공적 연금제도의 순환계보험료율에 관한 연구

최병호(Byongho Tchoe) 한국재정학회(구 한국재정·공공경제학회) 1999 재정논집 Vol.14 No.1

This paper calculates the marginal contribution rates of public pension and analyzes the economic implications which the marginal rates influence to the oehavior of participants in a sense of efficiency and equity. The marginal contribution rate means the net marginal burden which the insured bears at a given time. That is calculated as subtracting the expected additional benefits the insured could receive in the future from the additional contribution he/she Jays when he/she earns a unit amount of income. The result shows that the marginal contribution rate of the younger is estimated as higher than that of the elder: the rate of the male higher than that of the female, and the rate of the single higher than that of the married couple. These results imply that each group by sex, age, single or marriage bears inequitible net burdens among them, and would have different incentives to participate in the labor market. The benefits of public servants and private school teachers’ pension are now calculated based on he final salary, which increases the expected marginal benefit exponentially because the final salary is increasing as he/she become old. Thus under the seniority system, the incentive to maintain their job will be abnormally strong, and that will undermine the flexibility of public employment market. To improve these distortions, this paper suggests that first, the formular of national pension should be revised so that the marginal contribution has a deep linkage to the future marginal benefit, and second, the benefits of public servants and private school teachers’ pension should be calculated on the basis of lifetime average salary rather than the final single year’s salary. With the revised scheme, the simulation results indicate that the changed marginal contribution rates will improve both efficiency and equity.

주택임대소득에 대한 건강보험료 부과기반 확대방안

최병호 ( Tchoe Byongho ) 한국사회보장학회 2018 사회보장연구 Vol.34 No.3

The biggest controversy in the current national health insurance imposition system lies in the imposition of excessive insurance premiums on homeowners and rent tenants. In the course of reorganizing the system of health insurance premiums toward the income-oriented imposing scheme, this paper examined the method of imposing premium on the housing rental incomes or housing-related imputed incomes. Although the tax provision for housing rental revenue exceeding 20 million Won per year is included to the comprehensive income taxation code, health insurance premium on the rental income is unilaterally charged to regional residents subscribers. Under these circumstances, the followings are proposed. First, as an alternative of eliminating premiums on the property of housing, premiums on housing rental income and housing-related imputed incomes are an appropriate choice. Second, the policy of health insurance premium should not be distorted by linking that to the lease income tax policy which depends upon fluctuating housing market circumstances. Third, in the long-run, under the income-oriented social insurance premium system, all kinds of the revenues, whether they are direct or imputed, from housing lease of landlords should be charged for the health insurance premium, and premiums imposition on tenants should be abolished.

사회보장체계의 구조개혁에 관한 고찰

최병호 ( Tchoe Byongho ) 한국사회보장학회 2024 사회보장연구 Vol.40 No.2

This paper attempted to present future structural reform measures of social security system, recognizing that the current social security system cannot properly cope with the current problem and cannot respond to future paradigm changes. The social security system was approached and evaluated in terms of targets, benefits, finances, governance, and performance indicators. The current system has wide blind spots, inadequate benefits, confusion between universal and selective welfare, and inefficient governance, and as a result, the quality of life indicators are far behind in the light of global standards. Reform of the current system seems inevitable to prepare for the upcoming new normal. As a major proposal, first, it will be reorganized into a universal social security system that encompasses blind spots, but the Eup-Myeon-Dong administrative welfare center (‘self-governing village’) will be the first point of contact by unifying the organizations for financing and benefits/services delivery. Second, it aims for proportional welfare in proportion to the income (property) and situation of individuals or households. The basic livelihood benefits and work incentives (child incentives) system will be integrated, and a elderly three-tier income guarantee system of the basic pension, national pension, and retirement pension will be established. Third, the emphasis is on integrating Medical Aids into national health insurance and preventing medical poverty caused by severe-long term diseases. Fourth, in addition to the public security system, it should be active in organizing private welfare resources. Fifth, it is necessary to select and manage international standards of quality of life indicators according to the economic level every year.

