of the economical value of medical treatment to be offered to patients, that is, cost, as the medical insurance system that the medical care expense is decided by the contents of medical examination and treatment and the quantity of medical examination and treatment. In 1989, with the expansion execution of medical insurance of whole country, due to the improvement of national standard of living and the standard of consciousness, the demand of medical treatment of public health is increasing rapidly. And, due to the tendency to be advanced age of population, the development of medical technique, the high-class tendency of medical treatment equipment and the system for the fee by the action of the medical examination and treatment, the increase of national medical treatment expense is accelerated. Thus, it is the actual condition that they are pressing the insurance finance. In addition, the nursing expense to be required for the nursing of patients in the existing medical payment insurance rates is the main composition element of the fee for the medical examination and treatment. Nevertheless, it wasn't recognized as the payment unit, at the time of establishment of the fee of medical insurance. Then, it was included in the fee for patient management among the hospital charges, under the name of the fee for nursing management. Thus, it is being appropriated as the unreal amount. This study was tried, so as to grope for the developmental direction of the medical payment insurance rates of our country and for the calculation method of the fee for nursing which is suitable for the medical payment insurance rates, by illuminating the development process of the medical payment insurance rates of advanced nations again. As for the study method, through the literature study, the different medical payment insurance rates of advanced nations were grapsed, in accordance with the unfolding process of medical insurance system, the system of society and economy, and the historical and cultural features. And, the medical payment insurance rates of our country and its points at issue, the factor and method of the decision of the fee for nursing of Japan and America of which the system of the medical care expense is similar to our country were analyzed through literature study. The study results are as follows ; 1. As for the points at issue of the system for fee of our country which is choosing the system for the fee-for-service reimbursement, the points at issue such as the tendency of large amount of the medical care expense per the case of the medical examination and treatment based on the system for the fee-for-service reimbursement, the aggravation of insurance finance, and the delay of benefit payments about medical institutions are being generated. In addition, the points at issue related to the propriety nature of standard fee which is the base of calculation system of fee are the propriety nature of standard fee about the cost compensation, the unbalance of relative fee standard, the insufficiency of the compensation about the technique fee, and the point that the rate of fee increase fails to reach the rate of price increase etc. To change the basis of this system to which medical doctors have been accustomed is the difficult problem. But, to try to grope for the improvement scheme of calculation method of medical care expense as the institutional confrontation equipment of medical insurance is as follows ; First, is the method to appropriate the fee for medical examination and treatment on the basis of cost accounting and to control the difference between relative fees. Second is to restrain the total medical treatment expense by the introduction of partial case payment. Third, the introduction and expansion of alternative medical service are necessary. Fourth, the study and the business showing an example for converting into other payment system of the medical care expense are necessary. 2. As for the points at issue of the existing fee for nursing, the point that it is not the calculation of the fee for nursing based on the calculation method of cost, the point that the fee for nursing that the insurance benefit is not made seeks the payment of excessive medical treatment expense, as it is imposed on patients as general fee, and the point that unreal fee for nursing becomes the hindrance factor for the offer of nursing of good quality, as the man power for nursing becomes the subject of the curtailment of hospital expense etc. may be enumerated. Japan of which the system of medical insurance is similar to our country is arranging the proper number of the man power for nursing, in according with the disease state of patients, as it is appropriating the fee for nursing that the gradation tendency was made per 1 day by the rate of number of inpatients and nurses. The fee for nursing in America is being calculated by the gradation tendency, in accordance with the relative nursing strength and the system of patient classification, after the introduction of DRG. And, it is on the basis of nursing cost. This calculation of the fee for nursing becomes the momentum to make one recognize the nursing post as the profit post, and it is groping for the efficient management of nursing resources. To see through above study result, the fee for nursing must be calculated by the calculation method of nursing cost. And, it can be seen that the system of patient classification is desirable, about the calculation method of nursing cost. In can be seen that the fixing of the fee for nursing based on nursing cost gropes for the rationalization of the management of nursing resource and hospital through the analysis of output element and yield element of nursing unit, and that it can contribute toward the recovery and health management of patients by the offer of nursing of good quality from the viewpoint of the nurses who are medical treatment offerers, and that there will be the effect of curtailment of the medical care expense and that the nursing service of good quality may be offered from the viewpoint of the beneficiary of medical treatment. The suggestions through this study are as follows : 1. The introduction of partial case payment into the calculation method of the medical care expense, the calculation method of fee based on cost, and the repetitive study on the introduction of alternative medical service are necessary. 2. As for the study on the cost calculation for the calculation of the fee for nursing, the study to consider the degree of nursing demand of patients based on the subject of the medical examination and treatment, on the nursing unit, and on the medical institutions and the study to consider the features of area by simplifying the whole country will have to be made. 3. The fee for nursing will have to be fixed independently suitably for the action of nurses who are the trained high-class professional men power, by acquiring the systematic theory and technique.