자율점검제 실시 전·후 요양기관의 진료행태 변화: 「측두하악관절규격촬영」대상으로

Abstract

연구 목적: 부당청구 사전예방 강화 목적으로 도입된 자율점검제의 도입 전·후 요양기관의 청구 행태를 비교·분석함으로써 자율점검제의 효과적인 운영에 자료를 제공하는 데 있다. 연구 방법: 1차 자율점검 시범사업으로 진행된「측두하악관절규격촬영」항목의 실시 전 60개월, 실시 후 30개월의 건강보험심사평가원 요양급여비용 청구 데이터를 바탕으로 기관별 월별 청구 명세건수와 금액을 비교·분석하였다. 주요 관심변수는 자율점검 실시 여부이고, 종속변수는「측두하악관절규격촬영」의 요양기관별 월별 청구 건수(명세건수) 및 금액(종별가산적용금액)으로 선정하였으며, 독립변수에 영향을 줄 수 있는 혼란변수를 통제하고자 요양기관 특성과 계절변수를 통제변수로 설정하였다. 실험군은「측두하악관절규격촬영」항목의 자율점검기관 중 치과의원 156개소이고 측두하악관절규격촬영을 1회 이상 청구한 장비 미보유 치과의원 중 자율점검을 시행 받지 않은 468개소를 대조군으로 설정하였다. 이 때 로지스틱 회귀분석을 통해 성향점수를 추정한 후 nearest-neighborhood method를 사용하여 1:3 매칭을 시행하였다. 자율점검기관(case)과 미점검기관(control)의 자율점검 실시 전·후 진료 행태를 분석하기 위하여‘측두하악관절규격촬영’,‘파노라마촬영-특수’,‘측두하악관절규격촬영과 파노라마촬영-특수’,‘전체 진료내역’ 각각의 청구량에 대한 비교단절적시계열 분석을 시행하였다. 연구 결과:‘측두하악관절규격촬영’의 비교단절적시계열 분석 결과 자율점검 실시 전 점검기관은 미점검기관 대비 청구금액이 2,172% 더 많았으나(95% CI: 13.335 ~ 35.007; p-value<.0001), 실시 후 96.6% 더 적게 청구한 것으로 분석되었고 통계적으로 유의했다(95% CI: -0.986 ~ -0.918; p-value<.0001). 점검기관은 자율점검 실시 직후 청구 명세건수와 금액 모두 급격하게 감소하였고 이후 조금씩 감소 추세를 보였으며, 자율점검 실시 후 미점검기관 대비 점검기관의 청구금액 기울기는 3.5% 더 감소하는 추세였으나 통계적으로 유의하지 않았다(95% CI: -0.089 ~ 0.022; p-value=0.2253). 반면에‘파노라마촬영-특수’는 자율점검 실시 후 점검기관이 미점검기관 대비 청구금액을 191.3% 더 많이 청구한 것으로 분석되었고 통계적으로 유의했다(95% CI: 0.625 ~ 4.224; p-value=0.0003). 미점검기관은‘측두하악관절규격촬영’과‘파노라마촬영-특수’모두 자율점검 실시 전 청구 금액이 점진적으로 증가하였으나(95% CI: 0.002 ~ 0.015; p-value=0.0138) 실시 후 감소하는 경향을 보였고 통계적으로 유의했다(95% CI: -0.035 ~ -0.007; p-value=0.0028).‘측두하악관절규격촬영과 파노라마촬영-특수’는 자율점검 실시 전 점검기관의 청구금액이 미점검기관 대비 429.4% 더 많이 청구하였으나(95% CI: 2.646 ~ 6.687; p-value<.0001) 실시 직후 실험군과 대조군의 차이가 28.4% 더 작아졌음을 확인하였고 이는 통계적으로 유의했다(95% CI: -0.413 ~ -0.126; p-value=0.0010). 결론:「측두하악관절규격촬영」항목은 부당청구 개연성이 있었으나 거짓청구보다는 수가이해부족 또는 전산입력오류로 인한 착오청구에 가까워‘자율점검을 통한 정보 제공과 착오청구 진료분에 대한 정산 처리’만으로도 ‘측두하악관절규격촬영’청구량은 급감하고 대체청구 항목인‘파노라마촬영-특수’청구량은 증가하는 진료행태 개선 효과가 발생하였고 직접적인 개입이 이루어지지 않은 미점검기관도 자율점검 실시 후 청구량이 감소하는 간접적 개선 효과가 확인되었다. 자율점검제는 한정된 자원과 인력으로 수많은 기관들에 대한 부적정 진료비 청구를 사전에 예방하고 근절하기 위한 효율적 방안의 하나로, 현 운영 절차와 함께 자율점검을 활성화할 수 있는 유인책이나 분석 과정에서 제외된 기관들에 대한 추가적인 조처 등을 지속적으로 마련한다면 사전 예방적 체계의 한 축으로서 안정적 정착을 할 수 있을 것이다.

