외국의 묶음지불제도 도입 현황 및 한국에의 시사점 : 미국, 영국, 호주를 중심으로

서은원 ( Eun-won Seo ),위세아 ( Se-ah Wee ),신양준 ( Yang-jun Shin ),이근정 ( Keun-jung Lee ),이진용 ( Jin-yong Lee ) 한국보건경제정책학회(구 한국보건경제학회) 2021 보건경제와 정책연구 Vol.27 No.2

전 세계는 고령화와 만성질환 증가 등으로 의료비가 증가함에 따라 보건의료시스템의 지속 가능성 위기에 직면하였고 이에 대한 대안으로 지불제도 개혁을 추진하고 있다. 우리나라 또한 유사한 보건의료 환경에 대응하기 위하여 다양한 지불제도에 대한 모색이 필요한 시점이다. 이에 이 연구는 묶음지불제도를 도입한 OECD 국가 중 미국, 영국, 호주의 사례를 살펴봄으로써 한국의 묶음지불제도 도입에 대한 정책적인 시사점을 제시하고자 하였다. 미국과 영국, 호주는 기존 지불제도의 한계를 보완하면서 의료 질 향상, 비용 절감, 의료연계 강화 등의 목표를 달성하기 위해 묶음지불제도를 도입하였다. 미국과 영국은 특정 질환 또는 처치에, 호주는 만성질환 관리에 묶음지불제도를 적용하였고, 그 결과 의료 질 관리와 비용 절감에 긍정적인 효과가 있는 것으로 나타났다. 따라서 우리나라에서도 포괄적, 연속적인 서비스 제공의 필요성과 적용 대상이 명확한 특정 질환에 대해 시범적인 묶음지불제도 도입을 고려할 수 있으며, 추후 제도의 적용 가능성을 판단하고 세부사항을 내실화한다면 건강보험 제도의 재정적 지속가능성 제고를 위한 정책 수립의 근거를 마련하는데 도움이 될 것이다. This study aims to offer policy implications for introducing the bundled payment system in Korea by looking into other countries’ experience. Three countries, which include the United States, the United Kingdom, and Australia, were selected through the method of purposive sampling. These countries have adopted Bundled payment models with the aims of improving the quality of care, reducing cost, and enhancing care coordination, while addressing the limitations of existing payment systems. The U.S. and the U.K.’s application of bundled payment models focuses on certain conditions or treatments, and Australia’s targets chronic condition management. The introduction of the bundled payment system in these countries resulted in having a positive effect on managing the quality of care and reducing medical spending. Such results suggest that Korea may consider introducing pilot initiatives that implement bundled payment models for certain conditions, with clearly identifiable targets, which require comprehensive and continuous services. Pilot implementations of the system will provide an opportunity to examine applicability of the system and improve the details, which, in turn, will contribute to making policies for enhancing financial sustainability of Korea’s health insurance system.

권역외상센터의 질 관리와 수가 개선 현황

서은원 ( Eun-won Seo ),임지혜 ( Jeehye Im ) 한국보건행정학회 2021 보건행정학회지 Vol.31 No.4

The emergency medical service system in Korea was built upon the Emergency Medical Service Act, 1995 to respond adequately to be much in demand for emergency medical services. In addition, the government recognized the importance of the trauma care system and set out to plan for the designation and establishment of the regional trauma center by 2012. This study aimed to investigate features of quality management and trauma fee schedule on better understanding of trauma care system. First, quality management of the regional trauma center has been implemented by several quality programs involved in quality assessment, committee on trauma quality management, and mortality and morbidity conference. Second, the trauma fee schedule has reflected a specific quality of severe traumatic conditions and added the result to it, which are graded A, B, and C according to quality assessment. Although the government has contributed to instituting a trauma quality assessment program and trauma fee schedule for the regional trauma center, it could not lead to such a fixed standard for quality management of them. Therefore, it will promote discussion on the sustainability of the regional trauma center that requires reducing preventable trauma death rate and the way to apply comprehensive quality management.

