의료보험 재정조정사업의 합리적 개선방안에 관한 연구

Abstract

[한글]

우리 나라 의료보험에서는 재정조정사업으로 고액급여비 공동사업과 노인의료비 공동사업을 활용하고 있다 따라서 1995년의 자료를 이용하여 의료보험 재정 및 재정조정사업 현황과 그 문제점을 분석·파악하고 이에 근거한 합리적 개선방안을 제시하고자 하였다.

의료보험내의 상황측면에서 볼 때 최근 '95년도 중 발생한 시 ·군조합의 통합, 직장조합의 합병 흡수, 진료비 및 수진율의 급격한 증가 등으로 재정조정 사업 주변 여건이 크게 변동되었다. 그럼에도 불구하고 보험자 분류에 있어서 군조합, 시조합, 공동조합, 단독조합 등으로 구분하여 적용하는 것은 불합리한 또 다른 문제점을 발생시킬 소지가 있다.

따라서 전국 373개 보험자의 다양한 구조적 특성이 반영될 수 있는 보험자분류 방법을 보험재정외생변수를 이용한 집락분석법으로 찾았다. 이에 따라 재정조정사업의 개선 모형을 설정하여 '96년 사업규모를 기준으로 4가지모형에 대한모의실험을 실시하였다. 모의실험 결과를 재보험료의 갹출, 재보험 급부비의 교부, 재정이전효과, 보험재정 총수입, 수지율 등의 항목에 대한 대표값, 변이계수, 재정집중도 및 역진도, 균등도 등의 척도로 삼아 그 효과를 비교 평가한 주요 연구결과는 다음과 같다.

1. 전국 보험자의 재정지표를 직장공동조합, 직장단독조합, 공무원 및 사립학교 교직원 의료보험 관리공단(이하 공교라함), 군조합, 시조합, 구조합별로 비교해보면, 심한 재정 격차는 급여비 지출 격차보다 주로 보험료수입 격차에서 비롯되고 있었으며, 급여비 지출 격차는 군조합이 다른 종별 보험자에 비해 보험급여비 지출이 높아서 보험재정안정을 위협하고 있었다.

보험급여비 지출 중에서도 노인급여비 구성비와 고액급여비 구성비가 다른 보험 종별에 비해 크게 높은 지역보험의 경우 보험재정 지출 압박의 주요 요인이 되고 이로 인해 보험료 인상 및 부담을 가중하게 하는 악순환이 되고 있었다. 즉, 재정조정사업의 대상을

고액급여비와 노인의료비로 선정하고 있는 타당성을 입증할 수 있었다.

2. 보험자 구분을 관행적 구 시 군으로 구분하는 것보다는 구조적 요인에 의거 집락분석법으로 재분류하는 것이 보험자의 재정적 특성을 더 뚜렷하게 반영하고 있음을 알 수 있었다.

3, 재정조정사업의 합리적 개선방안으로 4개의 개선모형을 설정하였다. 제1모형은 현행과 같은 갹출 및 교부하는 방법으로 개선안과 비교하기 위한 모형이며, 제2모형은 형평계수를 조정하는 방식이며, 제3모형은 형평계수의 개선과 함께 보험자 재분류 결과에 의거 분류 ·할당하는 방식이며, 제4모형은 제3모형에서 재보험급부의 교부기준 중 노인급여비 기준을 전국 건당 평균금액으로 동일하게 하는 방식이었다.

즉, 한가지 개선사항을 하나의 모형으로 하여 그 개선사항의 효과를 정확히 알 수 있도록 모형설정을 하였다.

4. 현행 안과 개선 안중 어떤 방법이 보다 합리적인지를 알아보기 위해 모의 실험한 결과 다음과 같은 결론을 얻었다.

첫째, 형평계수는 제2모형에서 실질적 재정력 지표인 1인당 수지차액을 변수에 포함하여 개선할 경우 농어촌 조합의 이전효과가 더 커졌다. 즉, 형평계수의 구조적 요소 결합은 의료보험 내외의 상황변화에 적응할 수 있는 요인으로 결합하되 통계적 합리성과 현실

적 상황이 조화될 수 있도록 결정하는 것이 합리적이다.