국민연금 개혁의 정치경제학적 고찰

최병호 ( Byongho Tchoe ) 한국연금학회 2024 연금연구 Vol.14 No.1

국민연금제도는 1988년에 도입된 후 1998년, 2007년 두 차례의 개혁 이후에 정체 상태에 있다. 매 5년 마다 시행하는 재정계산을 통해 모수적 개선방안이 논의되고 있지만 좀처럼 합의를 이루지 못해 개혁은 지지부진하다. 재정안정론과 소득보장론을 옹호하는 진영 간의 대립이 갈등의 주 원인이다. 윤석열정부는 2022년에 국회에 연금특위를 설치하여 개혁을 추진하고 있지만 개혁안을 도출하는 데에 난항을 겪고 있다. 그간의 개혁논의에 비추어볼 때에 연금개혁은 이론적 혹은 분석적, 그리고 이념적 당위성으로 풀 수 없는 문제였고 정치적인 경쟁과 타협에 의해 개혁을 이루어내었다. 본고는 그간의 연금개혁의 과정을 정치경제학적 관점에서 접근함으로써 개혁을 이끌어내는 요인을 고찰하고 전략적인 방향을 모색해보았다. The national pension system was introduced in 1988 and has been stagnant after two major reforms in 1998 and 2007. Although parametric improvement measures are being discussed through fiscal calculation implemented every five years, reform is stagnant because an agreement has rarely been reached. The main cause of the conflict is the confrontation between the supporters who advocate thelong-term financial stability or the old-age income security. The new government (Yoon Seok-yeol administration) established a special pension committee in the National Assembly in 2022 to promote reform, but it is in a stalemate to draw up a reform plan. In the light of past experiences, pension reform could not be solved with theoretical and ideological justification, and rather it is inevitable to reach a consensus in the appropriate line through political competition and compromise. This paper attempted to find an appropriate compromise by examining the process of pension reforms so far from a political and economic point of view.

SGR 기준의 건강보험수가 산정 연구

최병호 ( Byongho Tchoe ),신윤정 ( Yoon-jeong Shin ),신현웅 ( Hyounwoong Shin ) 한국보건사회연구원 2006 保健社會硏究 Vol.26 No.2

