미국 사회복지정책변화와 메디케이드 매니지드 케어 도입 및 확대 : Lessons for Korea

신영전 한국사회보장학회 2004 사회보장연구 Vol.20 No.1

메디케이드(Medicaid)는 빈곤층에게 의료서비스와 건강관련서비스를 제공하는 미국 연방정부와 주 정부의 협력 프로그램이다. 1970년대 이후 미국 메디케이드 제도가 당면하고 있는 과제는 크게 두 가지인데 하나는 빈곤층의 건강문제를 지키는 건강안전망으로서의 기능을 더욱 강화하는 것이며, 다른 하나는 진료비의 급증에 따른 연방정부와 주정부의 재정적 부담에 대해 적절히 대응하는 것이다. 이 두 가지 과제를 해결하기 위해 미국의 연방정부와 주정부는 다양한 시도를 해오고 있으며 이 가운데 가장 기본적인 전략으로 선택한 것이 매니지드 케어의 도입이다. 1973년 건강유지접의 제정이후 매니지드 케어는 지속적으로 성장하여 2002년 현재 전체 메디케이드 가입자의 58%가 매니지드 케어 방식에 의해 서비스를 제공받고 있다. 1970년대 경제침체와 1981년 레이건의 집권 및 1990년대 공화당의 의화장악이라는 정치환경의 변화는 루즈벨트 이후 지속되어 오던 자유주의적 복지체계를 보수적 복지체계로 전환시켰다. 이러한 변화는 미국 보건복지 전반에 걸친 민영화(영리화 또는 상업화)를 야기하였는데, 1980년 이후 민간 영리 기관을 중심으로 한 메디케이드 매니지드 케어의 급속한 성장은 매니지드 케어의 내부적 운영특성이 가지는 장점에 기인하기보다는 이러한 변화의 연장선상에서 상호 긴밀한 관계를 맺으며 이루어진 것이었다. 따라서 미국 메디케이드 매니지드 케어의 다양한 경험을 참고할 때에는 그 내부 운영방식에 대한 분석 뿐만 아니라 그 도입과 확산이 이루어진 미국의 정치, 경제, 사회적 상황 및 사회복지정책의 변화들과의 관계에 대한 보다 분명한 이해와 비판을 기반으로 우리 사회의 적용 가능성을 검토하여야 할 것이다. 또한 여러 가지 제한점에도 불구하고, 미국 정부가 메디케이드 정책을 통해 보건의료전반에 걸쳐 정부의 정책기조를 관철시켜나가는 운영 전략, 연방정부가 주정부와 함께 정책수립과 집행과정에서 만들어내는 역동의 경험들, 그리고 메디케이드 매니지드 도입 과정에서 비용절감과 잘 개선을 위해 동원된 다양한 프로그램으로부터는 많은 아이디어와 기술적 도움을 얻을 수 있을 것이다. Medicaid, codified under the Title XIX of the Social Security Act, is a joint federal-state program to assist the poor for health and related services in the United States of America. Since 1970s, Medicaid has been faced with two problems: one hand is that it has to enforce its role as a health safety net and the other hand is that it has to adequately respond to the rapidly increasing fiscal burden of the US. To solve the problems, the federal and state governments have conducted various trials, but the most important major strategy that they finally chose was the introduction of Managed Care. After the enactment of the Health Maintenance Organization Act in 1973, Medicaid Managed Care has rapidly increased, and by 2002, more than 58 percent of Medicaid beneficiaries were enrolled in managed care arrangements. The economic recess in the 1970s and the changes in the political environment including the election victory of Ronald Reagan in 1981 and the dominance of the Republican Party in the congress since 1990s, made the transformation of the US welfare system from the liberal system to the conservative system. The conservative welfare system has changed the welfare including the health care service system into a more privatized one. The rapid increase in number and the commercialization of Medicaid Managed Care since the 1980s were closely linked to these kinds of changes of social policy under the political-economic environment rather than its intrinsic strength as an operational principle. When we would like to refer to the experiences from the introduction of Medicaid Managed Care, we must place it in the understanding of political context of the social policy in the United States of America. In spite of the limited application of the U's experiences to the health policies in Korea, some of them, especially the political strategy of the government using Medicaid as an important political vehicle for the health policy, political dynamics that the relationship between the federal and state governments is producing, and various idea and techniques for cost containment and quality improvement will be helpful to plan and implement health policies for the poor in Korea.

