일종합병원(一綜合病阮)의 비보험환자 처치행위 위상과 수가분석(酬價分析)에 관한 연구

Abstract

[한글]

우리나라의 의료보험제도 실시이후 3년째 접어드는 현재로써 많은 문제점을 수반하고 있는데 그중 제일 큰 문제가 보험수가가 일반환자 수가보다 현저히 저렴하여 병원운영에 압박을 가져오며 따라서 저질의 의료서비스를 야기시키고 있으므로 국가는 의료보험 개정안을 고려하지 않으면 안되게 되어있다. 이 조사는 그 이유중 하나인 진료기준수가표에서 의료행위 책정이 누락된 것을 보완시키는 문제로써 비보험환자의 수가와 큰 차이를 보이고 있는 처치료를 가지고 진료수가 산정을 고려하기 위하여 비보험환자의 처치료 양상을

분석하여 제시하고자 한다.

연구대상은 한 종합병원의 2,4분기점(1979. 4.1∼1979. 6.30)에 국한하여 비보험환자 902명을 대상으로 10%이상 같은 질병종류를 순위대로 분류하여 전수에 대한 처치료 전표를 환자의 인구학적 특성 및 재원시 특성별, 질병유형별, 과별 과 처치행위 유형별로 양상

과 수가를 분석하였다.

연구결과를 요약하면 다음과 같다.

1. 비보험환자가 각종 처치써비스를 받은 환자는 96.7%에 달하고, 1인회수는 7.2회이고 1인수가는 22,650원이었고, 단위회수는 0.8회이며 단위수가는 2,430원이었다.

2. 환자의 인구학적 특성 및 재원시 특성별 처치행위 유형은

가. 성별에서는 여자측의 단위수가가 모두 높았고, 독자적 간호행위 써비스도 높았다. 연령별에서는 고령에서 독자적 간호행위 써비스가 높았고, 최연소연령에서는 종합적 간호행위와 기재관리비의 서비스가 높았다.

나. 병실등급별에서는 중환자실의 환자가 모든 처치행위 써비스와 단위수가가 다 높았으며, 1인실 환자가 다인실 환자보다 단위수가가 높았다. 평균재원일수별로는 입원기일이 길수록 모든 처치행위 써비스는 L형으로 나타났다.

3. 질병종류별 처치행위 양상은

가. 보조적 간호행위 써비스는 외과적 질환환자와 뇌신경 병변환자에서 높았고, 독자적 간호행위 써비스는 내과적 질환환자와 분만환자에서 높았으며 종합적 간호행위와 기재관리비는 호흡기 질환환자와 뇌신경 병변환자 및 분만환자가 높았다.

나. 분문환자의 단위수가가 3.8회로 가장 높고, 단위수가도 10,880원으로 가장 높으며 다음이 뇌신경 병변환자가 4,690원으로 높았다.

4. 환자의 질병소속 과별 처치료 양상은

가. 일인수가는 정신과 환자가 제일 높고, 단위수가는 산과 환자가 제일 높았으며, 단위수가 산정회수는 산과·소아과 환자가 높았다.

나. 수술을 요하는 과의 환자는 보조적 간호행위 서비스가 높았고, 내과·산과 환자에서는 독자적 간호행위 서비스가 높았으며, 정신과 환자에서는 종합적 간호행위 서비스가 높았고, 소아과·산과 환자에서는 기재관리비가 높았다. 과별 환자의 처치료 평균 단위수가의 변이계수는 특수외과, 안과, 내과 환자가 크게 나타났다.

5. 처치행위 유형별 처치료 양상은

가. 전체 평균해이위 등가계수는 3.5회이고, 기재관리비가 4.3회, 독자적 간호행위가 3.9회로 평균보다 약간 높았으나 전체 평균행위 단위수가는 3,170원이고 타행위에 비해 큰 차이가 있었다.

나. 독자적 간호행위 서비스는 환자수 비율이 80.3%로 가장 높고, 보조적 간호행위 서비스는 31.7%로 가장 낮았다. 행위단위 평균수가의 변이계수는 보조적 간호행위가 전체적으로 다 높았고, 그중 의사진찰이 100.7%로써 가장 높았다.