건강보험수가(환산지수)를 의료기관의 원가(경영)분석에 의하여 산정하게 되면 의료공급이 증가함에 따라 진료비의 증가를 허용할 수밖에 없는 구조적인 문제점이 있었다. 그리고 의료기관이 제공하는 자료의 신뢰성 때문에 계산결과에 대해 매년 갈등이 되풀이되는 관례를 답습하여 왔다. 본 연구는 기존의 환산지수 산정방법의 한계를 극복하는 방안으로써 미국 메디케어의 SGR 방식을 우리 현실에 맞게 수정 보완한 모형을 구축하였다. 이에 따르면 매년도의 진료비의 목표치를 정하여 관리하게 되므로 의료공급자수의 증가에 따른 자동적인 진료비증가를 제어하게 된다. SGR 방식에 의한 계산결과, 2004년도의 환산지수는 2003년 환산지수 55.4원 보다 2.66~2.93% 인상된 56.87~57.02원으로 나타났다. SGR 방식의 환산지수 산정은 정부가 발표하는 공식적이고 객관적인 지표들을 이용함으로써 자료의 객관성과 신뢰성 문제로 인한 불필요한 논란과 갈등을 최소화할 수 있다. 그리고 환산지수 갱신의 자동조정 메커니즘과 목표진료비를 설정함에 따라 보험재정규모의 예측가능성이 향상됨으로써 보험료 및 국고지원의 조달목표액을 결정하는 데에 용이할 것이다. 장기적으로는 현행 행위별수가제의 보완적 및 대체적인 지불방식으로써 진료비총액 계약제의 도입 타당성을 검토하는 기초자료로서 활용할 수 있을 것이다. 그러나 SGR 방식의 환산지수 산정시스템이 정착되기 위해서는 SGR 환산지수 계산에서 제외되는 비급여부문의 의료행위에 대한 투명성과 유효성을 확보하고, 진료부문별 진료량의 증감에 대한 모니터링, 청구된 진료비에 대한 적정성 평가시스템이 함께 작동되어야 할 것이다. 이와 함께 상대가치 점수의 진료부문별, 진료행위별 적정한 구조조정이 이루어져야 할 것이다. It was a general method to calculate the fee level of social health insurance by the cost analysis of medical institutions. This method has entailed problems such that medical expenditures are likely to increase proportionally according to the increasing supply of hospitals and clinics, and the credibility of provider`s cost reports has always been doubtful every year. This article suggests a new method to overcome the limitations of the cost analysis which is a revised version of Sustainable Growth Rate(SGR) based calculation of Medicare`s fee level(so called `conversion factor`) in USA. SGR system manages to maintain a certain target expenditure and contains the automatic increase of expenditures according to medical providers` increments. The result calculated by the SGR system shows that the conversion factor is 56.87~57.02 won which is increased 2.66~2.93% compared to 55.4 won in 2003. The calculation of SGR based conversion factor would minimise an unnecessary disputes by utilising the official indicators published by government, and improve the predictability how the national health insurance expenditure will increase. To introduce SGR system successfully, the non-insured sector`s medical expenditures should be controlled, and if not, some of health insurance expenditures will be transferred to the medical cost outside of national health insurance.

문재인정부의 보건의료정책 평가와 차기 정부의 과제

최병호 ( Byongho Tchoe ) 한국보건행정학회 2021 보건행정학회지 Vol.31 No.4

Moon Jae-in Care can be seen as a 2.0 version of Roh Moo-Hyun Care. Just as Roh Care failed to achieve its coverage rate goal and 30% share of public beds, Moon Care also failed to achieve its expected goal. The reason is that it followed Roh Care’s failed strategy. Failure to control non-covered services has led to a long way to achieve a 70% coverage rate and induced the expansion of voluntary indemnity insurance, resulting in increased public burden. The universal coverage of non-covered services caused an immediate backlash from doctors. And Moon government also failed to control the private insurance market. The expansion of publicly owned beds has not become realized and has not obtained public support. Above all, it failed to overcome the resistance of doctors and failed to obtain consent from budget power groups in the cabinet for public investment. It was also insufficient to win the support of civic groups. Communication with interested groups failed and the role of private health care providers was neglected. The next government should also continue to strengthen health care coverage, but it should prioritize preventing medical poor and create a consensus with both medical providers and consumers for the control of non-covered services. Ahead of the super-aged society, the establishment of linkage between medical services and long-term care and visiting health care or welfare services is an important task. All public and private provisions and resources should be utilized in the view of a comprehensive public health perspective, and public investment should be input in sectors where public medical institutions can perform more effective functions. The next government, which will be launched in 2022, should design a new paradigm for health care in the face of a period of transformation, such as the coming super-aged society in 2026 and the Fourth Industrial Revolution, and recognize that the capabilities of the health care system represent the nation’s overall capacity.

보건의료체계의 거버넌스 개혁

최병호 ( Byongho Tchoe ) 한국보건행정학회 2018 보건행정학회지 Vol.28 No.3

The objectives of this study were to evaluate the current state of governance structure and management of the health system to achieve the goals of the health system in South Korea, and to propose reform plan. This study drew implications from the governance of United Kingdom, Germany, and Netherlands, based on the principle of health system proposed by World Health Organization. The presidency and the health ministry should make macroscopic decision-making. The government has to decentralize the enforcement by municipality to operate public health and national health insurance (NHI), and to distribute the centralized NHI fund by municipality. The front line health centers and community centers should provide integrated health and social services. The government has to establish diversified regulatory bodies to enhance both the patient-centered care and the efficiency and equity of health care, and to provide mechanisms for ensuring autonomy of providers. The governance of the health system should be composed of the centralization of macro decision-making, the decentralization of implementation by municipality, the integration of health and social services on the front line, and the well-balanced regulation and autonomy on both consumers and suppliers.

