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원가계산하여 나온 수가를 보통 수가라고 한다. 의료수가는 의료제도의 파생물로써 나오게 마련이다. 우리나라의 의료보험수가가 그렇듯이 가정간호수가 역시 가정간호사제도가 의료보험제도안에서 어떠한 위상을 차지하느냐에 따라서 결정될 것이다. 그러므로 이런 제도의 설정이 어느 정도 자리를 잡고 난 뒤에 가정간호수가에 대한 연구를 해도 늦지 않다고 생각되어진다. 가정간호수가는 세미나를 거쳐서 여러 분야의 의견이 수렴되고 종합되었으나 더 이상의 연구는 지금까지 이루어지지 않은 상태에 있다. 그러므로 수가가 얼마나 적당하다든지 포괄수가 혹은 건당 수가라든지 등 어떤 식의 수가가 적당하다고 말하기가 감히 어려운 상태에 있다. 본인의 전공은 보건경제학이고, 학교에서는 현재 보건경제학과 환경경제학을 강의하고 있다. 먼저 전공과 관련 있는 보건의료분야의 내용들을 검토한 후 가정간호사제도와 수가체계에 대해 간단하게 언급을 하겠다.
Hormone replacement therapy (HRT) is known as an effective treatment of menopausal symptoms and the usefulness of HRT in preventing osteoporosis and coronary heart disease (CHD) is well established. However, increase of risk in breast cancer is possible after long-term HRT. This study examined the overall risk-benefit balance of prolonged therapy to Korean population on the basis of the national statistics on mortality, morbidity and epidemiologic evidences and then appraised the cost-effectiveness of HRT for the postmenopausal women along with the prolongation of therapy at different ages of therapy initiation. A Markov model was used to evaluate the cost-effectiveness of 20 duration and age-related strategies comprising a hypothetical healthy woman at age 50 and a woman aged 60 in average health state with HRT (receiving CEE 0.625mg, MPA 5mg) for 1 to 10 years each. 8 transition states were set and probability of each state was calculated annually from age 50, 60 to age 84 each. Effectiveness was expressed with life-years gained (LYCs), quality-adjusted life years (QALY) and disability-adjusted life years (DALY). Estimated medical cost, composed with direct cost, indirect cost and induced cost per patient, was adopted and cost-effectiveness was evaluated for each strategy. Long-term use of HRT could be more effective and beneficial to menopausal women at any age. HRT was found to be more effective to 50-year old women in LYG: 1.52years and in QALY, it produced more benefit: 2.69years. In DALY. 60-year old woman counterpart was more effective due to high prevalence and burden of disease. It appeared that overall expenditure related to HRT was influenced critically by the direct costs of treatment rather than by any cost incurred or saved which is related to increased risk and prevention benefit because drug cost, fee and several screening and examinations related to HRT was expensive and immediate. The magnitude of estimated cast-effectiveness of 10-year intervention would be 1,125.388won, 1.187.481won per LYG in 50 and 60-year old woman respectively. When quality of life was considered. HRT was found to be more economical, amount to 623,578won per QALY in 8-year intervention and 444.598won per DALY in 50-year old woman. When the effect is discounted by 5, it may be more cost-effective alternative to apply to woman over 60-year old who is at high risk for fracture and coronary heart disease. A long-term use of HRT benefits the individual patient not only by obviating the acute symptom but also by preventing diverse diseases and ultimately, substantial public health could be also beneficially affected.
The rapid increase in the health care expenditure has motivated policy makers to search for ways to reduce health care costs without sacrificing the quality of care. The rate of increase will be highly accelerated when full-scale national health insurance covering all the rural and fishery area residents is implemented in early 1989. One way to reduce, or at least to curve, the rate of increase in health care expenditure in the long run is to have a structural reform. It is well known that a payment-reimbursement system should try to achieve the following objectives; (ⅰ) promote the efficient production and consumption of services; (ⅱ) provide a level of reimbursement to providers that will maintain their viability; (ⅲ) require minimal administrative costs; (ⅳ)provide for equitable financing from multiple purchasers. With these objectives in mind, this study proposes to change the payment-reimbursement method from the current fee-for-service(FFS) scheme to another type, so called as prepaymet-negotiating scheme. Changing the health care system as a whole does not mean that everything should be tackled at the same time. A proper strategy is to take one feasible step at a specified time and not undertake more than is necessary. Though there are many things that need to be changed along with refomed payment-rembursement scheme, it may be best to apply a penetration strategy, which reorients only those elements within the total system that are necessary to make room for the initial steps. This study suggests that it is the reform on payment-reimbursement scheme that should be followed by many other necessary reorientations to achieve proposed public health goals.
As Korean health care system is moving into more privatized health system through increased use of market approaches such as user fees and insurance plans, serious concern is raised on the rapid increase in national health expenditure. One of the contributing factors to rising health expenditure is a lack of referral channel among referral levels. There is "gatekeeper" who could guide the patient to a proper provider or a proper level of care. In the absence of "gatekeeper" in the system, there is inefficiency and lack of cost-effectiveness. An increased allocation of resources for primary care ought to be made. As part of the primary care network, this study suggests to establish a sound visiting nurse program in the system, who could care health of both the less mobilized excluded population and the average people. Health cost increase could be a lot eased through strengthening of the visiting nurse program.
Health of a nation is quite often represented by the statistics such as infant death rate and maternal mortality rate. It is indisputable that maternal child health(MCH) is the basis of health of a nation. MCH is also one of the cardinal component of primary health care. The importance of MCH is conspicuous especially in the developing countries. In Korea, People in the rural communities still have high access barrier to basic health care needs, including MCH services. Access to quality care during pregnancy and delivery seems to be the crucial factor in preventing deaths in women and children. The beneficial effects of prenatal and postnatal care on the outcome of pregnancy for mother and child, and those of health professional-attended institutional delivery on the health of mother and child have been well documented in many studies. Recognizing these effects, the government of Korea received IBRD loan of $30 million in 1979 for th purpose of constructing 89 rural MCH centers. The construction is complete now and all 89 MCH centers are under operation ti imporve primary health care for mothers and children in Korea. However, it has been observed over time that overall performance of public MCH centers is declining. The decline has been attributed partly to low quality services by public MCH centers, poor management by health center mangers, competition with for-profit private clinics, and to the development of national health insurance. This study investigates the utilization by rural communities in Korea of MCH services provided by public sector health centers deemed to be physically and financially accessible to the community but suboptimally used. It seeks also to determine the factors that influence people's utilizations. This study sets out to discover a desirable form of MCH center from among alternative forms of centers, thereby to construct a MCH model.
A microscopic survey was carried out in 1994 to measure the proportion of user charges out of total treatment costs. Charges for non-insurance services and out-of-pocket payments for insurance-covered services are included in user charge definition. Data on both inpatient and outpatient services rendered by four major clinical departments - internal medicine, surgery, pediatrics, and OB/GY (obstetrics & gynecology) - in general hospitals were collected. To see the difference in the rates by type of ownership, three different types of general hospitals were studied, a university hospital, a private hospital, and a public hospital. The rate ranges from 23.0 percent in the case of pediatric inpatient, public hospital, to 93.5 percent in the case of OB-GY outpatient, private hospital. The rate is higher in outpatient services than inpatient services, which has to do with the difference in regal coinsurance rates between insurance-covered outpatient service (55 percent) and inpatient service (20 percent). It is evident from the data that performance in terms of costs is affected by type of ownership.