국민건강보험법상 평가제도의 문제점과 향후 과제- 요양급여 적정성 평가를 중심으로-

Abstract

According to the National Health Insurance Law (NHIL), Health Insurance Review and Assessment Service (HIRA) is taking charge of managing healthcare benefit quality assessment to improve healthcare quality from the both medical and economical perspectives. Recently, however, trouble has arisen between healthcare providers and HIRA regarding performance measures, contents, outcome, incentives and the way of public performance reporting. One of the most important problems of healthcare benefit quality assessment is that the assessment is somewhat targeted to the services not covered by National Health Insurance (NHI) not to mention services covered. Another problem is that now the healthcare expense review and healthcare benefit quality assessment are intermingled although their own intends and purposes are different-in other words, healthcare expense review is for retrenchment NHI expenditures, but on the other hand healthcare benefit quality assessment is for improvement service quality. It is more important in that the adjusted incentives rendered to the healthcare providers are determined by the outcome of quality assessment. Therefore, these two systems should be administerd separately. According to the NHIL, outcomes of healthcare benefit quality assessment should be reported publicly, however, there is no guidelines or details where and how to report publicly. Public reporting through media without any explanation for performance contents or measures incites people concentrate on tertiary hospitals or simply rank the healthcare providers. Because current performance measures do not completely reflect each healthcare provider’s characteristic and levels of services provided, people unable to interpret the information correctly. Accordingly, the validity and reliability of performance measures or indicators should be attained to provide people valuable information. To attain an initial purpose of healthcare benefit quality assessment for enhancing the service quality, policy makers should not only define legal evidences and extents but also support healthcare providers to be interested in quality improvement.