본 조사의 결과에서와 같이 환자의 여러 가지 특성별 행위별에 따른 처치료의 다양한 양상을 보인 것은 환자에 따라 간호처치행위가 일괄획일적 일수가 없음을 보이므로 보험수가에서는 이 항목을 좀 더 상세히 구분지어 책정함이 마땅하고, 아울러 간호료가 반드시 첨부되어야 보험환자와 비보험환자의 수가와 의료서비스의 평준화를 기할 수 있을 것이다.

[영문]

The medical care insurance system, being put into ??actice nearly for three years, seen to have brought about some considerable problems as serious for the government as to consider a revision of that system. As one of the most serious

problems of present system, the treatment cost of insurance patients is so remarkably low in comparison with that of non-insurance acses that normal operation of hospitals is threatened carried out this survey to analyze and bring to light several aspects of treatment cost of non-insurance ostients as a material for a re-assessment of the cost of insurance cases which shows a considerable difference in amount at the standpoint of hospitals with that of on-insurance cases and further, hoping the significant blind spot of present insurance system(that is, the

abserics of regulations for cost assessment by patterns or types of health care treatment) will be mended in near future.

The survey was carried out with the treatment invoice sheets of total 902 in-hospital patients of a general hospital in Seoul during the period of the 2nd quarter of the year (1979). Among the total 902 patients, 694 cases were used for analysis, because those diseases,demographic charactertstics of patients, hospitalization patterns, types of nursing treatment, etc. The result of analysis was as follows.

1. Among all the non-insurance cases, those who received one or more kinds of nursing treatment mounted up to 96.7%.The invoice issue frequency per person was 7.2times, while that rrequency per day for a person was 0.8,: the treatment cost per person was ￦22,650 while its daily average was ￦2,430 due to the average 9.3 in-hospital days per person.

2. As to the nursing treatment types by the demographic characteristics of patients and hospitalization patterns.

a.Thd unit cost female patients was generally more expensive them that of males, and independent nursing service was more given than other types of treatment. As to age, higher age groups received independent nursing service most, while the youngest group received instrumental and integrated nursing services.

b.As to room grade, the unit cost of I.C.U. cases was the highest; and the cost of private room patients was higher than that of public room patients. By in-hospital days, the curve of function showed L type; that is, the longer stay, the lower function.

3. State of treatment types by kinds of disease were;

a. Dependent nursing service showed comparatively high availability in surgical and neurologic diseases, and independent nursing service was most received by medical, obstetrical and urological patients, while instrumental and integrated services were most available for respiratory desease and obstetrical and neurlolgic diseases next.

b. The invoice issue frequency per day for a patient was highest in obstetrical disease 3.8 times, and the unit cost (per one invoice sheet) was also highest in obstertrical disease (￦10,880) and next in neurologic cases (￦4,690).

4. As to the pertained departments,

a. Cost amount per person was highest in department of psychiatrics daily cost was highest in obstetrical cases; while the invoice issue frequency was highest in obstetrics and next in pediatrics.

b. In departments in need of surgical operation, dependent nursing care was highly available; while in internal medicine and obstetrics, independent service was higher. Psychiatrics showed the highest use of integrate nursing while pediatrics and obstetrics higher of instrumental services.

The variation co-efficient of treatment cost came out to be relatively in high in special surgery, opthalmology and internal medicine.

5. State of treatment cost by types of nursing behavior was:

a. The average frequency of invoice issue was 3.5(times). Among the type four types of treatment, instrumental service(4.3) and independent nursing behavior(3.9) showed higher frequency than average respectively. But as to unit cost (per invoice), dependent (￦5,200) and integrated (￦5,340) nursing care services were higher than average and considerably higher than the other two types.

b. In repect patient distribution, independent nursing behavior(80.3%) was the highest and dependent nursing(31.7%) the lowest. The variation co-efficient of treatment cost appeared highest in dependent nursing behavior as a whole, and among that, doctor's diagnosis showed the highest coefficient value(100.7).

In conclusion, the variaty of treatment cost(treatment itself) by various characteristics and treatment types proves that treatment various sort of patients and treatment cost of various types of nursing behavior cannot be uniform.

Therefore, to attain the equalization of health care service and its cost both for insurant and non-insurant patients, a more specific provision for assessment of cost should be added to the present medical care insurance system and, in addition, the cost of nursing treatment is desired to be inserted into the treatment invoice.