CT flouroscopy를 이용한 중재적 시술의 유용성

전혜정,박정희,서보경,박상우,신현준,최영철,한혜승,이창희 건국대학교 의과학연구소 2004 건국의과학학술지 Vol.14 No.-

Conventional CT-guided needle localization has been reported many times, but a few reports of interventional procedures by using multidetector CT scan with CT-fluoroscopy have been described. We presented 36 cases of CT-fluoroscopy guided interventional procedures focusing on the puncture technique. Two cases of small pneumothorax and one case of pulmonary hemorrhage out of 2lcases after lung biopsy, were not needed any treatments We can easily and accurately access to the lesion by using CT-fluoroscopy and unique our marker system.

간외담관 폐쇄에서의 초음파소견 : 담관벽 경계소실의 중요성 Significance of Decreased Echotexture of Bile Duct Wall-Interface

신현준,손은주,이창희,최영칠,전혜정,박정희,이태의 건국대학교 의과학연구소 2002 건국의과학학술지 Vol.12 No.-

Ultrasound is very useful in evaluation of obstructive jaundice. We retrospectively evaluated the useful findings of ultrasonography in differentiating benign extrahepatic duct obstruction from malignant diseases. Among the 36 patients, 25 patients were benign extrahepatic obstruction and 11 patients were malignant obstruction. The shapes of extrahepatic dilatation were classified into fustiform, meniscus, and abrupt cut off by bowel gas. The diameter, length, and bile duct wall-interface were compared between benign and malignant groups and serum bilirubin and alkaline phosphatase were also compared between two groups retrospectively. The results were as follows. The most common form of extrahepatic dilatation was meniscus(10 of 26 patients, 38%) in benign obstruction, and fusiform(8 of 11 patients, 73%) in malignant obstruction. No significant difference was noted in diameter, length, serum bilirubin, and alkaline phosphatase between benign and malignant groups. Only one case showed decreased bile duct wall-interface in benign obstruction, but loss or decrease of bile duct wall-interface were 8 patients in malignant obstruction. The combined findings of fusiform dilatation and loss of bile duct wall-interface in ultrasonography will be helpful in differential diagnosis of malignant extrahepatic bile obstruction from benign conditions.

풍진항체 검사법의 신뢰도에 관한 연구 : Comparison of the Methods between the Abbott RUBAZYME kit and the Abboutt IMx Automated Analyzer

신영전,최보율,최은주,박항배 한양대학교 의과대학 1995 한양의대 학술지 Vol.15 No.2

Abbott Rubazyme and Abbott IMx, which are most used to prevent Rubella IgG and IgM thesedays, were evaluated for their reliability. Both methods were tested on 305 women, 287 and 18 number of each pregnant and non-pregnant women, in Yangpyong county from March 1993 through September 1993. In addition, they had 14. 3 weeks of pregnant period and 25.8 of average age. It appeared that there was a significant correlation between the titers of Rubazyme and IMx for Rubella IgG (Coefficient Correlation 0.6167, p=0.000) but not for IgM(C. C. 0.0668, p=0.245). Additionally, the correlation coefficient of the two methods for IgG titer of 1st and 4th quartile, 0.6829, p=0.000, were higher than that of 2nd and 3rd, 0.4600, p=0.000, So does IgM : 0.1081, p=0.181 for ist and 4th quartile and 0.0230, p=0.780 for 2nd and 3rd quartile. The agreement rate of positivity was 92.5% for IgG and 99.0% for IgM. The kappa index for IgG was 0.51338. The agreement point of titer, where the number of a people who showed positivity for IgG in IMx test and that in Rubazyme kit test became equal, was 31.3 IU/ml, which was 315% of the original point, 9.949 IU/ml. The agreement rate of both tests for 1gG was decreased to 92.13% but the kappa index was increased to 0.66869 in rasing cut off point of the IMx up to 31.3 IU/ml. Abbott Rubazyme and Abbott IMx tests play important roles in determining the infection of pregnant women and even the prevention of deformation of child and artificial abortion. However, since these two methods turns out not to be reliable to be used through this experiment, physicians should examine the reliability of both methods, and even the possibility of technical errors of them before actual use.

