요양급여 사전승인제도의 현황과 개선 방안

윤국회,안보령,박소정 건강보험심사평가원 심사평가정책연구소 2023 연구보고서 Vol.2023 No.0

With the rapid development of high-cost drugs to treat rare diseases worldwide in recent times, discussions are actively underway to establish systems for the efficient management of health insurance finances. South Korea’s pre-approval system for reviewing the applicability of high-cost and high-risk medical services has been in operation since 1992, and it is attracting attention as an effective system for managing high-cost healthcare benefit drugs. Despite the implementation of the pre-approval system, there are yet to be studies related to the system. For the system to be established as a more efficient benefits management plan in the future, a comprehensive review of the system is required. This study aims to identify issues in the pre-approval system through a comprehensive review and seek ways to make improvements so that a stable and systematic implementation may be realized. In this respect, this study reviewed domestic and international research literature, analyzed the current system by looking at claim documents, carried out advisory meetings with experts, and surveyed relevant academic societies. Based on the analysis of the pre-approval system over the past five years (2017―2021), there were a total of 21,453 cases of review involving 14,289 patients, with the cost of paid medical expenses reaching KRW 9,277 billion. The number of reviews showed a steadily increasing trend over the years, with average annual increases in review cases (10.3%), claims cases (4.3%), and the number of actual patients (3.8%). The analysis of the current state confirmed the gradually growing impact of pre-approval items on health insurance finances. Furthermore, based on the literature review findings on the purpose of the system, this study proposed the following improvements: ① reestablish the purpose and functions of the system, ② set standards for the entry into and removal from the system, ③ provide a management mechanism post-removal, ④ improve the operational system, and ⑤ establish legal grounds. This study is significant in that it is the first study on the domestic pre-approval system, conducting a comprehensive review of the system. The study, however, needs a professional review of the legal grounds and necessitates reaching a consensus among departments related to the pre-approval system within the review committee and requesting the input of medical professionals to apply the entry and removal standards.

고혈압ㆍ당뇨병 복합질환자를 고려한 적정성 평가 개선 방안

안보령,윤국회,권영근 건강보험심사평가원 심사평가연구소 2022 연구보고서 Vol.2022 No.0

The Health Insurance Review and Assessment Service(HIRA) has implemented a quality assessment program since 2010 to improve the quality of medical care and reduce the risk of cardio-cerebrovascular disease by improving the management quality of patients with hypertension and diabetes. With the increased prevalence of chronic diseases and aging populations, the modern generation generally suffers from multiple (two or more) chronic conditions simultaneously, regardless of the types of diseases. Among the patients targeted for quality assessment, 23.4% with hypertension and 59.4% with diabetes were identified as patients with multi-morbid conditions in 2019. Thus, this study proposed measures for enhancing quality assessment program and redesigning relevant compensation systems considering muti-morbid patients with hypertension and diabetes. Therefore, this study analyzed the current state of quality assessments program of hypertension and diabetes. It also examined international quality assessments systems, such as indicators for assessments and result analysis methods, to derive implications for assessments model design. Moreover, it designed a quality assessment model that considers patients with hypertension and diabetes, based on implications derived from the analytical results of present conditions and international cases. Specifically, it listed preliminary indicators by reviewing existing literature, such as international quality assessment indicators, and Korean and international clinical practice guidelines. Further, it classified the listed indicators as generic and disease-specific indicators. Subsequently, it established a panel of experts and selected quality assessment indicators based on the panel’s opinions. It also examined a method that uses the selected quality assessment indicators to calculate a score based on the clinic unit and presented a grading method according to the calculated score. Finally, this study developed a method for providing incentives based on the unit of a clinic to replace the existing method of incentivizing based on the disease. The developed method reflects the existing method that incentivizes based on the number of patients managed and sections, to consider acceptance of systems among medical institutions. However, the developed method is distinguished from the existing method in that it differentiates the level of compensation according to grades and disease types(e.g., a single disease and multiple diseases). Additionally, this study presented a mid- and long-term direction for quality assessment indicators and compensation systems. quality assessment indicators are constantly required for implementing outcome indicators. Consequently, further research should be conducted to develop a method that reduces clinical burdens on data submission other than the claim data and to adjust the assessment results based on each medical institution by reflecting the patients’ characteristics. The results of this study may be used as the base data for further research on quality assessment improvement.

