요양급여 적정성 평가를 통한 의료 질 관리 및 국민건강 성과...

요양급여 적정성 평가를 통한

의료 질 관리 및 국민건강 성과

향상 방안 연구

발 간 등 록 번 호

G000DY1-2020-15

정책보고서 2019-67

신영석 ․ 강희정 ․ 황도경 ․ 김수진 ․ 이진형이근찬 ․ 유명순 ․ 하솔잎 ․ 이나경 ․ 이수빈

【책임연구자】신영석 한국보건사회연구원 선임연구위원【주요저서】

제3차 상대가치 개편 방안 연구건강보험심사평가원･한국보건사회연구원, 2018(공저)보건의료인력 실태조사 보건복지부･한국보건사회연구원, 2018(공저)【공동연구진】강희정 한국보건사회연구원 연구위원황도경 한국보건사회연구원 연구위원김수진 한국보건사회연구원 부연구위원이진형 성균관대학교 교수이근찬 우송대학교 교수유명순 서울대학교 교수하솔잎 한국보건사회연구원 전문연구원이나경 한국보건사회연구원 연구원이수빈 한국보건사회연구원 연구원

건강보험심사평가원장 귀하

본 보고서를 「요양급여 적정성 평가를 통한 의료 질 관리 및 국민건강 성과 향상 방안 연구」의 최종보고서로 제출합니다.

2019년 12월

주관연구기관명 : 한국보건사회연구원

연구책임자: 신영석

제출문

제1장 서 론 ······························································································································11

제1절 연구배경 및 목적 ··································································································································13

제2절 연구내용 및 방법 ··································································································································15

제2장 평가 관련 현황 및 문제점 ·······························································································17

제1절 평가 관련 일반 이론 ····························································································································19

제2절 의료기관 대상 평가제도 현황 및 문제점 ·····························································································22

제3절 요양급여 적정성 평가 및 의료 질 평가와 병원 인프라와의 관계 ·······················································71

제3장 의료 질 관리 및 성과 향상 프로그램의 국외사례 ························································101

제1절 덴마크 ·················································································································································103

제2절 호주 ····················································································································································114

제3절 영국 ····················································································································································119

제4절 기타 ····················································································································································126

제4장 의료 질 제고와 국민 건강성과 향상을 위한 종합평가체계 구축 ··································133

제1절 기본 방향 ············································································································································135

제2절 종합 평가 체계 틀 - 중·단기 ··········································································································141

제3절 종합 평가 체계 틀 – 장기(2025년 이후) ························································································160 제4절 평가정보공유시스템 구축을 위한 평가 사업 간 정보연계 방안 ·························································166

제5장 결론 ································································································································193

제1절 의료의 질 평가체계의 재구성 ·············································································································195

제2절 향후 연구 방향 ···································································································································199

참고문헌 ····································································································································201

부 록 ········································································································································205

부록 1. 요양급여 임상적 결과 지표 ·············································································································205

목 차

표 목차

평가지표 분류체계 초안 ···········································································································································26

의료기관 대상 평가사업 현황 ··································································································································28

평가사업별 평가영역 및 대상 ··································································································································29

의료기관 대상 평가사업 현황: 평가대상 기관 ········································································································30

의료기관인증평가 참여기관 수(2017년 말 누계) ··································································································30

의료질평가지원금 평가 참여 기관 수(2019년 평가) ·······························································································30

요양급여 적정성 평가 절차 ·····································································································································33

요양급여 적정성 평가 프레임 ··································································································································34

2019년도 요양급여 적정성 평가 추진 항목 ···········································································································35

평가항목별 가감 산정 기준 ···································································································································36

국내 요양급여 적정성 평가 관련 연구 동향 ·········································································································39

의료질평가지원금 평가 대상 및 재정규모 변화 추이 ···························································································42

2016년 기준 의료질평가지원금 수가 ····················································································································43

2018년 기준 의료질평가지원금 수가 ····················································································································43

2019년 기준 의료질평가지원금 수가 ····················································································································44

2019년 의료질평가지표 58개 ·······························································································································44

평가대상 등 평가기준 ············································································································································46

2018년, 2019년 의료질 평가 비교 ·····················································································································47

2020년 신규 및 시범 지표 ···································································································································47

2020년 의료질평가 영역별 목표 ··························································································································48

국내 연구 동향 정리 ·············································································································································48

의료기관 인증 현황(2019년 2월 기준) ················································································································55

제3기 상급종합병원 절대평가 항목 ·······················································································································57

제3기 상급종합병원 상대평가 항목 ·······················································································································58

제4기 상급종합병원 지정·평가 기준 주요 변화 ··································································································59

전문병원 지정 분야 ···············································································································································60

전문병원 지정 기준 ···············································································································································61

분야별 전문병원 지정 현황 ···································································································································62

지역거점 공공병원 운영 평가 부문의 구성 ···········································································································63

평가영역별 가중치 연도별 변화 ····························································································································64

2019년도 응급의료기관 평가 신규 지표 목록 ······································································································67

