본문 바로가기
KERD
논문KCI 등재

약제비 억제와 처방의 질 제고의 딜레마: 처방인센티브제도와 내재적 동기

Financial Incentives and Intrinsic Motivation in the Incentive Program for Prescribers in Korea

강민아|배그린|이수옥
생명의료법연구소 (Ewha Institute for Biomedical Law & Ethics)|2016.06|생명윤리정책연구 (Asia Pacific Journal of Health Law & Ethics)|제9권 제3호|pp. 161-183|DOI 10.38046/apjhle.2016.9.3.006

0

조회

0

다운로드

0

인용

0

참고문헌

키워드

자율성autonomy내재적 동기intrinsic motivation불안정성precariousnesspolicy effectiveness제도의 실효성처방 인센티브제도금전적 인센티브financial incentive program for prescribermonetary incentive

초록

국민 건강과 삶의 질을 보장하기 위한 정책적 방안으로 효율적인 건강보험재정 운영과 보건의료서비스의 질적 수준 및 비용 적정성 제고가 중요해지면서 이에 대한 정책 수단으로 금전적 인센티브 제도가 점차 확대 적용되고 있다. 제도의 불안정한 운영과 정책 실패는 건강보험제도 운영 자체에 큰 불안정성을 야기할 수 있음에도 불구하고 보건의료 전문인의 행위변화에 대한 이러한 제도의 효과는 아직 명확한 근거가 보고되지 못하였다. 본 연구에서는 국내에서 국민건강 향상을 위한 적정처방 고취 및 보험제도의 안정적 운영을 위한 약제비 절감을 목표로 하여, 처방행위와 관련한 금전적 인센티브제도의 수혜대상자인 개원의를 대상으로 인센티브 제도에 대한 인식, 태도, 실천의지를 조사함으로써 정책 수용성과 효과를 재검토 하였다. 그 결과 내재적 동기의 고취를 동반하지 않는 금전적 인센티브는 전문가의 행태변화에 큰 효과가 없을 것으로 추정된다. 이러한 불완전한 정책의 시행은 건강보험재정의 효율적 운영과 보건의료 서비스의 질적 제고 측면에서 상당한 불안정성을 내포한다. 건강보험제도의 질적 향상과 안정적 운영을 위해 전문가 자율성과 자부심을 통한 내적동기 고취를 병행하는 정책목표 설정을 통해 정책수용성 및 효과를 극대화 할 수 있는 인센티브제도 마련이 필요할 것으로 보인다.

Abstract

The Financial Incentive Program, in South Korea, to improve quality and cost appropriateness is gradually expanding its efforts toward the goal of increasing effective health insurance administration and providing proper health services in Korea. But, there is no clear evidence of the effectiveness of these financial incentives. In particular, the effectiveness of financial incentives among health professionals has not been identified, nor do we know conclusively what best motivates improved professional behavior. In addition, there is no clear evidence of causality between changing behavior and cost of health utilization. Uncertain policy may cause precariousness of health system. An investigation into the knowledge bases, policy assumptions, and practices, of the Financial Incentive Program in South Korea, to improve prescribing behavior, is necessary for an enhancement of policy acceptance and the effectiveness of the Financial Incentive Program. Through this study, we suggest some policy implications, and implementations, for the Incentive Program to improve prescribing behavior. External rewards, such as monetary incentives, should be compatible with intrinsic motivation. If policies do not harmonize with intrinsic motivations, which are a function of autonomy among health professionals, external rewards will fail. Future policy to improve prescribing behavior and contain the drug cost should consider experts’ needs, values, personality traits, and environments.

참고문헌 (93)