둘째, 사회경제적 변수인 구조적 특성을 반영한 보험자종별 재분류 결과에의해 할당하는 제3모형이 수직재분배 기능측면에서 재정이전효과 및 재정균등지수에 있어서 제2모형 보다 효과적인 방안으로 입증되었다.

셋째, 갹출액 할당에 있어서 새로운 형평계수, 보험자 재분류 기준을 적용하고 동시에 재보험 급부비 교부시 균등성 원칙에 의거 노인급여비 배분기준을 전국 건당 평균액으로 개선하는 방식인 제4모형이 재정이전효과 및 이전액 규모, 재정력 집중도 및 역진도 분석평가에서는 3모형과 비슷하나 농어촌 지역조합에로의 재정이전효과를 극대화할 수 있다는 점 등 종합적 면에서 가장 효과적이고 합리적이였다.

요약하면 이 연구는 재정조정사업을 합리적으로 개선 운영함으로써 제도 정착발전에 기여하고자 시도하였다. 의료보험 재보험장치인 재정조정사업에 있어서 원보험의 취약기능인 수직적 재분배 기능을 강화하는 방향으로 개선해 나가야 한다는 제도운영의 정책방향

을 확인할 수 있었으며, 그 접근방법론 측면에서 볼 때우리 나라처럼 소득파악율과 노정률이 불균형한 사회 경제 여건 하에서는 임금소득자와 비임금소득자를 공통으로 측정 평가할 수 있는 수단의 하나로 다요소방식의 구조적인 접근법(형평계수)을 택하는 것이 최

선의 선택임을 실증해 보였다는데 그 의의가 있다. 아울러 지출부문 조정수단인 노인의료비 배분기준을 전국평균액으로 균일화할 수 있는 가능성을 검증함은 재정조정사업을 진일보 발전시킬 계기가 될 것이며, 의료보험에서 이 같은 재정조정사업의 합리적 개선을 통

하여 보험자간 재정력의 형평화를 달성할 수 있을 뿐만 아니라 더 나아가 장기적으로 보험자간 보험료 부담률의 상대적 형평성을 도모할 수 있을 것으로 판단되며, 향후 의료보험의 균형 발전과 정책 차원에서의 중요성에 비추어 이 분야에 대한 보다 심층적인 연구들이 나와야 할것이다.

The Improvement of Rational Method of Financial Adjustment Program in Medical

Insurance Scheme

Sung-Tae Yoon

Department of Public Health, The Graduate School, Yonsei University

(Supervised by Professor Han-Joong Kim, MD., Ph.D)

To find rational method for improving financial adjustment program in medical

insurance scheme such as high-cost medical care benefit and elderly medical

expenses, present conditions and problems of general finances and financial

adjustment were analyzed making use of 1995 data. Conditions of financial

adjustment have been greatly changed due to various factors as follows : merge of

Si and Kun societies, consolidation of employee's societies and rapid increase of

medical care cost and frequency rate.

In spite of these changes, classification of insurance carrier into County, city,

local and individual may be the cause of irrational problems. Therefore, first, to

find ways for rational classification of insurance carrier reflecting various

structural characteristics, and then to develop model for improving financial

adjustment, and to carry out simulation test based on the scale of 1996 projects,

and to evaluate and compare effects making use of reinsurance contribution,

financial transfer, whole amount of insurance income, ratio of income to

expenditure, parameters for financial transfer, degree of financial concentration,

reverse, and equality, were made. Major results of study are as follows.

1. Comparing financial indicators of whole insurance carrier with employee's

local society, employee's individual Societies, KMIC, RS(County, City, Ku), great

financial difference was caused by difference in insurance income, not by benefit

expenses. The amount of county society is higher than that of other society, which

is major cause of threat to financial stability. Among expenses of benefit,

component ratio of elderly and high cost is also higher than other insurer.

These are also major cause of raising contribution and financial burden, which

makes proof of validity for selecting high cost and elderly medical care cost as

target of financial adjustments.

2. Structural reclassification of insurance carrier with method of cluster

analysis reflects financial characteristics more clearly than conventional method.

3. Total four models are presented for improving rational financial adjustment.

The first model is to compare present method of contributing and granting with

improved methods. The second model is adjusting equity parameter. The third model

is improving equity parameter and reclassification, allocation of insurance

carrier.

The fourth model is to equalize granting yardstick for elderly medical care cost

as a whole average amount per case in third model.