여고생의 자아 이미지와 의복구매 행동에 관한 연구

全英信,韓明淑 服飾文化學會 1998 服飾文化硏究 Vol.6 No.1

The objective of this study is to measure self-image of adolescence, analyze empirically clothing-purchasing-behavior of adolescence and clarify correlation of two variables, self-image and clothing-purchasing-behavior, For this purpose, the techinques involve theoretical studies and researches based on historical data obtained from previous related studies and surveys. 431 high school female students who reside in Seoul are asked to answer selected survey questions to examine three aspects, clothing-purchasing-behavior, self-image and demographics. The evaluation of surveyed information is analyzed by statistical techniques to improve the accuracy of data, Statistical methods used are as follows: Descriptives (frequency, mean, percentage), Factor Analysis(varimax rotation), Crosstabs(Chi-square), T-test, One-Way ANOVA, Correlation Analysis, Reliability Analysis and Duncan's Multiple Range Test. The major results of this study were as follows : Firstly, there is a discrepancy between real self-image and ideal self-image. Furthermore more significant differences is seen from physical aspects than psychological aspects, Consequently, research proves that the difference derived from their ideal situation and leads to psychological unstableness, In addition, making their real self-image is dependent upon several elements such things as family economic level, pocket money, expenditure on clothing. Therefore, it is critical to combine all factors in order to decide how much to spend for children's clothing and pocket money in parents point of view. Secondly, research shows that there is correlated relationship between average expenditure on clothing and presence of mother's job. Average expenditure on clothing is, generally, influenced by vogue which is tend to be changed seasonally. It, also, shows that there is positive linear regression between expenditure on clothe and sensitivity for vogue. That is to say, dependent vriable, expenditure on clothing, is varied as independent variable, sensitivity for vogue, changes, Female high school students are likely to give much value on brand, moreover people who are spending more money on clothes have higher tendencies in prompt purchases than who are not. Thirdly, the analysis of clothing-purchasing-behavior and self-image shows that the difference between real self-image and ideal self-image draws the main reason of dissatisfaction after purchase of clothes. As a consequence, their unfilled needs lead them to keep making another purchase to satisfy themselves. Therefore, it is strongly recommended that parents' advices and directions on their children's money spending on clothes are imperative to establish well-behaved purchasing patterns.