  1. Bernard Lo, "Resolving Ethical Dilemmas: A Guide for Clinicians", pp.81~ (2013)
  2. Schloendorf v, "Society of New York Hospital", N.Y, 211(125), pp.129~ (1914)
  3. Cobbs v. Grant, "8 Cal. 3d 229, 244, 245, 104 Cal. Rptr. 505, 502 P.2d 1, 12", ~ (1972)
  4. "Canterbury v. Spence", 781~782 (1972)
  5. Cruzan v. Director, "Missouri Dept of Health, 497 U.S. 261, 270", ~ (1990)
  6. Bartling v. Superior Court, "163 Cal. App. 3d 186, 194, 195, 209 Cal. Rptr. 220", ~ (1984)
  7. Bouvia v. Superior Court, "179 Cal. App. 3d 1127, 1137, 225 Cal. Rptr. 297,302, 303", ~ (1986)
  8. "Conservatorship of Drabick, 200 Cal. App. 3d 185, 206, 245 Cal. Rptr. 840, 853", ~ (1988)
  9. Luis Kutner, "Due Process of Euthanasia: The Living Will", Indiana L. J, 44(539), pp.552~ (1969)
  10. Scott P. Hays, "The Role of Agenda Setting in Policy Innovation: An Event History Analysis of Living-Wills Laws", 25 American Politics Quarterly, 25(497-516), pp.502~ (1997)
  11. "In re Quinlan, 70 N.J. 10, 23-24, 355 A.2d 647", 653~654 (1976)
  12. Eleanor Blau, , N.Y. Times, (5), pp.47~ (1975)
  13. Jean Seligmann, "A Right to Die", Newsweek, pp.58~ (1975)
  14. Matt Clark, "The Quinlan Decision", Newsweek, pp.107~ (1975)
  15. "Quinlan Alive Two Years Off Respirator, Facts on File World News Digest", ~ (1978)
  16. Stanley N. Wellborn, "Death in America: No Longer a Hidden Subject", U.S. News and World Report, pp.67~ (1978)
  17. "Lawscope; Death", 70(29) (1984), 70 American Bar Association Journal
  18. Francis J. Flaherty, "A Right to Die?; The Premier Privacy Issue of the 1980s", National Law Journal, 7(3) (1985)
  19. John Pickering, "Final Frontier: Life, Death, and Law; Life at All Costs", Legal Times, 12(3) (1989)
  20. "Hays & Glick, supra note 13", 504~
  21. "Omnibus Reconciliation Act of 1990, including amendments known as The Patient Self-Determination Act, P.L", 101~508
  22. Robert Steinbrook, "Preferences of Homosexual Men with AIDS for Life-Sustaining Treatment", New England Journal of Medicine, 314(457-60) (1986)
  23. Robert M. Wachter, "Life-Sustaining Treatment for Patients with AIDS", Chest, 95(647), pp.650~ (1989)
  24. "Making Medical Decisions for Someone Else: A How to Guide"[URL]
  26. Jaya K. Rao, "Completion of Advance Directives Among U.S. Consumers", American Journal of Preventive Medicine, 46(65) (2014)
  27. David I. Shalowitz, "Accuracy of Surrogate Decision Makers: A Systematic Review", Archives of Internal Medicine, 166(493-497) (2006)
  28. Shana Wynn, "Decisions by Surrogates: An Overview of Surrogate Consent Laws in the United States", Bifocal, 36 (2014)
  30. "Superintendent of Belchertown State School v. Saikewicz", Mass, 373(728) (1977)
  31. "The Florida Bar, What is Guardianship?"[URL]
  32. "Wynn, supra note 32; Default Surrogate Consent Statutes as of June 2014, ABA Commission on Law and Aging 2014 (September 8, 2016, 9:00am)"[URL]
  33. "Lo, supra note 2", 77~84
  34. Michael A. Refolo, "The Patient Self-Determination Act of 1990: Health Care’s Own Miranda", J. Contemporary Health L. & Policy, 8(455), pp.458~ (1992)
  35. Kimberly S. Johnson, "What explains racial differences in the use of advance directives and attitudes toward hospice care?", J. Am Geriatr Soc, 56(1953-1958), pp.1957~ (2008)
  36. Susan J. Diem, "Cardiopulmonary Resuscitation on Television", N. Engl. J. Med, 334(1578-1582) (1996)
  37. "Are Doctors More Likely to Refuse CPR?" (2012)[URL]
  38. "Doctors Really Do Die Differently: Research Say that More Physicians Plan Ahead, Reject CPR, and Die in Peac"[URL]
  39. "Most physicians would forgo aggressive treatment for themselves at the end of life, study finds" (2014)[URL]
  40. Alan Meisel, "Seven Legal Barriers to End-of-Life Care, Myths, Realities, and Grains of Truth", JAMA, 284(2495-2501) (2000)
  41. Justin E. Bekelman, "Comparison of Site of Death, Health Care Utilization and Hospital Expenditures for Patients Dying with Cancer in 7 Developed Countries", JAMA, 315(272-283) (2016)
  42. Paul E. Marik, "The Cost of Inappropriate Care at the End of life: Implications for an Aging Population", American Journal of Hospice & Palliative Medicine, 32(703-708) (2015)
  43. "NHPCO’s Facts and Figures: Hospice Care in America" (2014)[URL]
  44. Robert Buckman, "Breaking bad news: why is it still so difficult?", British Medical J, 288(1597-1599) (1984)
  45. "The Robert Wood Johnson Foundation", 1999
  46. Gregg K. Vandekieft, "Breaking Bad News", Am. Fam. Physician, 64(1975-1979), pp.1975~ (2001)
  47. Joseph A. Carrese, "Western Bioethics on the Navajo Reservation: Benefit or Harm", JAMA, 274(826-829) (1995)
  48. Joseph A. Carrese, "Bridging cultural differences in medical practice: The case of discussing negative information with Navajo patients", Journal of General Internal Medicine, 15(92-96) (2000)
  49. Sumathi Reddy, "How Doctors Deliver Bad News", The Wall Street Journal, (18) (2015)