4. To understand which models will be the most rational, simulation test was

made, Major results are as follows.

First, combination of structural factor for equity parameter should be one which

can apply to changing condition within medical insurance. Statistical rationality

and realistic conditions should be harmonized in adjusting.

Second, in financial transfer effects and financial equalization indicator, the

third model is proved more rational than the second model. The way of allocating is

based on the reclassification of insurance carrier reflecting social economic

variances and structural characteristics.

Third, in case of allocating contribution, the fourth model is shown as the most

rational and effective method, considering all effects such as financial transfer,

financial concentration, reverse and evaluation of equalization.

In short, this study is carried out to contribute to improving financial

adjustment rationally and to establish the medical insurance scheme. In the policy

goal of financial adjustment, it was confirmed that vertical redistribution should

be strengthened, Considering poor grip and exposure of income in our country, it is

thought that structural approach evaluating income of employee and self-employed on

common ground should be most suitable one. Through rational improvement of

financial adjustment, equalization of financial capacities between societies and

moreover, comparative equality of contribution can be possible.

It can be conducive not only to make equity of fiscial capacities between

societies, but also to comparative equalization of contribution rate between

societies in the long term. And it is expected that this study will be deeply made

in light of importance of policy and balanced development in medical insurance

scheme.

[영문]

To find rational method for improving financial adjustment program in medical insurance scheme such as high-cost medical care benefit and elderly medical expenses, present conditions and problems of general finances and financial adjustment were analyzed making use of 1995 data. Conditions of financial adjustment have been greatly changed due to various factors as follows : merge of Si and Kun societies, consolidation of employee's societies and rapid increase of medical care cost and frequency rate.

In spite of these changes, classification of insurance carrier into County, city, local and individual may be the cause of irrational problems. Therefore, first, to find ways for rational classification of insurance carrier reflecting various structural characteristics, and then to develop model for improving financial adjustment, and to carry out simulation test based on the scale of 1996 projects, and to evaluate and compare effects making use of reinsurance contribution, financial transfer, whole amount of insurance income, ratio of income to expenditure, parameters for financial transfer, degree of financial concentration, reverse, and equality, were made. Major results of study are as follows.

1. Comparing financial indicators of whole insurance carrier with employee's local society, employee's individual Societies, KMIC, RS(County, City, Ku), great financial difference was caused by difference in insurance income, not by benefit expenses. The amount of county society is higher than that of other society, which is major cause of threat to financial stability. Among expenses of benefit, component ratio of elderly and high cost is also higher than other insurer.

These are also major cause of raising contribution and financial burden, which makes proof of validity for selecting high cost and elderly medical care cost as target of financial adjustments.

2. Structural reclassification of insurance carrier with method of cluster analysis reflects financial characteristics more clearly than conventional method.

3. Total four models are presented for improving rational financial adjustment. The first model is to compare present method of contributing and granting with improved methods. The second model is adjusting equity parameter. The third model

is improving equity parameter and reclassification, allocation of insurance carrier.

The fourth model is to equalize granting yardstick for elderly medical care cost as a whole average amount per case in third model.

4. To understand which models will be the most rational, simulation test was made, Major results are as follows.

First, combination of structural factor for equity parameter should be one which can apply to changing condition within medical insurance. Statistical rationality and realistic conditions should be harmonized in adjusting.

Second, in financial transfer effects and financial equalization indicator, the third model is proved more rational than the second model. The way of allocating is based on the reclassification of insurance carrier reflecting social economic

variances and structural characteristics.

Third, in case of allocating contribution, the fourth model is shown as the most rational and effective method, considering all effects such as financial transfer, financial concentration, reverse and evaluation of equalization.

In short, this study is carried out to contribute to improving financial adjustment rationally and to establish the medical insurance scheme. In the policy goal of financial adjustment, it was confirmed that vertical redistribution should be strengthened, Considering poor grip and exposure of income in our country, it is thought that structural approach evaluating income of employee and self-employed on common ground should be most suitable one. Through rational improvement of financial adjustment, equalization of financial capacities between societies and moreover, comparative equality of contribution can be possible.

It can be conducive not only to make equity of fiscial capacities between societies, but also to comparative equalization of contribution rate between societies in the long term. And it is expected that this study will be deeply made

in light of importance of policy and balanced development in medical insurance scheme.