지역가입자 건강보험료 부과기준의 개선방안에 관한 연구

유재권 사단법인 인문사회과학기술융합학회 2017 예술인문사회융합멀티미디어논문지 Vol.7 No.7

Notwithstanding finance unification of national health insurance in 2003, heath insurance premium has been levied on the groups of workplace-insured individuals and regionally-insured individuals separately. Separate health insurance levying system causes many defects in national health insurance system such as moral hazard of individuals and disparity between the group of workplace-insured individuals and the group of regionally-insured individuals. This study indicates defects and directions for improvement in relation to the current health insurance levying system for regionally-insured individuals. The main points of this paper are as follows. First, the health insurance levying standard for regionally-insured individuals needs to be simplified because it is too complicated in comparison with that of workplace-insured individuals. Insurance premium for regionally-insured individuals is determined by the premium charge score calculated in household unit whereas insurance premium for workplace-insured individuals is determined by the level of income. Health insurance levying system for regionally-insured individuals is overly complicated and causes complaints. In addition, it takes a lot of administration costs for health insurance corporation to collect insurance premium. Second, The current separate levying system impedes the equity of the premium burden between the group of workplace-insured individuals and the group of regionally-insured individuals. Therefore the current separate levying system should be reformed into unifying it in the long term. As a concrete method of unification, it is necessary to examine how to impose health insurance premium on the basis of income tax and property tax. Third, the current dependent system undermines the equity of the national health insurance system since the dependents of workplace-insured individuals don't need to pay insurance premium at all while they can enjoy all the benefits of national health insurance. Thus, the supporting and income requirement for acknowledging dependents should be tightened to reduce free riders. Fourth, the current grading system of income and property for regionally-insured individuals is regressive and lacks logical validity. The grading rule should be changed into proportionate one at least and the disparity between income and property should be resolved. Fifth, the levying system of basic insurance premium for all individuals including dependents may be introduced as a method to mitigate disparity between the group of workplace-insured individuals and the group of regionally-insured individuals. 2003년에 건강보험의 재정이 통합되었음에도 불구하고 보험료는 직장가입자와 지역가입자로 구분하여 부과되어 왔다. 이원화된 건강보험료 부과체계로 인해 가입자의 도덕적해이가 야기되고, 직역 간 보험료 부담의 형평성이 떨어지는 문제가 발생한다. 본 연구는 현행 지역가입자 건강보험료 부과체계가 안고 있는 문제점을 분석하고 그에 대한 개선방안을 제시하였으며, 그 주된 내용은 다음과 같다. 첫째, 직장가입자에 비해서 지역가입자에 대한 현행 보험료 부과기준이 지나치게 복잡하므로 이를 단순화할 필요가 있다. 직장가입자의 보험료는 소득에 기초하여 결정되지만 지역가입자의 보험료는 세대 단위로 산정된 보험료부과점수에 따라 결정된다. 지역가입자에 대한 보험료 부과체계가 너무 복잡해서 민원이 발생할 뿐만 아니라 건강보험공단이 보험료를 징수하는데 많은 행정비용이 소요된다. 둘째, 현행 이원화된 보험료 부과체계는 직장가입자와 지역가입자 사이에 보험료 부담의 형평성을 저해한다. 따라서 장기적 관점에서 건강보험제도의 근본적인 개혁을 이루기 위해서는 재정 통합의 취지에 맞게 보험료 부과에 있어서도 직역 간 구분을 없애 부과기준을 단일화하는 방향으로 통합되어야 한다. 그 구체적인 통합 방안의 하나로 소득세와 재산세의 부가세 형식으로 건강보험료를 부과하는 방안을 검토할 필요가 있다. 셋째, 직장가입자의 피부양자제도는 보험료를 전혀 내지 않고 보험급여의 혜택을 누리기 때문에 건강보험제도의 형평성을 저해한다. 따라서 피부양자 부양요건과 소득요건을 강화하여 보험료를 부담하지 않는 피부양자 수를 줄여야 한다. 넷째, 현행 소득등급별 점수와 재산등급별 점수는 역진적이고 논리성이 부족하다. 소득 및 재산의 금액당 점수를 일정한 비율로 적용하고, 재산기준 보험료의 역진성이 소득기준 보험료보다 더 심한 점도 고쳐야 한다. 다섯째, 가입자 직역 간 형평성을 제고하기 위해 직장가입자 피부양자를 포함한 모든 건강보험 적용대상자에게 기본보험료를 부과하는 방안을 제시한다.