  51. Walter F. Baile, "SPIKES—A Six-Step protocol for Delivering Bad News: Application to the Patient with Cancer", The Oncologist, 5(302-311) (2000)
  53. "EPEC, supra note 58 at M2-", ~
  54. M.L. Borum, "The effect of patient race on outcomes in seriously ill patients in SUPPORT: an overview of economic impacts, medical intervention, and end-of-life decisions. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments", J. Am Geriatr. Soc, 48(S194-8) (2000)
  55. E. Phipps, "Approaching the end of life: attitudes, preferences, and behaviors of Africans American and white patients and their family caregivers", J. Clin. Oncol, 21(549-554) (2003)
  56. "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care"[URL]
  57. Oluwaseyi B.Bolorunduro, "Disparities in Revasculari zation After ST Elevation Myocardial Infarction (STEMI) Before and After the 2002 IOM Report", Journal of the National Medical Association, 108(119-123) (2016)
  58. Eryn Brown, "“A dangerous conversation”: Medical interpreters need extra training to help dying patients", Kaiser Health News Stat, (17) (2016)
  60. A. M. Torke, "Jr. Medical Care at the End of Life: Views of African American Patients in an Urban Hospital", J. Palliative Med, 8(593-602) (2005)
  61. T. E. Quest, "Vulnerable populations: Cultural and Spiritual Direction", Emerg. Med. Clin. N. Am, 24(687-702) (2006)
  62. Patricia A. King, "Empowering and Protecting Patients: Lessons for Physician-Assisted Suicide from the African-American Experience", Minn. L. Rev, 82(1015) (1998)
  63. Perry Bacon Jr., "Black Lives Matter Has Shifted National Debate, Despite Controversial Reputation", NBC News, ~ (2016)
  65. Daniel Funke, "From Ferguson to Baton Rouge: Deaths of black men and women at the hands of police", LA Times, (12) (2016)
  68. Bernard Lo, "Resolving Ethical Dilemmas: A Guide for Clinicians at 61-66" (2005)
  69. Texas Health, "To Be or Not to Be, Should Doctors Decide? Ethical and Legal Aspects of Medical Futility Policies", Marquette Elder’s Advisor, 7(313-355) (2006)
  70. Jacqueline M. Kruser, "“Best Case", Worst Case”: Qualitative Evaluation of a Novel Communication Tool for Difficult in-the-Moment Surgical Decisions, 2015, pp.63(1805-1811), ~
  71. Jacqueline M. Kruser, "“Best Case", Worst Case”: Training Physicians to Use a Novel Communication Tool for High-Risk, Preference-Sensitive Decision Making, 2016, pp.D102, ~
  72. Lisa Bliss, "Collaborative Diagnosis: Interdisciplinary Problem-solving between Physicians and Lawyers", International Journal of Health, Wellness and Society, 2(37-41) (2013)
  73. Robert Pettignano, "Can Access to a Medical-Legal Partnership Benefit Patients with Asthma who Live in an Urban Community?", Journal of Healthcare for the Poor and Underserved, 24(706-717) (2013)
  74. Forrest Lang, "Making Decisions with Families at the End of Life", American Family Physician, 70(719-723) (2004)
  75. Alexia M. Torke, "A Conceptual Model of the Role of Communication in Surrogate Decision Making for Hospitalized Adults", Patient Education and Counseling, 81(54-61) (2012)
  76. David Wendler, "Systematic Review: The Effects on Surrogates of Making Treatment Decisions for Others", Annals of Internal Medicine, 154(336-46) (2011)
  77. Michael Gordon, "Conflicting Demands of Family At the End of Life and Challenges for the Palliative Care Team", Annals of Long-Term Care: Clinical Care and Aging, 23(25-28) (2015)
  78. Glenn McGee, "A National Study of Ethics Committees", American Journal of Bioethics, 1(60-64) (2001)
  79. Georgina Ledvinka, "Reflection and assessment in clinical legal education: Do you see what I see?", J. Clinical Legal Ed, (29–56) (2006)
  80. D. A. Kolb, "Experiential learning – experience as the source of learning and development" (1984)
  81. D. Shön, "The Reflective Practitioner: How Professionals Think in Action" (1983)
  82. Fitzhugh Mullan, "Narrative Matters" (2006)
  83. Lisa Bliss, "A Model for Interdisciplinary Clinical Education: Medical and Legal Professionals Learning and Working Together to Promote Public Health", International Journal Clinical Education, 18(149-164) (2012)
  84. "Health In All Policies. A Guide for State and Local Governments" (2013), Public Health Institute and American Public Health Association
  86. End of Life Care for Victorians with Intellectual Disability Living in Residential Services: A Concept Paper, , La Trobe University Palliative Care Unit, ~ (2015)
  88. "Disability Health Promoting Palliative Care (HPPC) Framework", La Trobe University Palliative Care Unit, ~
  90. "HPPC Framework"[URL]
  91. Canterbury v. Spence, "464 F.2d 772", 464 F. 2d, 780~782 (1972)
  92. Two police shootings, two videos, two black men dead, "Two police shootings, two videos, two black men dead", CNN, (7) (2016)
  93. D. Shön, "Educating the Reflective Practitioner" (1987)