성별에 따른 지역 간 자살률 차이 및 영향요인 분석

서은원 ( Eun Won Seo ),곽진미 ( Jin Mi Kwak ),김다양 ( Da Yang Kim ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.4

Background: Suicide is one of important health problems in Korea. Previous studies showed factors associated with suicide in individual levels. However, suicide was influenced by society that individuals belong to, so it was required to analyze suicide in local levels. The purpose of this study was to analyze the regional disparities of suicide mortality by gender and the association between local characteristics and suicide mortality. Methods: This study included 229 city·county·district administrative districts in Korea. Age- and sex-standardized suicide mortality and age-standardized suicide mortality (male/female) were used as dependent variables. City·county·district types, socio-demographics (number of divorces per 1,000 population, number of marriages per 1,000 population, and single households), financial variable (financial independence), welfare variable (welfare budget), and health behavior/status (perceived health status scores and EuroQol-5 dimension [EQ-5D]) were used to represent the local characteristics. We used hot-spot analysis to identify the spatial patterns of suicide mortality and negative binomial regression analysis to examine factors affecting suicide mortality. Results: There were differences in distribution of suicide mortality and hot-spot regions of suicide mortality by gender. Negative binomial regression analysis provided that city·county·district types (city), number of divorces per 1,000 population, financial independence, and EQ-5D had significant influences on the age- and sex-standardized suicide mortality per 100,000. Factor influencing suicide mortality was the number of divorces per 1,000 population in both male and female. Conclusion: Study results provided evidences that suicide mortality among regions was differed by gender. Health policy makers will need to consider gender and local characteristics when making policies for suicides.

정신질환 관련 의료자원 이용의 생산성 변화 분석

서은원 ( Eun Won Seo ),곽진미 ( Jin Mi Kwak ),진다빈 ( Da Bin Jin ),이광수(교신저자) ( Kwang Soo Lee ) 한국보건경제정책학회(구 한국보건경제학회) 2016 보건경제와 정책연구 Vol.22 No.1

본 연구는 맘퀴스트 생산성 지수(Malmquist Productivity Index, MPI)를 이용하여 정신질환 관련 의료자원 이용의 7년 간 생산성 변화 추이를 지역별로 분석하였다. 분석 단위인 DMU(DecisionMaking Units)는 16개 광역시·도이며 중앙정신보건사업지원단에서 제공하는 7개년 자료(2007-2013년)를 이용하였다. 맘퀴스트 생산성 지수 분석에 사용된 투입변수는 정신 의료기관 수,정신 병상 수, 정신과 전문의 수이며 산출변수는 정신 의료기관에 입원 및 외래로 방문한 환자수이다. 분석 결과, 생산성은 전반적으로 평균 0.6% 증가하였고 이 생산성 증가에 주된 영향을 미치는 요인은 기술 변화로 나타났다. 또한 지역별로 생산성 변화에 큰 차이가 있었는데, 평균적으로 생산성 증가가 크게 나타난 지역은 강원, 서울이었던 반면 생산성 감소가 큰 지역은 인천,제주였다. 본 연구는 7년 간 우리나라 정신질환 관련 의료자원 이용의 생산성 추이를 지역별로 파악할 수 있었고, 앞으로의 정신질환 관련 의료자원 이용 계획 수립 시 기초자료로 활용될 수있을 것이다. This study purposed to analyze the productivity trend of healthcare resources utilization about mental health by region in Korea. Data were derived from the National Mental Health Commission and this study included 16 metropolitan cities for 7 years from 2007 to 2013. To analyze productivity change using Malmquist Productivity Index(MPI), number of mental hospitals, number of mental hospital beds and number of psychiatrists were used as input variables. Number of inpatients and outpatients were used as output variables. Overall, MPI was increased by 0.6% on average during the period from 2007 to 2013. Technical change had more influence on productivity advance than pure efficiency change and scale efficiency change. There were differences in MPI by regions. Gangwon showed the highest productivity increase, while Incheon showed the highest productivity decrease. Study results presented that productivity change of healthcare resources utilization about mental health was differed by regions and that technical changes were mainly due to productivity change. Thus, health policy makers will need to prepare interventions to use resources about mental health efficiently by regions.