추간판 조직에서 연령 및 퇴행성 변화와 신생혈관과 섬유모세포 성장인자발현에 대한 연구

전창훈,김한겸,강신영 대한척추외과학회 1999 대한척추외과학회지 Vol.6 No.3

연구계획 : 추간판 조직에서 신생혈관의 연구는 탈출된 추간판 조직에서 이루어졌다. 본 연구는 퇴행성 척추질환의 추간판 조직에서 신생혈관과 섬유모세포 성장인자의 발현에 대한 연령 및 퇴행성 변화와의 관계를 연구하고자 한다. 연구목적 : 추간판 조직에서 신생혈관과 섬유모세포 성장인자의 발현을 관찰하고 추간판 조직의 연령 및 퇴행성 변화와의 상관관계를 연구하고자 한다. 대상 및 방법 : 주된 증상이 요통인 퇴행성 척추 질환으로 전방 추체유합술을 시행받고 12개월 이상 추시 가능하 였던 환자의 추간판 조직 30례를 연구대상으로 하였다. 조직학적 관찰은 H-E염색과 혈관내피세포 성장인자와 섬유 모세포 성장인자를 이용한 면역 조직화학염색을 실시하였다. 대조군으로 부검시 채취한 신생아의 추간판 조직 12례를 대상으로 하였다. 결과 : 질환군에서 Hematoxylin - eosine염색 및 혈관내피세포 성장인자와 섬유모세포 성장인자를 이용한 면역 조직 화학염색상 신생혈관과 섬유모세포 성장인자의 발현은 전례에서 섬유륜의 바깥 1/2 층에서 관찰되었으나, 수핵에서는 혈관형성이나, 면역염색상 양성반응을 보이는 세포는 관찰되지 않았다. 대조군 12례의 추간판조직에서 Hematoxylin-eosin염색상 혈관형성이 관찰되었으나, 혈관내피세포 성장인자 항체와 섬유모세포 성장인자를 이용한 면역 염색상 양성 반응을 보이지 않는다. 대조군과 질환군 사이의 신생혈관에 대한 혈관내피세포 성장인자와 섬유 모세포 성장인자의 발현의 차이점은 통계학적으로 의미가 있었다( P<0.05). 질환군 사이의 신생혈관에 대한 혈관내 피세포 성장인자 항체 및 섬유모세포 성장인자의 발현의 차이는 없었다( P>0.05 ) . 결론 : 추간판내의 신생혈관과 섬유모세포 성장인자의 발현은 추간판 조직의 연령 및 퇴행성 변화와 관계가 있다 고 사료되었다. Numerous studies have shown neovascularization and basic fibroblast growth factor(bFGF) expression in herniated nucleus pulposus. It is not clear whether the neovascularization and bFGF expression are due to herniated nucleus pulposus with secondary reaction phenomenon or due to disc aging and degeneration. The purpose of this study is to investigate neovascularization and bFGF expression in both nucleus pulposus and anulus fibrosus tissues from aging and degenerated discs and compare it to neonate intervertebral disc. Thirty disc blocks obtained during anterior interbody fusion of the lumbar spine with degenerative spine disease were studied by immunochemical stains to observe neovascularization with vascular endothelial cell growth factor(VEGF) and bFGF expression. There were 8 disc blocks from the patients with degenerative disc disease, 15 with spondylolytic spondylolisthesis, and 7 with spinal stenosis with instability. For the control group, 12 neonate disc blocks obtained at autopsy. The neovascularization and bFGF expression were observed in the outer one half layer of the anulus fibrosus in the disease group but not in the nucleus pulposus. The neovascularization and bFGF expression were not observed in the control group. There was a statistical significant difference of neovascularization and bFGF expression between the control and disease group(p<0.05). There was no statistical significant difference of neovascularization and bFGF expression among the disease group(p>0.05). The results of this study suggest that neovascularization and bFGF expression are inherently related to aging and degeneration of the intervertebral disc.

국소 폐병변에서의 역동적 조용증강 CT의 유용성

신현준,최영철,전혜정,박정희,김요한 건국대학교 의과학연구소 1998 건국의과학학술지 Vol.8 No.-

The blood supply and metabolism of malignant nodules are qualitatively and quantitatively different from those of most benign nodules. We evaluated the efficacy of dynamic CT for differentiation of benign malignant lesions. Thirty-six patients with malignant nodule(n=20), tuberculoma(n=7), and pneumonic consolidation(n=9) were evaluated by thin section dynamic CT. CT numbers of lesion and aorta were measured before enhancement, and 1 minute, and 3 minutes after enhancement. Malignant lesions(maximum, 31.1±10.7 HU) enhanced significantly more than tuberculoma(maximum, 13.5±12.9 HU), but mass/aorta ratios were not so significantly different between malignant lesions(maximum, 0.61±0.27), tuberculoma(maximum, 0.36±0.15), and pneumonic consolidation(maximum,0.49±0.14). Dynamic CT is very useful for differentiation of malignant lesions from tuberculoma.