민간의료보험의 선택에 영향을 미치는 요인 : 민간의료보험 활성화에 대한 함의

윤태호,황인경,손혜숙,고광욱,정백근 한국보건행정학회 2005 보건행정학회지 Vol.15 No.4

Since the introduction of mandatory health insurance in 1977, the Korean national health insurance(KNHI) has grown rapidly. In 2004, about 96.9% of the total population are covered by the KNHI and the remaining 3.1% by the Medical Aid program. Despite national health insurance system in Korea, private health insurance market has grown rapidly. In 2004, the size of the private health insurance market was estimated at 6,568 billion won. The purpose of this study is to identify the factors that determine the purchasing decisions of supplementary private health insurance under mandatory national health insurance system in Korea. The data from 2004 Busan Health Survey were analysed for the purpose. The variables in this study are demographic factors, health status and health behavioral factors, health care systemic factors, and socioeconomic factors. For statistical analyse, we used logistic regression. The Findings show that female, economically active age group(especially 35-49 years), persons with better health status or experience of health screening test are more likely to purchase private health insurance. And higher household income and expenditure, higher education level are more associated with the increased probabilities of private health insurance purchases. This results imply that the expanding of private health insurance market could widen the gap between the have and have-not in terms of equal health care accessibility.

독일건강보험법의 기본모형과 개혁논의 - 우리 건강보험법에 주는 시사점 -

전광석 ( Kwang-seok Cheon ) 한국의료법학회 2004 한국의료법학회지 Vol.12 No.2

German Health Insurance Act has taken actions to reform a structure in the field of health insurance since 1989. These actions are classified as four steps. Health Insurance Reform Act of 1989 would readjust social solidarity and rules of self-responsibility in health insurance and improve insurance services economy. Health Insurance Changing Organization Act of 1993 concentrated on cost controls to health care providers including medical personnel. The bare skeleton of the third Health Insurance Reform Act of 1997 was that in case of increasing the rate of insurance, self-insured cost of an insured was raised by legal provisions and many private insurance factors were introduced into the public health insurance. The purpose of Modernizing Health Insurance Institution Act of 2003 were the improvement of the quality of medical services, balanced finance in health insurance, the pursuit of stability of an insurance bill, etc. These series of actions in the structural reform of German Health Insurance Act provide a goal of our healthl insurance system with several suggestions. In the first place, in the point of institutional evaluation of health insurance system our medical insurance system should be reexamined about how much it was appropriate to an institutional purpose. Second, as a structural problem of health insurance the General Group Contract(GGC) in force cannot fulfilled its functions practically. It is required, therefore, that this General Group Contract should be transferred the Individual Group Contract(IGC) by diversifying an insured's opponents. Finally external and comprehensive environmental factors surrounding health insurance must be predicted and the solution to such factors must be presented.