연구기본역량 ··························································································································································69

연구역량의 질 ························································································································································69

수련환경평가 업무 절차 ········································································································································70

수련환경평가 체계 및 평가 부분 ··························································································································70

요양급여 적정성 평가의 발전단계 ·······················································································································72

각 항목별 연도별 과정지표 변화 ··························································································································76

의료 질 평가 평가지표 ··········································································································································79

평가항목별 종합점수 산출 및 결과공개 현황 개요 ·······························································································82

종합점수 산출 평가항목별 가중치 부여 현황 ·······································································································83

요양급여 평가 결과 종합 점수 ····························································································································84

질 평가 영역별 결과 ·············································································································································86

종별 결과 ·······························································································································································86

폐렴 ·······································································································································································87

수술의 예방적 항생제 ············································································································································88

심근경색 ································································································································································88

급성기뇌졸중 ··························································································································································88

위험도표준화재입원비(1차 평가 상급) ···················································································································89

위험도표준화재입원비(1차 평가 종합) ···················································································································89

위험도표준화재입원비(1차 평가 지역) ···················································································································90

위험도표준화재입원비(귀원 RSRR) ·······················································································································90

위험도표준화재입원비(귀원 실제 재입원율) ···········································································································90

유방암 ····································································································································································91

만성폐쇄성폐질환 ···················································································································································91

대장암 ····································································································································································91

관상동맥우회술 ······················································································································································92

병원표준화사망비(HSMR) ······································································································································92

병원표준화사망비(상급종합병원) ····························································································································93

병원표준화사망비(실제사망률) ································································································································93

병원표준화사망비(종합병원) ···································································································································93

병원표준화사망비(지역) ··········································································································································94

혈액투석 ································································································································································94

중환자실 ································································································································································94

의료급여정신과 ······················································································································································95

요양병원 ································································································································································95

충수(퇴원 시 환자상태 이상소견율) ······················································································································96

충수(기본의료서비스 실시율) ·································································································································96

탈장(기본의료서비스 실시율) ·································································································································96

항문(퇴원 시 환자상태 이상소견율) ······················································································································97

약제급여 ································································································································································97

주사제 처방률(전체상병) ········································································································································98

항생제 처방률(급성상기도감염: J00~J06) ············································································································98

근골격계 처방건당 약품목수 ··································································································································98

호흡계 질환 처방건당 약품목수 ····························································································································99

인증 기준 – specialist physician practices ·····································································································112 성‧연령별 SWPE 가중치 ·······································································································································115

Korea Institute for Health and Social Affairs

Payment under the PIP Quality Stream ·······································································································117

Payment under the PIP Capacity Stream ····································································································117

Payment under the PIP Rural support Stream ···························································································118

CQC 필수 기준(fundamental standard) ···········································································································119

평가 결과 ·······························································································································································121

2019/20 QOF 지표 및 점수 ·······························································································································123

LQ2F 질평가 영역 및 지표 ··································································································································130

평가사업별 타평가결과와 타기관 관리정보 인용(연계) 및 활용 현황 ···································································138

국제기구 및 주요 국가들의 의료 질 성과 측정 영역의 비교 ···············································································142

주요 국가에서 P4P 프로그램 시행 범위 ··············································································································155

주요 평가 사업의 평가 목적 분류 ························································································································156

적정성 평가에서 평가자와 피평가자 간 목표 비교 ·······························································································157

통합 평가체계 구축을 위한 기본 방향과 실천 전략 ···························································································159

평가 영역 안 ·························································································································································160

평가사업별 수집자료 및 자료제출시스템 현황 ······································································································166

미국 Hospital IQR 프로그램의 eCQMs 수집지표 ·····························································································170

미국 Hospital QQR 프로그램의 수집지표 ········································································································171

미국 PQRS의 청구자료 기반 지표 ·····················································································································173

미국 Hospital compare 공개 항목 ··················································································································178

Hospital Compare: Data sources ·················································································································178

영역별 가중치 ······················································································································································179

Star rating system의 7개 영역별 지표 ···········································································································179

〈부표 1〉 급성기 뇌졸중 ·························································································································································205

〈부표 2〉 폐렴 ········································································································································································205

〈부표 3〉 관상동맥우회술 ·······················································································································································205

〈부표 4〉 만성폐쇄성질환 ·······················································································································································206

〈부표 5〉 심근경색증 ······························································································································································206

〈부표 6〉 유방암 ·····································································································································································206

〈부표 7〉 대장암 ·····································································································································································206

〈부표 8〉 혈액투석 ·································································································································································207

〈부표 9〉 폐암 ········································································································································································207

〈부표 10〉 위암 ······································································································································································207

〈부표 11〉 의료급여 정신과 ···················································································································································208

〈부표 12〉 7개 질병군 ···························································································································································208

〈부표 13〉 중환자실 ·······························································································································································208

그림 목차

〔그림 1-1〕 연구배경 및 목적 ·················································································································································15