원발성 폐암의 CT상 병기 결정:새로 재정된 TNM 체계와의 비교

신현준,최영칠,전혜정,박정희,김요한,이원진 건국대학교 의과학연구소 1998 건국의과학학술지 Vol.8 No.-

Accurate staging of lung cancer is essential for defining operability, selecting treatment regimens, predicting survival, and reporting comparable end results. Revisions in stage grouping of the TNM subsets in the International System for Staging Lung Cancer have been adopted by the American Joint Committee on Cancer and the Union Internationale le Cancer at 1996. We compared the previous TNM systems with revised stage grouping rules, and tried to applicate the new size-criteria for metastatic lymph nodes in mediastinum. Twenty-two patients were undergone CT stagings by using three different systems of previous, revised, and modified TNM subsets. Ten patients showed different TNM stage by the revised stage grouping rules and seven patients were altered in lymph node stage by the new size-criteria. Recognition of revised stage grouping rules is very important for treatment plan and predicting the correct prognosis.

ZnSe 단결정에 대한 열자극 발광과 열자극 전류의 동시측정

전경남,유승철,고석룡,신용규,김택성,이춘호 全北大學校 基礎科學硏究所 1994 基礎科學 Vol.17 No.-

두 종류의 ZnSe 분말을 사용하여 sublimation 방법으로 성장한 ZnSe 단결정(as grown)에 대하여 TSC와 TSL을 동시 측정하였으며, PL과 DLTS를 측정하였다. PL 측정으로 I_1, I_2와 DAP 발광을 관측하였으며 DLTS에 의한 깊은준위를 관측하였다. TSL과 TSC의 동시 측정으로부터 얻은 그로우 곡선을 점근 해법으로 분해하여 세개의 준위를 얻었으며 그들의 활성화에너지값은 0.22 eV, 0.30 eV, 0.39 eV이었다. PL spectrum과 열자극 완화과정의 동시 측정 결과로부터 0.22 eV 근방에 impurity에 의한 주게준위와 native defect에 의한 받게준위가 각각 전도대의 아래와 가전자대의 위에 존재하는 것으로 판명되었다. DLTS 측정과 동시측정 결과로부터 0.30 eV와 0.39 eV의 준위는 V_se vacancy와 관련되는 주게 준위임을 알았다. Simultaneous measurements of TSL were carried out on ZnSe single crystals grown by high pressure Bridgman technique and the PL and DLTS signals were observed. Photoluminescence spectrum at 10 K on the ZnSe crystal reveals I_1 and I_2 lines, as well as DAP emission line. DLTS spectrum on the ZnSe crystal show electron trap at 0.33 eV. Two TSC and TSL peaks were observed near 215 K and 230 K, which are identified as having originated from two donor trap levels at 0.30 eV and 0.39 eV, respectively, below the bottom of the conduction band. We also observed single TSL and TSC peaks at 150 K which were identified as having originated from a donor and acceptor trap levels at about 0.22 eV below the conduction band and over the top of the valence band, respectively.

전방 십자인대의 파열시의 자기공명영상:직접소견의 중요성

신현준,이창희,최영칠,전혜정,박정희,김동헌 건국대학교 의과학연구소 2001 건국의과학학술지 Vol.11 No.-

It is Important to know the normal size, shape, and signal intensity of anterior cruciate ligament in the evaluation of knee injury Many studies have reported findings of tear or rupture as well as normal anatomy of these structure, especially with MR images. To our knowledge, there are few studies about normal structures of anterior cruciate ligament in MR images. The purpose of this study is to compare normal finding with tear of anterior cruciate ligament on MRI. Twenty-three cases with rupture of anterior cruciate ligament were evaluated on MRI, measuring the length, thickness, width of anterior cruciate ligament, and angles of anterior and posterior cruciate ligaments. Mean length, thickness, and width of anterior cruciate ligament in patients with rupture were 37.7±4.8mm, 9.0±1.2mm, 8.0±0.8mm, and mean angles of anterior cruciate ligament, and posterior cruciate ligament were 48.1±9.6˚, 118.8±13.1˚. Curvature ratio of posterior cruciate ligament was 0.25±0.09. The results showed significant differences between normal persons and patients with complete or partial rupture, and the mean angle and curvature ratio of posterior cruciate ligament which are known to related with indirect sign in tear of anterior cruciate ligament showed significant differences between ours and that of western countries. These results will be useful in the evaluation of patient wish rupture of anterior cruciate ligament, especially on MRI.