국민건강보험 총액 예산제 도입을 위한 소고

최병호 ( Byongho Tchoe ),신윤정 ( Yoon-jeong Shin ) 한국보건사회연구원 2004 保健社會硏究 Vol.24 No.1

의료자원배분의 효율성이나 의료비용 억제 측면에서 문제점이 있는 제도로써 비판을 받고 있는 행위별수가제의 대안으로 진료비를 사전적(prospective)으로 예측 가능한 총액으로 지불하는 총액예산제의 도입방안을 검토하였다. 선진국들은 1970~80년대의 진료비증가에 대처하고 의료보장성을 확보하기 위하여 예산제를 대부분 채택하였다. 그런데 총액 예산제를 단기적으로 도입하기에는 우리 의료시장의 특성상 많은 장애요인을 안고 있으며, 장애요인을 극복하기 위한 세심한 준비와 여건조성을 다져나가야 한다. 진료비총액을 계약하더라도 비 보험 진료부문으로 비용을 전가하는 왜곡을 방지하기 위하여 보험급여를 확대하되 재원조달의 한계를 감안하여 본인 부담률을 조정하여야 할 것이다. 혹은 비 보험 진료의 투명성을 확보하기 위하여`전자진료카드`의 도입이 필요하다. 의료서비스의 질(성과)과 연계한 총액예산을 계약하되, 배분을 의료공급자단체에 맡기고, 의료기관 및 병상, 의료인력 등 의료자원에 대해 의료계에서 스스로 조절할 수 있는 자율을 부여하는 방안을 검토할 수 있다. 그러나 서비스의 질 확보를 위한 의료자원 투입기준을 마련하거나, 서비스 질 평가에 근거한 성과중심의 예산제가 도입되어야 한다. 총액 진료비를 통제하는 대신에 의료공급에 대한 규제를 완화하기 위해서 요양기관 계약제로 전환하는 방안을 검토한다. 한편 총액예산과 의료서비스의 질(성과)만 계약하는 방식을 취하지 않는 한, 진료영역별 지불보상방식(즉 행위별수가 혹은 DRG, 일당제, 인두제 등)을 비롯한 보험약가, 재료 대를 포함하는 포괄적인 계약이 되어야 할 것이다. Despite its positive effect on increasing the quality of healthcare services and practitioner`s self-regulation, the current fee-for-service reimbursement has been often criticized as an inefficient means of curbing expenditures and allocating resources. Most advanced countries have been adopting global budgeting system to induce cost-effective treatment behaviors from healthcare providers and to increase equity in the National Health Insurance. In this context, this study aims to examine the appropriateness of introducing global budgeting into Korea. To this end, this study: i) theoretically reviews previous studies and the pros and cons of global budgeting; ii) examine reimbursement systems in advanced countries, and draws implications for Korea; and iii) propose ways to introduce global budgeting to the National Health Insurance. With its in-depth examination of risk factors and proposed solutions associated with the introduction of global budgeting, this study will contribute to further research on improvement of reimbursement system. Also, in proposing ways to make global budgeting beneficial to consumers, providers and the insurer, this study can serve as an effective bridging tool between various interest groups.