〔그림 2-1〕 평가 통합 및 효율성 전략의 모형 ·······················································································································25

〔그림 2-2〕 가산 지급 산정 방법 ············································································································································37

〔그림 2-3〕 의료질평가 중장기 개선방향 ································································································································49

〔그림 2-4〕 기준의 기본 틀 ···················································································································································52

〔그림 2-5〕 전문병원 지정 추진체계 ·······································································································································61

〔그림 2-6〕 결과종합 위계체계 ················································································································································63

〔그림 2-7〕 지역거점 공공병원 운영평가 시행 절차 ···············································································································64

〔그림 2-8〕 응급의료기관 평가 시행 절차 ······························································································································66

〔그림 2-9〕 연구중심병원지정평가 지정절차 ·························································································································68

〔그림 2-10〕 요양급여 적정성 평가 결과 공개 예시 ··············································································································74

〔그림 3-1〕 Organization of the public sector in Denmark ························································································103

〔그림 3-2〕 Organization of the Health System in Denmark ·····················································································104

〔그림 3-3〕 National goals and local footholds ·············································································································106

〔그림 3-4〕 덴마크 보건의료 시스템의 국가 목표 및 지표 ··································································································108

〔그림 3-5〕 지역별 지표 평가 결과 ······································································································································109

〔그림 3-6〕 CQC 운영 모델 ·················································································································································120

〔그림 3-7〕 의료기관 평가 결과 공개 예시 ··························································································································121

〔그림 3-8〕 NHS digital 홈페이지 - QOF 지표 ················································································································125

〔그림 3-9〕 MIPS Value Pathways ···································································································································128

〔그림 3-10〕 LQ2F 수행 타임라인 ·······································································································································129

〔그림 3-11〕 성과달성 점수 및 성과향상 점수 산출 방법 ···································································································130

〔그림 4-1〕 가치기반 의료시스템 구축을 위한 패러다임 변화와 핵심 동인 ······································································135

〔그림 4-2〕 의료 질 제고 및 국민 건강성과 향상을 위한 종합 평가 체계 구축 틀 ·························································141

〔그림 4-3〕 국가 의료 질 기반 하향식 추진 체계 사례(미국) ····························································································147

〔그림 4-4〕 보건의료자원 신고 일원화 체계 ·························································································································168

〔그림 4-5〕 QualityNet Secure Portal 초기화면 ···············································································································176

〔그림 4-6〕 Hospital Compare 병원별 주요 정보 비교 화면 예시 ···················································································177

〔그림 4-7〕 NHS Digital의 GP별 QOF 지표정보 비교 화면 예시 ····················································································181

Korea Institute for Health and Social Affairs

서 론

제1절 연구배경 및 목적

제2절 연구내용 및 방법

1제 장

제1절 연구배경 및 목적

1. 연구배경

⧠ 우리나라는 2000년부터 요양급여 적정성 평가가 실시되었으며, 최근 질 기반 지불 시스템의 필요성이 강조되면서 의료 질 평가의 중요성이 높아지고 있음.○ 요양급여 적정성 평가는 초기 의료 이용도 중심에서 임상적 질 영역으로, 급성기 질환에서

중증·만성 질환으로 평가 영역이 점차 확대되고 있음.－ 요양급여 적정성 평가는 질적, 양적 발전을 거듭하여 우리나라 의료 질 향상과 국가 차원

보건의료 체계의 성과 평가에 크게 기여함.－ 그러나 만성질환자 및 노인 인구 증가 등에 따른 의료비 지출과 양질의 의료에 대한 국민

의 기대 및 효율적 자원 분배에 대한 필요성이 증가하고 있음.○ 또한 정부의 지속적인 보장성 강화 정책에 따라 이에 상응하는 의료 질 관리와 의료계 수가

인상 요구에 따라 의료 질 기반 비용 지불 시스템 구축 제기 등 평가를 둘러싼 보건의료 패러다임이 변화하고 있음.

⧠ 현재 의료기관 대상의 다양한 평가제도가 분절적으로 시행되고 있어 의료기관의 부담이 증가하고 있고 평가를 관리하는 기관에 있어 비효율이 발생하고 있음.○ 국내에서 의료기관 대상 평가제도는 1981년 병원신임평가를 시초로 현재 요양급여 적정성

평가, 상급종합병원 및 전문병원 지정 평가, 응급의료기관 인증평가 등 다양한 평가가 시행되고 있음. － 그러나 개별 평가마다 평가 목적 및 시기, 평가 지표 등이 상이하기 때문에 정부에서는

그에 대한 재정 소요 및 의료기관 종사자들의 부담 또한 증가하고 있음.－ 특히 기관 간 정보 연계가 미흡하여 효과적인 정책 개발과 지원의 한계로 통합적인 의료

질 관리가 필요함.