의료보장유형에 따른 Percutaneous Transluminal Coronary Angioplasty 입원 환자의 의료이용 차이 분석: Propensity Score Matching을 이용하여

서은원 ( Eun Won Seo ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.1

Background: Previous studies showed differences in healthcare utilization among insurance types. This study aimed to analyze the difference in healthcare utilization for percutaneous transluminal coronary angioplasty inpatients by insurance types after controlling factors affecting healthcare utilization using propensity score matching (PSM). Methods: The 2011 national inpatient sample based on health insurance claims data was used for analysis. PSM was used to control factors influencing healthcare utilization except insurance types. Length of stay and total charges were used as healthcare utilization variables. Patients were divided into National Health Insurance (NHI) and Medical Aid (MA) patients. Factors representing inpatients (gender, age, admission sources, and Elixhauser comorbidity index) and hospitals (number of doctors, number of beds, and location of hospitals) were used as covariates in PSM. Results: Tertiary hospitals didn’t show significant difference in length of stay and total charges after PSM between two insurance types. However, MA patients showed significantly longer length of stay than that of NHI patients after PSM in general hospitals. Multivariate regression analysis provided that admission sources, Elixhauser comorbidity index, insurance types, number of doctors, and location of hospitals (province) had significant influences on the length of stay in general hospitals. Conclusion: Study results provided evidences that healthcare utilization was differed by insurance types in general hospitals. Health policy makers will need to prepare interventions to influence the healthcare utilization differences between insurance types.

당뇨병 유병률의 지역 간 변이와 지역 특성과의 관계 분석

조은경 ( Eun Kyung Jo ),서은원 ( Eun Won Seo ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2016 보건행정학회지 Vol.26 No.1

Background: This study purposed to analyze the relationship between spatial distribution of Diabetes prevalence rates and regional variables. Methods: The unit of analysis was administrative districts of city·gun·gu. Dependent variable was the age- and sex- adjusted diabetes prevalence rates and regional variables were selected to represent three aspects: demographic and socioeconomic factor, health and medical factor, and physical environment factor. Along with the traditional ordinary least square (OLS) regression analysis, geographically weighted regression (GWR) was applied for the spatial analysis. Results: Analysis results showed that age- and sex-adjusted diabetes prevalence rates were varied depending on regions. OLS regression showed that diabetes prevalence rates had significant relationships with percent of population over age 65 and financial independence rate. In GWR, the effects of regional variables were not consistent. These results provide information to health policy makers. Conclusion: Regional characteristics should be considered in allocating health resources and developing health related programs for the regional disease management.

공간분석을 이용한 지역별 비만율에 영향을 미치는 요인분석

김다양 ( Da Yang Kim ),곽진미 ( Jin-mi Kwak ),서은원 ( Eun-won Seo ),이광수 ( Kwang-soo Lee ) 한국보건행정학회 2016 보건행정학회지 Vol.26 No.4

Background: This study purposed to analyze the relationship between regional obesity rates and regional variables. Methods: Data was collected from the Korean Statistical Information Service (KOSIS) and Community Health Survey in 2012. The units of analysis were administrative districts such as city, county, and district. The dependent variable was the age-sex adjusted regional obesity rates. The independent variables were selected to represent four aspects of regions: health behaviour factor, psychological factor, socio-economic factor, and physical environment factor. Along with the traditional ordinary least square (OLS) regression analysis model, this study applied geographically weighted regression (GWR) analysis to calculate the regression coefficients for each region. Results: The OLS results showed that there were significant differences in regional obesity rates in high-risk drinking, walking, depression, and financial independence. The GWR results showed that the size of regression coefficients in independent variables was differed by regions. Conclusion: Our results can help in providing useful information for health policy makers. Regional characteristics should be considered when allocating health resources and developing health-related programs.