요양병원의 중증도 보정 사망률

조상아,윤국회,김민수,정설희 건강보험심사평가원 심사평가정책연구소 2023 연구보고서 Vol.2023 No.0

A long-term care hospital applies per diem payment systems rather than fee-for-service systems for the medical services provided to long-term care inpatients. To prevent the potential underprovision of medical services due to these per diem payment systems and promote improvement in medical quality, the quality assessment program for long-term care hospitals was introduced in 2008. Despite the development and introduction of various criteria in recent quality assessments, there is an increasing demand for the development of new criteria. Among these, there is a growing demand for the introduction of criteria related to mortality rates. Therefore, the purpose of this study is to examine the feasibility of introducing a mortality rate criterion in long-term care hospitals through an analysis of the relationship between severity-adjusted mortality rates and evaluation criteria. The study conducted an examination of domestic and international evaluation criteria related to long-term care hospitals and mortality rate evaluation criteria. Based on data including health insurance claim data from 2020 to 2022, patient assessment forms from long-term care hospitals, and results of quality assessment of long-term care hospitals, models for severity-adjusted mortality rates in long-term care hospitals were developed. Mortality rates were defined as in-hospital mortality rates, and the development of the severity model considered factors obtained through Bootstrap, literature review, patient assessment forms, and whether patients had a history of COVID-19 infection as adjustment variables. To understand mortality rates according to various treatment characteristics of long-term care hospitals, institutions with treatment volumes exceeding 30% were classified based on their representative treatment characteristics (cancer, dementia, rehabilitation, others). The developed models' goodness-of-fit was assessed using Bootstrap, C-statistics, Corrected C-statistics, AIC (Akaike Information Criterion), and SBC (Schwarz-Bayesian Criterion). The final models were selected through model comparisons based on AIC and SBC, and the severity-adjusted mortality rates were analyzed. Additionally, to understand the relationship between quality assessment criteria and mortality rates, correlation analyses were conducted, and ROC curve analyses were used to determine the discrimination ability of evaluation grades of mortality rate. Evaluation criteria related to long-term care, both domestically and internationally, include pressure ulcer occurrence rates, community reintegration rates, urinary tract infection rates, improvements in activities of daily living rates, among others. However, evaluations of mortality rates related to long-term care are not conducted on a national level. Furthermore, long-term care hospital mortality rates have shown significant increases after the COVID-19 pandemic. The final selected severity-adjusted model was one that adjusted for clinical risk factors. If an institution's mortality rate significantly exceeds the 95% confidence interval of the severity-adjusted mortality rate, it may indicate factors other than severity adjustment influencing the mortality rate and necessitate monitoring of that institution. Nevertheless, before concluding that the severity-adjusted model fits well and has good predictive power or that monitoring is required for the institution, it is necessary to confirm the models' representativeness. The relationships between mortality rates and evaluation criteria have been demonstrated through various papers, and statistically significant results have also been derived from this study's data, showing significance not only for activities of daily living but also for pressure ulcer presence. Analyses of the discrimination ability of evaluation grade of mortality rate revealed AUC (Area Under the Curve) values of 0.5727 for pre-adjusted mortality rates and 0.5220 for post-adjusted mortality rates. In conclusion, based on the examination of the feasibility of introducing mortality rate criteria through the severity-adjusted models and the discrimination ability of evaluation grades, it is determined that the data available for generating the severity-adjusted models are limited and the discrimination ability of evaluation grades for mortality rates is lower compared to other indicators. Therefore, the introduction of mortality rate criteria is considered difficult. Instead, enhancing the reliability of current evaluation criteria through improvements is suggested, and for the severity-adjusted models to be representative, the accuracy and reliability of the data should be validated.