⧠ 보건복지부는 ‘제1차 국민건강보험 종합계획(2019-2023)’을 발표하고, 우리나라 건강보험 제도의 추진 방향과 세부 추진 과제 등을 제시한 바 있음.○ 의료 질 평가제도 및 보상 내실화 과제 수행을 위하여 국가 단위성과 목표를 설정·관리하기

서 론

14 요양급여 적정성 평가를 통한 의료 질 관리 및 국민건강 성과 향상 방안 연구

위한 평가제도간 조정·연계 강화 방안의 검토가 필요함.

⧠ 따라서 이 연구에서는 평가제도별 역할의 재정립과 함께 국가 의료 질 제고를 위한 종합평가체계 구축이 필요함.

2. 연구목적

⧠ 연구의 목적은 다음과 같음. ○ 평가의 실효성 제고

－ 시스템 성과(outcome) 지표 중심의 통합 평가 방식으로 전환하되 가치기반 보상 체계와 접목

○ 의료기관 대상 평가제도별 관계 정립－ 통합적 의료 질 관리에 부합하는 의료기관 대상 평가제도별 통합적 관리 방안 모색

○ 국가 의료 질의 통합적 관리를 위한 종합 평가체계 구축 － 통합 거버넌스 정립방안과 그에 따른 적정성 평가의 역할 모색－ 실질적인 국민건강 향상을 위한 신 평가체계 마련

○ 요양급여 적정성 평가를 통한 의료 질 관리 및 국민 건강성과 향상 방안 모색－ 의료 질 평가 모형에 대한 국내·외 현황을 검토하고, 이를 기반으로 국가 의료질의 목표

설정 관리를 통한 종합적인 평가 체계 구축

제1장 서론 15

〔그림 1-1〕 연구배경 및 목적

제2절 연구내용 및 방법

1. 연구 내용

⧠ 연구의 주요 내용은 다음과 같음.○ 국가 의료 질 관리의 의의와 의료 질 평가 모형에 대한 국내외 현황 파악○ 현행 의료기관 대상 평가제도별 역할 및 기능 등 현황 검토○ 의료 질 평가의 자원 공동 활용을 위한 정보 연계 및 업무 공조 방안○ 의료 질 제고를 위한 종합적인 평가체계 구축 방안 제시

2. 연구 방법

⧠ 국내·외 문헌 고찰○ 주요 국가의 의료 질 관리 체계 관련 선행 연구 및 문헌을 통해 시사점 및 한계점 등 파악


－ 미국, 영국, 캐나다, 덴마크, 호주, 영국 등 의료 질 관리 및 평가 체계 조사○ 선행 연구 및 자료를 통해 적정성 평가 관련 국내 제도 및 동향 파악

⧠ 기초 자료 수집 및 분석○ 의료기관을 대상으로 수행되고 있는 각종 평가제도 현황 조사

－ 요양급여 적정성 평가, 의료질평가지원금평가, 의료기관인증평가, 응급의료기관평가, 상급종합병원지정평가, 전문병원지정평가, 연구중심병원지정평가, 수련환경평가

○ 각 평가제도의 방법, 주기, 절차, 지표 등을 비교·분석하여 문제점을 파악－ 이를 통해 국내 현실에 맞는 의료 질 관리 통합적 평가에 대한 방안 마련

⧠ 연구 자문단 구성 및 운영 ○ 연구 전반에 걸쳐 수용성, 신뢰성을 확보하기 위하여 전문가 및 관련 기관, 단체와의 자문회

의 및 토론회를 통해 협의를 진행함.○ 통합적 평가 체계 방안 설정 등 연구 진행 과정에서 관련 전문가 자문 → 연구 결과의 신뢰도

제고 － 운영 목적: 이해관계자 의견 반영과 연구 진행 과정 공유－ 자문단 구성: 의료계, 가입자 단체, 전문가, 평가 기관 담당자, 보건복지부 및 건강보험심

사평가원 실무진, 연구진으로 구성.－ 논의내용

Ÿ (자문회의 1차) 보건의료 평가체계 개편방안 모색Ÿ (자문회의 2차) 환자중심성(Patient Centeredness)을 토대로 한 평가의 틀 Ÿ (토론회) 의료 질 평가 개편 방안

평가 관련 현황 및 문제점

제1절 평가 관련 일반 이론

제2절 의료기관 대상 평가제도 현황 및 문제점

제3절 요양급여 적정성 평가 및 의료 질 평가와 병원 인프라와의 관계

2제 장

제1절 평가 관련 일반 이론

1. 평가의 의미와 원리

⧠ 정책 과정은 정책 형성, 정책 집행, 정책 평가로 이어지는 정책의 순환을 의미함.○ 정책 형성: 정부기관에 의하여 미래에 취할 행동 지침을 결정하는 것○ 정책 집행 : 정책 목표 또는 내용을 구체적으로 달성하는 것

－ 정책 집행은 근본적으로 정치적인 성격을 지니고 있음. 정책 환경과 정책체제의 내부에 있는 다양한 행위자들의 상호 작용 속에서 이루어지게 되므로 당초의 정책 의도와는 상이한 결과를 초래할 수 있음.