병원서비스지역 내 병원자원과 의료서비스 이용 간의 관련성 분석

곽진미 ( Jin Mi Kwak ),김다양 ( Da Yang Kim ),서은원 ( Eun Won Seo ),이광수 ( Kwang Soo Lee ) 한국보건행정학회 2015 보건행정학회지 Vol.25 No.3

Background: This study explored the relationship between hospital resources and services uses in outpatient/inpatient-based hospital service area (HSA) in Korea. Methods: Study hospitals included all acute care hospitals except tertiary hospitals. Inpatient and outpatient hospital claims from the Korean National Health Insurance (NHI) program in 2010 were used to identify the service uses. Hospital resources and the degree of insurance premium in study areas were identified with the NHI corporation data. Study variables were computed by summing the service uses or hospital resources of study hospitals in each HSA. Service uses were represented by the total medical charges and number of visits/inpatient days. Hospital resources were measured by number of beds, number of doctors, and number of computed tomography (CT). The economic status of NHI enrollees in each HSA was controlled by the average monthly premium of NHI program per household in each HSA. The degree of using local hospitals was controlled with the localization index. Results: Analysis results showed that hospital resources such as beds, CT were statistically related to the service uses. And also localization index was found to have positive significant relationships with service uses. Conclusion: Hospital resources such as beds, CT had not only positive impacts on inpatient service uses, but also influences on the outpatient setting. Health policy makers will require monitoring and assessing the hospital resources in Korea.

지역사회 의료자원 이용의 효율성과 건강수준 간의 관련성 분석 -서울,경기 지역을 중심으로-

곽진미 ( Jin-mi Kwak ),이광수(교신저자) ( Kwang-soo Lee ),서은원 ( Eun-won Seo ) 대한보건협회 2016 대한보건연구 Vol.42 No.2

연구목적: 본 연구는 지역의 의료자원 대비 의료서비스 이용에 초점을 두어 서울과 경기지역을 중심으로 지역사회 의료자원 이용의 효율성과 지역 내 주민의 건강수준 간의 관련성을 분석하였다. 연구방법: 2013년 기준으로 국민건강보험공단, 통계청, 보건복지부에서 제공하는 데이터를 활용하였으며, 분석단위는 서울과 경기 지역의 56개 시·군·구이다. 의료자원 이용의 효율성 점수를 계산하기 위해 자료포락분석을 사용하였고, 의료자원이용의 효율성과 지역 내 주민의 건강수준 간의 관련성 파악을 위해 구조방정식을 활용하였다. 연구결과: 분석결과 의료자원 이용의 효율성과 건강 수준 간에 통계적으로 유의미한 관련성은 없는 것으로 나타났다. 고등학교 이상 졸업자 분율, 주민등록인구수, 시·군·구 유형은 건강수준과 유의미한 관련성을 보였다. 결론: 본 연구는 지역의 건강 관리는 의료서비스 이용에 치중하기보다는 복합적이며 다학제적인 방식으로 접근할 필요가 있음을 시사한다. 또한 지역사회 수준에서의 건강관리를 하기 위해서는 탈시설화 개념을 도입하고, ACO와 같이 지역 내에서 건강을 통합 관리하는 지역사회 의료중심 체제를 갖추는 것이 필요할 것으로 판단된다. Objective: This study analyzes the relationship between the efficiency of regional health care resource uses and health status of population focusing on Seoul and Gyeonggi Province in South Korea. Methods: Data was collected from the 2013 statistical yearbook published by the National Health Insurance Corporation, Statistics Korea, and the Ministry of Health and Welfare. Study units included 56 basic local governments, city (si in Korean), county (gun in Korean) and district (gu in Korean), in 2013. Data envelopment analysis (DEA) with input-oriented BCC model was applied to produce efficiency score. Structural equation modeling (SEM) was applied to explore the relationship between efficiency of regional health care resource uses and health status of population. Variables such as the percentage of high school graduates, population size, types of local government, level of subjective health awareness, and level of financial independence were included in the model to control their differences among regions. Results: Analysis result showed that the efficiency of regional health care resource uses were not statistically related to health status. Regional variables such as the percentage of high school graduates, population size, and county local government were found to have significant relationships with health status. Conclusion: It suggests that it is need to manage the health of local residents with multidisciplinary approaches consisted with various members of the local health system organizations rather than mainly focusing on health service uses. Health policy makers will require introducing the concept of deinstitutionalization and building an integrated community health to manage the health of population.