관련 논문AI추천

처방 총액 절감 인센티브 시범사업과 약품비 절감 노력: 질적 및 양적연구김동숙, 송현종, 이수옥, 장선미, 채정미한국보건경제정책학회 · 보건경제와 정책연구2013 · 제19권 제4호약제비 절감을 위한 처방 인센티브 모형 개발 연구김남순, 이승미한국보건경제정책학회 · 보건경제와 정책연구2010 · 제16권 제3호건강보험 진료비 보상방식과 일차진료의사 서비스이태진한국보건경제정책학회 · 보건경제와 정책연구2006 · 제12권 제2호외래처방 인센티브 제도의 병원 확대 가능성 평가를 위한 의료기관 현황 및 의약품 선정 담당자의 인식도 조사이수옥, 이승미한국보건경제정책학회 · 보건경제와 정책연구2013 · 제19권 제4호보험 약가제도에 대한 분석과 개선방안: 유인합치성 관점에서양채열한국국제경제학회 · 국제경제연구2002 · 제8권 제3호국내 의료계에서 시행 중인 금전적 인센티브 제도의 윤리적 쟁점들박석건, 정유석한국의료윤리학회 · 한국의료윤리학회지2015 · 제18권 제2호

이 간행물의 다른 논문 (8건)

가습기 살균제 연구의 배후에 있는 재정적 이해상충에 대한 비판적 검토- 미국대학의 경우와 비교를 통하여 –김옥주, 공혜정, 신연선pp. 1-43인체유래물 거버넌스: 바이오뱅크 제도화 과정에서 나타난 제공자의 권리포기 문제박범순, 신미이pp. 45-78줄기세포기반치료에 대한 미국의 규제 경향 고찰박수헌pp. 79-101보조생식술 규제 입법에 대한 각국의 현황과 그 영향: 기록부와 이식 배아 수를 중심으로하정옥pp. 103-131동물실험 연구자의 정신적 스트레스에 관한 예비 연구모효정pp. 133-159
원문 보기