－ 정책집행과정은 정책과 정책 결과의 영향을 연결하는 매개변수로 작용함. 정책을 구체적인 사업계획으로 전환시키는 동시에 각종 자원을 동원하여 사업계획을 추진함으로써 현실 세계에 각종 공공재 및 용역을 정책 환경에 산출하고 제공하는 기능을 수행함.

○ 정책 평가 : 특정 정부 사업이 국민에게 미치는 모든 단기, 장기적 효과에 대한 정보를 제공하기 위해 특정 정부 사업을 체계적으로 검토하는 것(Harty, 1973)－ 정책평가란 진행 중인 정부 사업의 목표와 관련하여 그것이 대상 집단에 미치는 효과를

객관적, 체계적, 실증적으로 검토하는 것(nachmias, 1979)－ 정책평가란 정책의 내용, 집행 및 그 결과와 영향 등을 추정하거나 사정 또는 평정하기

위해 체계적 연구 방법들을 적용하는 것(Anderson, 1979)

2. 평가의 필요성 및 목적

⧠ 평가의 필요성○ 평가를 통해 공공제도의 목적을 달성하고, 그 결과로 인해 사회적 비용보다 그 산출이 높다

는 것을 증명할 필요(이상홍, 1984).○ 정책의 수정, 보완, 종료 등 합리적 결정을 내리는 판단을 할 때에 해당 정책의 영향, 운영

결과 등 관련 정보들이 활용○ 집행의 효율성을 제고할 수 있는 전략 및 방안, 기초자료 등을 집행자들에게 제공

평가 관련 현황 및 문제점


⧠ 평가의 목적(Epstein, 1992: 516, 이현주 외, 2002: 47에서 재인용)○ 정부의 책임성 강화○ 유인책, 보상, 제재 등을 통한 동기부여○ 국민 관심 증대와 관료들이 양질의 서비스를 제공할 수 있도록 장려○ 예산 결정에 필요한 자료제공○ 정책결정을 위한 실증적 자료제공○ 정부 프로그램 및 정책의 향상○ 서비스 관리자와 관료간의 소통 향상○ 성과평가지표를 예산·재정 예측모형과 연계하여 수년간 진행될 서비스를 계획 및 공동체 목

표를 설정하는 기초자료를 제공

3. 평가의 원칙

⧠ 평가목적을 구체화하고 정확하게 하여야 함.(정책집행자가 반영할 수 있는 수준)

⧠ 평가는 상충하는 평가가치, 기준의 절충 필요

⧠ 지표체계의 객관성 확보 : 평가자의 주관적 개입 여지 최소화(가능하면 평가대상을 계량적인 수치로 확인할 수 있는 지표 중심으로 개발)

⧠ 민주적 절차와 정책과정의 통합 : 평가자와 피평가자가 평가대상에 대해 정보 공유

⧠ 정책개선 지향적 평가 : 결과가 환류 되어 제도개선에 활용

⧠ 평가가 의미 없는 경우○ 쟁점이 없을 때○ 명확한 가치 지향이 없을 때○ 목적을 달성하기 위한 노력의 지향점에 대해 관련자들 간 의미 있는 정도로 견해가 다를 때○ 평가를 위한 인프라 구축이 안 될 때(인력, 재원 등)

제2장 평가 관련 현황 및 문제점 21

4. 평가의 유형

⧠ 평가의 단계 및 내용에 따른 구분○ 총괄 평가(summative evaluation) : 프로그램 운영이 종료된 후 평가(영향 평가, 산출 평

가 등) : 의료관련 평가는 산출평가에 해당○ 형성평가 (formative evaluation) : 프로그램 운영 도중에 실시 (과정 평가 : 결정과정과 집

행과정으로 구분) － 집행 계획이 정책의 기본방향과 일치되고 있는지 확인－ 업무수행이 잘 조정될 수 있도록 인프라를 설치하는 과정으로 공식기구, 업무의 배분 및

조정이라는 관점에서 평가(공식기구 내 업무의 전문성과 작업량에 따른 적절성, 권위의 배분, 부처 간 조정 및 협력)

－ 과정평가가 수행되는 조건 : 정책결정권자가 프로그램 집행내용에 대해 이해를 증진하고자 할 때, 개선점을 찾고자 할 때, 외부자에 대한 이해 증진이 필요할 때, 시범사업의 성과를 확인하고자 할 때

⧠ 평가의 주체에 따른 구분○ 자체평가 : 제도를 집행하는 조직이 평가 실시○ 내부평가 : 조직체의 다른 구성원이 행하는 평가○ 외부평가 : 제3자가 수행하는 평가

5. 평가 결과의 활용성을 제고하기 위하여

⧠ 평가 계획을 체계적으로 개발하여야 함 : 평가를 수행하는 기관이 피평가자들에게 평가의 내용에 대해서 충분히 이해시키지 못할 수 있음.○ 높은 우선순위를 가진 질문 식별○ 현실 적용여부 : 응답 가능 여부(방법론, 자료의 신뢰성, 평가에 대한 이해, 정확성, 적합성,