국민건강보험법상 보험급여수급권의 제한규정에 관한 고찰 - 대법원 2010. 6. 10. 선고 2010도1777판결(공2010하,1393) -

소건영 대한변호사협회 2013 人權과 正義 : 大韓辯護士協會誌 Vol.- No.437

국민건강보험은 국민의 질병·부상·출산·사망 및 건강증진에 대하여 보험급여를 실시함으로써,국민보건 향상과 사회보장 증진에 보험방식으로 대처하여 재정적 부담을 최소화하고 의료비를 보장하는 제도이다. 이로써 국민들의 의료이용과 혜택을 용이하게 하고, 국민들의 건강증진에 큰 영향을 주는사회보험제도이다. 그러나 국민건강보험법 제53조 제1항 제1호에서 ‘공단은 보험급여를 받을 수 있는사람이 고의 또는 중대한 과실로 인한 범죄행위에 그 원인이 있거나 고의로 사고를 일으킨 경우에는보험급여를 하지 아니한다.’고 규정하여 보험급여를 제한하고 있다. 이 규정은 중과실을 포함한 광범위성과 자기 및 타인에 의한 범죄행위의 적용여부에 대한 불명확성의 문제 등이 제기된다. 현대사회는 인간수명연장에 따른 고령화와 산업화로 인간의 사회위험이 상존하며 증가하고 있는 생활의 위험성으로 인하여 국민건강보험의 활용이 증가하고 있다. 그러나 위 보험급여수급권 제한규정의광범위성과 모호성은 국민의 건강하고 행복한 생활을 보장하기 위하여 국가가 보험자로서 국민의 건강증진을 목적으로 국민에게 의료혜택을 제공하고자 하는 입법취지와 목적에 비추어 볼 때 적법하다고볼 수 없다. 따라서 이 글에서는 국민건강보험법의 보험급여 제한사유의 범위와 의미에 관하여 고찰하고자 한다. The legislative purpose of National Health Insurance is to promote national health and improve the social security by providing necessary health insurance claim for disease, injury, birth,and death, etc. In accordance with provisions of paragraph 1, Article 53 of the National Health Insurance Act, when a person who is eligible to receive health insurance claim falls under one of the following subparagraph,the National Health Insurance Public Corporation shall not provide any insurance benefit: 1. When he has intentionally or through gross negligence caused a criminal act or intentionally contributed to the occurrence of an accident. According to this provisions, how to interpret and apply them, it may cause some problems related with insurance benefit which will be paid or not. This thesis will take a look at problems what have regarding the limited-payment health insurance claim in the National Health Insurance Act. A rapidly the aged, growing industrialization in modern society, longer life expectancy and various social risk are increasing the demand for insurance care as a remedy. The legislative purpose of National Health Insurance Act is to provide fundamental medical care service with low cost to national as much as possible. The National Health Insurance Act will preserve national health and property as protect social risk with National Health Insurance. But this is against both the legislative intention and legislative purpose which is the object of the country as insurer to promote national health and happy life in the National Health Insurance Act.

공공 및 민영의료보험의 비급여 관리정책에 대한 국가별 비교

김하윤,장종원 한국보건행정학회 2022 보건행정학회지 Vol.32 No.2

In the process of promoting policies to strengthen health insurance coverage, the relationship between public health insurance andprivate health insurance, along with the management of non-benefit, is also emphasized as a policy issue. First, the concept andscope of non-benefit were comparatively analyzed by country. Second, the interaction between the public and private healthinsurance was classified as ‘large or small,’ and the government’s regulation and management policy on private health insurance wasclassified as ‘strong or weak.’ Korea has relatively smaller benefits covered by public health insurance, higher copayment expenses,and more areas and scope of non-benefits. In countries where the interaction between public and private health insurance is small,private health insurance-related policies are weak. And in countries with large interactions had public-private partnerships and thegovernment’s management policies were also strong. On the other hand, Korea has a large interaction, but the actual structure ofcooperation between public and private insurance and management policies were weak. Because the non-benefit sector in Korea isrelatively wide, it is difficult to manage compared to other countries where the concept of non-benefit is limited. In addition, thehealth authorities rarely perform the role of supervision over private health insurance, and they have so few linkages and cooperationfor public-private insurance. Therefore, practical policy enforcement is necessary to achieve the easing of the burden of nationalmedical expenses through linkage and cooperation of public-private health insurance with reference to relevant other countries’cases.