DRG 분류(分類)에 의한 선지불제도(先支拂制度) 고찰(考察)

최병호 ( Byongho Tchoe ) 한국보건사회연구원 1998 保健社會硏究 Vol.18 No.2

본 연구는 현행 행위별수가제에 대한 대안으로써 진단명(DRG)에 기초한 先支拂制度의 도입을 검토하는 데에 있다. 미국이 1983년에 메디케어(노인의료보험)의 입원진료에 도입하였는데, 병원이 이윤을 남기기 위해 임상적 적정성을 희생하는 상반관계(trade-off)의 증거는 불확실하였다. 병원의 비용절감 인센티브는 분명히 나타났으나 재무 상태는 개선되지 않는 것 같다. 입원진료 이용량이 감소하는 대신에 외래진료 이용량이 증가하는 `외래대체`효과가 나타났다. 의료의 질은 우려와는 달리 떨어지지 않았으나 퇴원시 환자상태의 불안정성은 증 가하였다. 국민의료비의 증가억제는 장기적으로 실효를 거두지 못하는 것 같으며, 병원외래서비스의 급격한 증가가 우려되고 있다. 우리나라에서는 1997년 2월부터 시범사업중에 있는데, 시범사업 대상이 희망하는 기관 중심으로 선정되었기 때문에 DRG 적용이 병원경영에 유리하다고 판단하는 기관이 참여하였을 가능성이 크다. 따라서 시범사업의 결과를 그대로 받아들이기에는 한계가 있다. 그리고 DRG 수가(보상수준) 산정에 이용된 표본이 2개의 3차 진료기관만을 대상으로 하였으므로 대표성에 문제가 있으며, 더구나 원가분석자료에 의존 하고 있어 수가를 인상하기 위한 수단으로 비쳐질 우려가 있다. 다음으로 입원전·퇴원후 외래에서의 검사횟수 및 방문횟수가 증가함으로 써 `외래대체`의 우려가 나타났다. 더구나 DRG를 개발한 기관에서 평가까지 전담하고 있는 것은 바람직하지 않다고 판단된다. DRG 지불제도를 전국적으로 도입하기 전에 다음과 같은 보완장 치가 반드시 갖추어져야 한다. DRG의 부작용(진단명조작 등)이 장점보다 크게 나타나 보험재정이 오히려 악화되고 의료의 질이 떨어 질 가능성을 예방하기 위한 조치가 필요하다. 그리고 병원 경영개선은 진료량 증가보다는 원가절감에 의해 달성될 수 있는 장치가 마련되어야 한다. 또한 DRG를 단계적으로 확대적용 할 때에 DRG 비적용 환자에 대한 부담전가 문제에 대한 대비책이 필요하고, 보험재정 확대에 따른 재원조달방안이 반드시 마련되어야 한다. This study investigates the feasibility of the introduction of the PPS(Prospective Payment System) based on DRG(Diagnosis Related Groups) classification in response to criticism of FFS(Fee-for-service) payment in Korea. The demonstration project applying PPS is based on Korean-DRG classification, and began February 1997. The results of the project are positive and are as follows; decrease of volume, improvement of hospital profits, efficiency of claim and review administration, decreased copayment of patients, and sustainable quality of care. However, this study also investigates the negative sides and suggests some improvements. First, the selected diagnoses only had small variations in costs, and only the participant institutions were selected. Therefore, we could not guarantee similar results if PPS is expanded into most diagnoses nationwide. Second, serious bias may exist as the calculations of the price level of each diagnosis are dependent upon data from only two tertiary institutions. Moreover, the price levels are mostly based on input-costs reported by sample institutions themselves. Since the costs are much higher than the fee levels under the current FFS payment, there is much criticism that PPS could be utilized as an implicit way of increasing fees. Third, the number of check-ups and visits before admission and after discharge increased, meaning that there were substitution effects from the controlled inpatient reimbursement into the increasing volume in the outpatient area. Fourth, the decreased copayment of patients implies cost shifting to non-DRG patients. Therefore, if PPS is expanded step by step, cost-shifting would be a serious problem. Fifth, applying PPS into the outpatient as well as the inpatient area could control sustitution effects. Lastly, we could effectively protect patients from more serious diseases by including uncovered services and materials in the price setting of diagnoses