비용 등), 계획된 대로 수행할 수 있는지 여부○ 예산, 인력 등 인프라 구축

⧠ 인식 공유 강화○ 다양한 주체의 참여

⧠ 평가 결과의 반영에 대한 모니터링 필요 : 이를 위한 평가관리 체계화 및 전담 조직 신설


제2절 의료기관 대상 평가제도 현황 및 문제점

1. 평가제도 검토배경 및 문제점

가. 검토배경

⧠ 의료기관의 자발적인 의료서비스 질 향상 및 질적 보장을 위해 의료기관을 대상으로 각종 평가제도가 시행되고 있음(이윤태, 2013).○ 우리나라에서는 1981년 대한병원협회에서 도입한 병원신임평가를 시작으로 현재는 요양급

여 적정성 평가, 상급종합병원 및 전문병원 지정 평가, 의료 질 평가, 응급의료기관 인증평가 등 다양한 평가가 시행되고 있음.

⧠ 그러나 이러한 평가 제도들은 각각의 평가 목적과 주기, 평가 지표, 그리고 이를 수탁하는 기관 등이 상이하기 때문에 의료기관의 부담은 증가하고, 평가를 관리하는 기관에 있어서도 비효율이 발생하고 있음. ○ 예를 들어 병원급 이상에서 받는 의료기관인증제도 주기는 4년, 상급종합병원 및 전문병원

지정 제도 주기는 3년으로 주기에 따른 준비 등의 부담 문제가 있음.○ 또한 상급종합병원 등은 동일한 평가 결과에 기반 하여 의료질평가지원금과 동시에 적정성

평가 가산금이 지원되는 이중 지급의 문제가 있음.

⧠ 의료기관 대상의 다양한 평가제도의 평가기준과 보상의 중복을 조정하기 위한 기술적 또는 제도적으로 이를 총괄하는 기전의 필요성이 증대함(강희정, 2017).

나. 의료기관 대상 평가제도의 종합적 문제

⧠ 의료기관 대상 다양한 평가제도에는 다음과 같은 종합적인 문제점이 있음.

⧠ 평가의 목적, 기준, 방법 등에 대한 재정립 필요○ 현행 평가제도는 근본적 목적인 의료의 질 제고와 환자 안전의 향상을 위한 변화를 가져오

지 못하는 것으로 보임(조우현, 2008)○ 대부분의 의료기관 대상 평가제도는 부문별 등급화 결과가 대중에게 공개되는 방식으로 시

행되고 있음. 평가결과 공개로 인해 의료기관 간의 순위 경쟁으로 평가 기간에 과도한 경쟁 또는 불필요한 과잉 의료자원 투자가 초래될 수 있음.


○ 좋은 평가를 받기 위하여 평가 기간에만 잘 하고, 평가가 끝나면 다시 기존 방식으로 돌아가게 되는 ‘눈 가리고 아웅식’ 평가라는 지적이 있음.1)

⧠ 다양한 평가제도가 각각 시행되고 있어 통합적 관리가 필요○ 평가 제도별로 평가 주기가 반기부터 4년까지 다양함.

○ 다양한 평가방법 － 서류 평가, 서면평가, 현지조사, 설문조사, 전산 분석 등

○ 평가제도마다 상이한 수행기관－ 건강보험심사평가원: 요양급여 적정성 평가, 상급종합병원지정평가, 전문병원평가－ 중앙응급의료센터: 응급의료기관평가－ 의료기관평가인증원: 의료기관인증평가－ 국립중앙의료원: 지역거점공공병원 운영평가

⧠ 의료기관의 진료 외적 부담 가중○ 평가들마다 목적과 시기, 지표 등이 제각각 상이하여 의료기관 종사자들은 각각의 평가 준

비를 위해 많은 시간과 노력이 소요되어 업무 과중, 시간 외 근무를 하는 상황이 발생함(김경숙, 2018).

⧠ 여전히 중소병원, 정신병원, 요양병원, 의원 등은 평가 기전에서 소외○ 대형 상급종합병원 또는 전문병원 등에서는 자체적으로 경쟁력을 강화하기 위하여 노력을

하고 있음. ○ 그러나 실제 적절한 인력, 병상 기준을 충족하지 못하는 병원들에 대해서는 평가대상에서

1) 병원신문(2018.3.5.), 의료기관 인증제와 의료 질 평가, http://www.khanews.com/news/articleView.html?idxno=134715

평가 주기 제도

반기 ~ 요양급여 적정성 평가

1년 요양급여 적정성평가, 지역거점공공병원 지정평가, 응급의료기관 평가, 의료질평가지원금, 수련환경평가

3년 상급종합병원 지정평가, 전문병원지정평가, 연구중심병원지정평가4년 의료기관인증평가


제외되어 있는 실정임.

⧠ 강제평가 방식에 따른 의료기관의 수동적 대응과 자발적 질 향상 동기 부재(염호기, 황인선, 2012).

