비급여 의료비 관리 체계 개선방안 : 국민건강보험과 실손의료보험 연계를 중심으로

Abstract

The public health insurance has been implementing a policy to strengthen its continued coverage, but the coverage rate has been stagnant at the early 60 percent level, with an increase in non-coverage health care costs being cited as the main reason. In addition, non-coverage health care costs not only directly bear the expense burden, but also increase the loss rate of private health insurance, which in turn leads to higher insurance premiums, which continues to be a vicious cycle in which the damage goes to the people. On the other hand, while the private insurance has been introduced to ease the public's health care cost burden due to the low coverage of the public health insurance, critics continue to point out that it has a negative impact on the public health insurance, including moral hazard and encouraging non-coverage medical care and over-care. Thus, although both public health insurance and private health insurance require urgent management of non-coverage health care costs, systematic management is not properly carried out. This study identified causes of increase in non-coverage health care costs and management system problems using literature review and analysis of expert in-depth interviews and text-mapping, and suggested the need to partnership public health insurance with private health insurance as a way to improve the non-coverage health care cost management system. The study found that the increase in non-coverage health care costs had an important effect on the increase in non-coverage health care expenses, in which the public health insurance's reservoirs were over-producing and supplying non-coverage health care for profit-generating purposes under the policy and action-by-action benefit system, and the private health insurance neutralized the sense of expense for both health care institutions and patients, thereby increasing the supply and consumption of non-coverage health care. While these non-coverage health care is an important issue for both the public health insurance and the private health insurance, neither insurance had an effective non-coverage management system. Problems with the non-coverage health care system include the lack of control mechanisms for new non-coverage health care that arise in response to the policy of enhancing coverage, the lack of information exchange between public health insurance and private health insurance, the lack of health care perspective management for lost health care insurance, the lack of non-coverage medical care and pricing criteria, and the lack of the standardization of non-coverage health care codes and names. On the other hand, the problem caused by the lack of connection between public health insurance and private health insurance was that the both insurance policies lacked information exchange and the management of non-coverage health care, and in particular, it was confirmed that public health insurance and private health insurance were necessary to manage non-coverage health care costs. Finally, the partnership between the public health insurance and the private health insurance enabled significant improvements in the non-coverage medical care management system, including the lack of control mechanisms for new non-coverage health care, lack of understanding the mutual effects of public health insurance and private health insurance, and the partnership between the public health insurance and the private health insurance. Other issues of insufficient standardization of non-coverage medical codes and names, and lack of medical volume and price criteria, were found to be addressed through the benefit of non-coverage health care. Since the public health insurance's measures to enhance its coverage were announced in August 2017, a strong coverage policy has been in place. The management of non-coverage health care costs is critical for the successful implementation of the assurance-enhancing measures. Therefore, it is expected that an effective management system for non-coverage health care costs will be established as soon as possible through the partnership between public health insurance and private health insurance, which are closely related around non-coverage health care costs.