미국(美國) 국민년금(國民年金) 실효한계세율(實效限界稅率) 개혁(改革)의 경제적(經濟的) 효과분석(效果分析)

최병호 ( Byongho Tchoe ) 한국보건사회연구원 1995 保健社會硏究 Vol.15 No.1

社會保障制度의 經濟的 效果分析은 先進各國에서 많이 이루어져 왔으며, 이를 바탕으로 社會保障制度의 改革方案이 논의되고 있다. 본 硏究는 美國 國民年金制度에서 年齡別로 젊을수록 實效限界稅率이 낮아지도록 改編하는 경우 所得階層別 厚生變化와 資本 및 勞動市場에 미치는 영향을 분석하고 있으며, 연구방법으로서 生涯週期理論에 바탕을 두고 消費者를 生涯所得別로 5分位로 나눈 一般均衡 시뮬레이션模型을 이용하였다. 본 硏究가 寄興하는 주요한 점으로는 첫째, 一般均衡 시뮬레이션模型을 이용한 生涯週期的 分析틀에 의한 分配效果를 측정하는 方法을 시도하였고, 둘째, 기존의 年金稅-給興間 連結에 의한 實效限界稅率의 분석에서 나아가 實效限界稅率 改編에 따른 經濟的 厚生效果를 一般均衡的 接近으로 분석하였다는 점이다. 分析結果 年齡別 實效限界稅率 改革은 全生涯所得分位에 있어서 厚生을 增加시키고, 高所得 V분위의 厚生增加가 상대적으로 가장 낮게 되는 累進的 改革을 보여주고 있다. 또한 개혁으로 資本스톡 및 勞動供給 양자가 증가하고 資本集約度가 상승함으로서 經濟的 效率性이 增進되고 있다. 본 연구를 우리나라 國民年金制度에 적용함에 있어서 留意해야 할 점으로서는, 制度에 進入하는 世代別, 階層別로 醵出料率이 달라 각각의 厚生變化에 상당한 차이를 나타낼 것이므로 世代別, 階層別 實效限界醵出料率의 計測과 이에 따른 厚生의 變化分析이 필요한 것이며, 年齡間 資金所得의 隔差가 큰 年功序列型 資金構造로 인해 미국에 비해 연령별 연금세율 개혁의 政策效果는 더욱 크리라 생각된다. 實效限界醵出料率을 改編하는 方案으로서 年金算式 중 全加入期間 平均 所得부분의 算定時에 젊은 年齡에서의 所得에 높은 平價加重値를 두어 實質的인 醵出料率을 高年齡에 비해 낮추는 방안을 檢討할 수 있을 것이다. There have been many discussions about the economic distortions of social security, and several social security reforms have been suggested to alleviate the distortions. This paper analyzes the welfare incidence among income groups and the effects on the capital and labor supply when the effective marginal social security tax rates in the U.S. are reformed to be dependent on age, i.e. the social security tax rate becomes lower in the younger ages. The method used is an applied general equilibrium model in the context of lifecycle theory where the consumes are devided into five groups according to the lifetime income level. Contributions of this paper are as follows. First, it is a new approach to measure the distributional effects of social security taxation with lifecycle applied general equilibrium model. Second, this paper analyzes the welfare effects of the effective tax rates reform through the social security tax-benefit linkage in the framework of general equilibrium. This paper concludes that the reform improves the overall welfare level and produces the progressive structure which the welfare improvement in the highest lifetime income group is relatively lowest. The capital stock and labor supply both increase and the capital intensity increases resulting in the improvement of economic efficiency. Some points should be considered on the application of the results into Korea`s national pension scheme. It is necessary to measure the effective marginal contribution rates by generation and group, and then analyze the incidence of welfare, since the contribution rates schedule is varying according to generation and group. Korea`s wage would be stronger since the wage gap level mostly tends to be dependent on between ages is larger compared to the age. Therefore the effects of reform U.S.`s.