중,고령자의 민간의료보험 가입 여부의 결정 요인

유기봉 ( Ki Bong Yoo ),조우현 ( Woo Hyun Cho ),이민지 ( Min Jee Lee ),권정아 ( Jeoung A Kwon ),박은철 ( Eun Cheol Park ) 한국병원경영학회 2012 병원경영학회지 Vol.17 No.3

Objectives : The coverage of Korean National Health Insurance is limited to basic level. Korean government encourages private health insurance for covering medical securities. So, many studies examined the determinants of purchasing private health insurance. However, 11% of Korean population is older than 65 in 2011. Considering the elderly is important to establish a health policy. The aim of this study is to examine factors determining the purchase of private health insurance among middle-aged and elderly Korean adults. Methods : We used the second Korean Longitudinal Study of Ageing (KLoSA), selected 8,688 sample of the aged 47 or older for the analysis. KLoSA collected information on demographic characteristics, income, health- related factors. KLoSA data include in the number of outpatient, inpatient, oriental hospital visit, dental clinic visit for two years. Logistic regression was used to examine the relationship between the determinants of purchasing private health insurance and the factors which include age, gender, education, residential district, marital status, smoking, drinking, physical exercise, economic activity status, national health insurance type, income, the number of chronic disease, and the number of outpatient, inpatient, oriental hospital visit, dental clinic visit for two years. Results : People who were older, did not live in a city, had higher IADL, currently drunk alcohol, did exercise regularly and had chronic diseases more than three were inclined not to purchase private health insurance. Females, the married, well-educated, past & currently smokers, the employed, high income earners, national health insurers, metropolitan citizens and someone who got high MMSE were more likely to purchase private health insurance. The more people experienced outpatients, inpatients, dental clinics and Chinese medicine clinics, the more private health insurance was purchased. The elderly people over 75 had more private health insurance than the aged 65-74. The strongest factors for private health insurance is gender, and economic status such as income. Conclusion : In this study, we found healthy-high income people were more likely to purchase private health insurance. In contrast, unhealthy-low income and older people did not. The economic factors were strongly related with private health insurance in aged over 75. These mean inequality exists in the using private health insurance. Therefore, the government should consider vulnerable social group before expanding private health insurance.

민간의료보험 활성화에 대한 입원환자의 인식 및 태도에 미치는 영향 -서울시내 일개 종합병원을 대상으로-

윤수진 ( Soo Jin Yoon ),김성주 ( Seong Ju Kim ),유승흠 ( Seung Hum Yu ),오현주 ( Hyohn Joo Oh ) 한국병원경영학회 2008 병원경영학회지 Vol.13 No.1

This research is aimed at analyzing and understanding the perception and attitudes of inpatients in a general hospital in Seoul towards the activation of private health insurance. Survey was conducted against 231 inpatients, results of which were analyzed in the methods of frequency analysis, chi square test, and logistic regression. The results are summarized as follows; First, better-educated population who finished college education at least, higher-income population, and people who had more knowledge about private health insurance showed more perception about activation of private health insurance. Second, better-educated population who finished college education at least, higher-income population, those who are insured in existing private insurance, oncological patients, and people who had more knowledge about private health insurance showed more positive attitude towards private health insurance paying for actual damages, long-term care insurance, and income security insurance. Third, age and education were the factors affecting perception about activation of private health insurance. The older the age is, perception was 1.035 times positive towards activation of private health insurance, and those who finished college education or above showed 3.148 times positive perception towards the same. Forth, surgical patients showed 1.087 times more positive attitude towards private health insurance paying for actual damages than internal medicine patients, while oncological patients showed 2.314 times more positive attitude than internal medicine patients. Further, understanding on the activation of private health insurance was 6.014 times higher in the higher understanding group than in the lower understanding group. Intention to use long-term care insurance was 2.692 times stronger in the male group than in the female group, and 3.616 times stronger in the oncological patients group than in internal medicine patients group. Further, understanding on the activation of private health insurance was 3.881 times deeper in the higher understanding group than in the lower understanding group. Intention to use income security insurance was 3.185 times stronger in those who have academic background of under the high school than those over the college, and 4.175 times higher in the group those whose monthly average income is over 4 million won than those under 4 million won. Also, intention to use income security insurance was 4.323 times higher in the group those who are insured by existing private insurances than those who are not insured by those insurances and it was 5.234 times higher in the group of oncological patients than in the group of internal medicine patients. Further, intention to use income security insurance was 3.559 times higher in the group those who thought that out-of-pocket money of the National Health Insurance is too much to bear than those it is quite endurable. Understanding on the activation of private health insurance was 4.875 times deeper in the higher understanding group than in the lower understanding group. There were some suggestions could be made based on the results of this research. First, reinforced publicity and education is needed for the low-educated or low-income group, as there are gaps in the understanding on the activation of private health insurance depending on the degree of education and income. Second, government should prepare administrative complementary measures to solve the problem of adverse selection by the consumer which is foreseen when private health insurances are activated. Third, government should suggest the desirable course of development of private health insurance items to ensure efficient use of enormous fund of private insurance market for health security of the people. Further, institutional complementary measures are needed to convert existing cancer insurances or specific disease insurances to private health insurances paying for actual damages guaranteeing against