Purpose: To provide data on the effective operation of the self-check system by comparing and analyzing the claim behavior of healthcare institution before and after the introduction of the self-inspection system, which was introduced for the purpose of strengthening the prevention of Healthcare Fraud and abuse. methods: Based on the Health Insurance Review and Assessment Service medical care benefit cost claim data 60 months before and 30 months after the implementation of ‘Temporomandibular joint transcranial view radiography’item self-inspection, which was conducted as the first pilot project, the number and amount of monthly claims for each institution Compared and analyzed. The main variable of interest was whether to conduct self-inspection, and the dependent variables were selected as the number of monthly claims (Number of billing statements) and billing amount(Amount of money applied by type of medical institution) for each medical institution in the‘Temporomandibular joint transcranial view radiography, and the characteristics of the medical institution and seasonal variables were set as control variables to control confusion variables that could affect independent variables. The experimental group(case) consisted of 156 dental clinics among the self-inspection institutions in the category of‘Temporo mandibular joint transcranial view radiography’, and 468 dental clinics that did not have the equipment for which Temporomandibular joint transcranial view radiography was claimed more than once were set as a control group. At this time, 1:3 matching was performed using the nearest-neighborhood method after estimating the propensity score through logistic regression analysis. In order to analyze the treatment behavior before and after the self-inspection of the self-inspection institution(case) and the non-inspection institution(control), Comparative interrupted time series analysis was conducted on the amount of claims for each of 'Temporomandibular joint transcranial view radiography', 'panoramic radiography-special', 'Temporomandibular joint transcranial view radiography and panoramic radiography-special', ' overall medical treatment details'. Results: As a result of the Comparative interrupted time series analysis of 'Temporomandibular joint transcranial view radiography’, the self-inspection agency group(case) before the self-inspection was charged 2,172% more than the non-inspection group(control) (95% CI: 13.335 ~ 35.007; p-value<.0001), but it was analyzed that they(cases) charged 96.6% less after self-inspection, which was statistically significant(95% CI: -0.986 ~ -0.918; p-value<.0001). In the case of the self-inspection agency, immediately after the self-inspection, both the number of claims and the amount of claim billings decreased rapidly, and then gradually decreased. After the self-inspection, the slope of the billing amount of the self-inspection agency compared to the non-inspection agency tended to decrease by 3.5%, but was not statistically significant(95% CI: -0.089 ~ 0.022; p-value=0.2253). On the other hand, in the case of‘panoramic radiography-special’, it was analyzed that after the self-inspection, the self-inspection agency charged 191.3% more of the billing amount compared to the non- inspection agency, but it was statistically significant (95% CI: 0.625 ~ 4.224; p-value=0.0003). Immediately after the self-inspection was conducted, both the number of claims and the amount increased, and thereafter, the slope showed a gentle increase, but it was not statistically significant. In the case of non-inspection institutions, the billing amount charged before the self-inspection for both‘Temporomandibular joint transcranial view radiography’,‘panoramic radiography-special’was gradually increased (95% CI: 0.002 ~ 0.015; p-value=0.0138) and then decreased after the implementation which was statisticall significant(95% CI: -0.035 ~ -0.007; p-value=0.0028). In the case of‘Temporomandibular joint transcranial view radiography and panoramic radiography special sum’, before the self-inspection was conducted, the billing amount of the inspection agency was 429.4% higher than that of the non-inspection agency, but it was confirmed that the difference between the experimental group and the control group was 28.4% smaller immediately after the implementation, which was statistically significant. Conclusion: The ‘Temporomandibular joint transcranial view radiography’ item was likely to be an unfair claim, but it was closer to an error claim due to lack of understanding of medical insurance cost or electronic input error rather than false claims. There was a sharp decrease in the claims of ‘Temporomandibular joint transcranial view radiography’and increase in the claims of‘panoramic radiography -special’which is an alternative item, resulting in improved treatment behavior. In addition, even non-inspection institutions that did not directly intervene were confirmed to have an indirect improvement effect in reducing the amount of claims after self-inspection. The self-inspection system is one of the effective measures to prevent and eradicate inadequate medical bills to numerous institutions with limited resources and manpower. In addition to the current operating procedures, if the incentives to activate self-inspection or additional measures for institutions excluded from the analysis process are continuously prepared, it will be able to settle down as an axis of the preventive system.