⧠ 평가 후 급여기준 개선, 수가 조정 등 후속 조치 미흡 : 평가 이후 질 향상을 위한 조치 미흡

⧠ 외국에서 사용하는 지표를 차용할 때 의료체계의 차이, 제도의 차이, 문화 환경의 차이를 반영할 필요○ 예) 환자들은 중환자실에서 병동으로 옮기고자 하지만 병원은 재입원율 지표 때문에 입원을

허락하지 않는 경향이 있음.

⧠ FFS가 적용되는 분야와 DRG가 적용된 분야는 평가도 차별화 될 필요○ 과소진료와 과잉진료에 대한 평가기전 필요(재입원율 지표 등)

2. 선행 연구 및 그간의 논의 검토

⧠ 국내에서 의료기관 대상 평가 관련 연구는 주로 의료기관 평가제도와 인증제에 대한 인식이나 성과, 만족도 등을 다루는 연구가 주로 수행되었으며, 평가제도 자체를 개별적으로 연구한 경우는 매우 드문 실정임(김경숙, 2018).

⧠ 김경숙(2018)의 연구에서는 의료기관을 대상으로 시행되고 있는 각종 평가의 지표를 분석하고, 다음과 같이 평가 통합 및 효율화 방안을 제시함.① 전체 평가 통합을 위해 인증전담기관의 조사위원을 대상으로 다양하고 지속적인 교육을 통하여 전문적 평가 수행을 위한 전문성 강화가 필요② 현재 인증 조사위원들이 평가하는데 한계가 있는 특수 전문 영역의 평가지표의 평가를 위하여 외부 전문가를 조사위원에 포함시켜 통합조사팀을 구성하는 방안에 대한 검토③ 외부 전문가로도 평가가 어려운 경우, 청구 자료 등 평가 시행 기관만이 수집가능한 자료가 포함된 경우는 현행 평가체계를 유지하되, 다른 영역의 평가결과와 통합하여 결과를 활용하는 방안 마련○ 각종 평가를 각각 목적에 따라 시행하여 결과를 각각 활용하는 것보다는 국가적 차원에서

모든 평가와 지표를 일제히 검토하여 효율적인 평가 시행과 결과 활용 방안을 마련하는 것이 필요하다고 지적


○ 즉 하나의 체계에 해당되는 의료기관의 모든 것을 아우를 수 있는 통합적 평가 시행과 함께 평가결과를 통합적으로 활용할 방안을 모색할 필요가 있음을 주장

〔그림 2-1〕 평가 통합 및 효율성 전략의 모형

자료: 김경숙(2018). p.38.

⧠ 이와 유사하게 이윤태(2013)의 연구에서도 의료기관 대상 평가 현황을 검토하여 평가체계의 효율화 방안을 제시함.○ 평가체계의 효율화를 위하여 평가지표 측면과 거버넌스 측면이 동시에 진행되어야 하고, 관

련 법규 재개정 및 평가제도 측면의 고려가 필요함을 제안○ 평가 지표 측면: 진료과정, 진료 결과 부분에 있어 단계적 접근이 필요

－ 단기적: 의료기관인증과 요양급여 적정성 평가 중심의 통합－ 장기적: 의료기관 대상 평가의 통합화

○ 관리 및 거버넌스 측면: 의료기관 대상 평가제도와 관련한 의사결정기구를 설립을 제언－ 보건복지부 및 유관부서와의 의견 조정 및 자료 협조－ 평가자료 수집 및 결과 활용－ 평가 관련 주요 정책 심의 등

⧠ 강희정(2018) 연구에서는 각 평가의 기능과 관계성에 대한 연구와 논의를 통해 연계성을 강화할 필요가 있음을 제언하며, 다음과 같은 질 평가 거버넌스 구축 방안을 제시하였음.○ 질 평가 거버넌스 구축: 평가 연계 체계 강화를 위하여 평가 제도별 역할을 분담할 필요

－ 요양급여 적정성 평가: 분야별 의료서비스 질 평가－ 의료기관 인증평가: 구조·과정 중심의 시스템 평가


－ 의료 질 평가: 종합평가 등－ 각 평가 제도별 유사한 지표는 일원화 또는 중복 조정 → 중장기적으로 평가자료 수집 체

계 연계 및 통합을 통해 의료기관 부담을 경감함.－ 자료 제출 시스템 연계 및 통합, 자료 제출 시기 단일화 등

⧠ 최근 연구된 이광수(2019) 연구에서는 ‘의료 질 관련 평가지표 분류체계’의 초안이 발표된 바 있음.2)○ 아래 표와 같이 공개된 분류체계(안)에서는 주 분류영역과 부가 분류영역으로 구분됨.