민간의료보험의 역할 설정 방안에 관한 연구

정두채,문승권 남서울대학교보건의료개발연구소 2005 보건복지 연구 논집 Vol.2 No.1

The purpose of this paper is how to set rational role of private health insurance system in Korea. The present national health insurance system(NHI) has some in covering people's need of medical care services. Moreover, the health insurance industry monopolized by NHI led to the unbalanced supply of medical resources and made social costs. Supplementary private health insurance can be a solution of problems in the NHI System. First, private health insurance will be activated more efficiently than NHI. Second, it will provide various packages of insurance service which individuals want based on quality-premium relations. Third, the private sector will improve the health industry to be more sufficient and will reduce health care cost with the higher satisfaction. The basic change of health insurance system suggested by this paper are as follows. First, the health insurance system should be changed to a diversified and multi-pillar system including private health insurance. Second, the private health insurance should cover the coinsurance fee as a supplementary to NHI. Third, the increase of medical costs would be controlled by private health insurance. Fourth, private health insurance would activate and diversify medical care needs. Fifth, intensification of guarantee should follow by reverse selection of private health insurance and decrease of insurance premium.

민간의료보험 가입이 의료이용에 미치는 영향

윤희숙 한국개발연구원 2008 KDI Journal of Economic Policy (KDI JEP) Vol.30 No.2

Nearly all Koreans are insured through National Health Insurance(NHI). While NHI coverage is nearly universal, it is not complete. Coverage is largely limited to minimal level of hospital and physician expenses, and copayments are required in each case. As a result, Korea's public insurance system covers roughly 50% of overall individual health expenditures, and the remaining 50% consists of copayments for basic services, spending on services that are either not covered or poorly covered by the public system. In response to these gaps in the public system, 64% of the Korean population has supplemental private health insurance. Expansion of private health insurance raises negative externality issue. Like public financing schemes in other countries, the Korean system imposes cost-sharing on patients as a strategy for controlling utilization. Because most insurance policies reimburse patients for their out-of-pocket payments, supplemental insurance is likely to negate the impact of the policy, raising both total and public sector health spending. So far, most empirical analysis of supplemental health insurance to date has focused on the US Medigap programme. It is found that those with supplements apparently consume more health care. Two reasons for higher health care consumption by those with supplements suggest themselves. One is the moral hazard effect: by eliminating copayments and deductibles, supplements reduce the marginal price of care and induce additional consumption. The other explanation is that supplements are purchased by those who anticipate high health expenditures - adverse effect. The main issue addressed has been the separation of the moral hazard effect from the adverse selection one. The general conclusion is that the evidence on adverse selection based on observable variables is mixed. This article investigates the extent to which private supplementary insurance affect use of health care services by public health insurance enrollees, using Korean administrative data and private supplements related data collected through all relevant private insurance companies. I applied a multivariate two-part model to analyze the effects of various types of supplements on the likelihood and level of public health insurance spending and estimated marginal effects of supplements. Separate models were estimated for inpatients and outpatients in public insurance spending. The first part of the model estimated the likelihood of positive spending using probit regression, and the second part estimated the log of spending for those with positive spending. Use of a detailed information of individuals' public health insurance from administration data and of private insurance status from insurance companies made it possible to control for health status, the types of supplemental insurance owned by theses individuals, and other factors that explain spending variations across supplemental insurance categories in isolating the effects of supplemental insurance. Data from 2004 to 2006 were used, and this study found that private insurance increased the probability of a physician visit by less than 1 percent and a hospital admission by about 1 percent. However, supplemental insurance was not found to be associated with a bigger health care service utilization. Two-part models of health care utilization and expenditures showed that those without supplemental insurance had higher inpatient and outpatient expenditures than those with supplements, even after controlling for observable differences. 민간보험은 공적보험과 보완적인 관계를 형성함에도 불구하고 우리나라의 민간보험은 소득계층에 따른 접근성 차이로 인한 사회적 불평등, 도덕적 해이로 인한 공적보험 재정악화 등의 우려를 낳고 있다. 그러나 이에 관한 실증적 분석은 그간 이루어지지 못하여 정책적인 방향을 정립하는 데 장애가 되어 왔다. 본 연구는 건강보험공단, 심사평가원, 민간보험사, 행정자치부 주민등록세대정보 등의 관련 정보를 종합하여 이에 대한 실증분석을 시도했다. 그 결과, 우리나라의 민간보험 가입률은 전 국민의 64%에 달하고 있으며, 고소득층과 저소득층 간에 민간보험 가입률의 차이가 나타나지 않았다. 이는 공적보험의 보장성이 미흡한 상황에서 저소득층 역시 갑작스런 의료지출에 대비하고 있으며, 민간보험이 의료접근성의 계층화를 초래하지 않고 있다는 것을 시사한다. 또한 민간보험 가입자는 평균적으로 미가입자에 비해 의료이용량이 높지 않았으며, Two- Part Model을 통해 다양한 변수를 통제했을 경우에도 동일한 결과가 나타났다. 연령대에 따른 차이로 미루어 이러한 결과는 노동시장과 연관된 한시적인 성격일 것으로 추측되나, 현재로서는 민간보험 가입에 따른 도덕적 해이가 강하게 나타나고 있다는 근거는 발견되지 않았다.

치과의사의 국민건강보험에 대한 교육경험 실태 조사

김경미 ( Kyung Mi Kim ),마득상 ( Deuk Sang Ma ),정세환 ( Se Hwan Jung ),김철신 ( Cheoul Sin Kim ),박덕영 ( Deok Young Park ) 대한구강보건학회 2014 大韓口腔保健學會誌 Vol.38 No.1

Objectives: The purpose of this study was to investigate Korean dentists` perceived experience with and contents of education on National Health Insurance, and their competence in the practice of cases involving a health insurance claim. Methods: A survey was conducted with 600 dentists who secured their dentist license during 2000-2004. A systemic stratified sampling, with "school graduated from" as a stratum, was conducted on a population of 3,947 dentists, using the register of the Korean Dental Association. A survey request and questionnaire sample was mailed, and responses were collected using a web-based replying method. The impact of the experience of education related to health insurance on the frequency of, and perceived competence on health insurance claims was analyzed using the chi-square test. Results: Only 21% dentists replied that they had educational experiences related to health insurance when they were dental students, and the content of this education was ``health insurance system`` (69%) and ``health insurance law`` (59%). Only 28% of the respondents replied that they had practiced cases related to health insurance claims at dental schools. The rate of dentists who had educational experiences related to health insurance after their graduation was 73%. The experience of education related to health insurance and the perceived competency on handling health insurance claims showed a statistically significant correlation (P<0.01). Conclusions: It is necessary to develop a standardized curriculum related to health insurance and health insurance claims in dental schools.