－ 특히 주 분류영역에서는 모든 지표를 분류할 수 있어야 하며, 상호배타적인 분류가 가능해야함(이를 위해 환자경험, 비용 관련, 복합 항목을 추가)

평가지표 분류체계 초안

구분 분류영역 분류항목

주 분류영역 지표 유형 구조, 의료서비스의 과정, 의료서비스 제공 결과, 복합, 비용 관련, 환자경험

부가 분류영역

의료 질 구성요소 환자안전, 효과성, 환자중심성, 효율성, 연계성, 접근성임상주제 호흡기계, 신장, 내분비계, 화상 등적정성평가 항목 제왕절개, 전산화단층촬영, 혈액투석, 의료급여 정신과 등보건의료서비스 유형 예방 및 만성질환 관리, 급성기치료, 재활치료, 장기요양, 호스피스·완화의료서비스 제공 형태 입원, 외래, 응급평가대상연구 신생아, 소아·청소년, 성인, 노인평가대상기관 상급종합, 종합병원, 병원, 의원, 요양병원, 전문병원, 치과, 한방, 보건기관, 응급의료기관평가자료원 방문조사, 조사표, 행정자료, 설문조사, 기타지표사용현황 예비지표, 정규지표, 모니터링지표, 사용 종료된 지표평가결과활용 가감지급, 가산지급, 수가연계, 지정 평가 제도지표활용제도 요양급여 적정성 평가, 응급의료기관평가, 지역거점공공병원 운영평가, 의료기관인증평가, 상급종합병원 지정평가, 전문병원 지정평가지표관리기관 건강보험심사평가원, 국립중앙의료원, 중앙응급의료센터, 의료기관평가인증원

○ 또한 이 연구에서는 소비자와 공급자를 고려해 의료기관 대상 평가 결과 공개를 개선하고 타 기관과의 연계 방안을 마련해야 함을 제언함.

2) 메디게이트뉴스(2019.9.17.), 적정성 평가 분류체계 개선안에서도 비중 커지는 ‘환자 경험’, https://www.medigatenews.com/ news/3171132669

https://www.medigatenews.com/


－ 특히 의료기관 질 평가공개에 부담을 느끼게 할 수 있는 서열화 된 공개 방식의 개선이 필요3)

○ 나아가 각 평가마다 중복이 있는 항목은 공통화 하되 고유 항목에 대해서는 유지하는 기조로 항목 간 조정 원칙을 설정할 필요가 있다고 제안함. 그리고 데이터 형태를 통일화 하여 전산 자동화 지표 산출이 가능하도록 하고, 이해당사자들이 자발적으로 의료 질 지표들을 구성할 수 있도록 권한을 양도할 필요가 있다고 제언하였고, 이를 운영관리하기 위한 거버넌스 체계 구축도 고려해야 함을 제언함.

⧠ 김윤 외(2015) 연구에서는 여러 기관의 질 평가 프로그램 간 중복을 피하고 유기적으로 연계될 수 있도록 심의조정기구 설치를 제안

⧠ 의료질평가심의위원회(2016.12) 논의에서는 의료기관 대상 평가의 총괄 관리, 법적 기반 마련, 평가지표 개발 체계 등 거버넌스 체계 마련의 필요성을 제기○ 특히 의료기관 평가에 대한 행정적인 부담을 줄이기 위하여 다양한 평가제도의 연계 및 통

합에 대해 중점적으로 검토할 필요가 있음을 제언

⧠ 서제희(2016) 연구에서도 의료기관 대상 평가 제도의 통합 관리를 위해 의료기관평가인증원의 인증 결과와 건강보험심사평가원의 적정성 평가 결과 등 관련 제도 또는 시스템들의 연계도 장기적 차원에서 고려가 필요함을 제언한 바 있음.

3. 의료기관 대상 평가사업 현황

⧠ 현행 의료기관 대상 평가 제도는 요양급여 적정성 평가(항목별로 전체 의료기관)부터 의료 질 평가(종합병원 대상), 상급종합병원 및 전문병원평가 등 동일한 피 평가자들을 대상으로 다양한 평가 제도가 존재함. ○ 현행 의료기관 대상 평가 사업은 크게 인증평가와 의료서비스 및 의료기관의 성과평가, 특

정 기능에 대한 자격 평가로 분류○ 주요 의료기관 대상 평가제도의 주요 내용을 살펴보면 다음 표와 같으며, 각 평가 제도별로

평가 영역, 대상, 방법, 자료 산출 기간이 모두 상이

3) 메디게이트뉴스(2019.11.26.), “적정성 평가 지표 중 ‘환자 경험’ 비중 낮아... 등급별 서열화된 공개방식 개선해야. http:// medigatenews.com/news/369328670


의료기관 대상 평가사업 현황

no. 구분 평가명 평가근거 평가주체 평가위탁 평가방법평가자료산출기간

인센티브기관별

평가결과 공개

1인증평가

의료기관인증평가 의료법 58조 보건복지부 의료기관평가인증원서면평가, 현지조사 4년 - O

2 (질) 성과 평가

요양급여적정성평가 국민건강보험법의료급여법

건강보험심사평가원

- 서류평가 일부 3개월~1년

가감지급,만성질환 인센티브

O

3 지역거점공공병원 운영평가

지방의료원의 설립 및 운영에 관한 법률 21조

보건복지부 국립중앙 의료원

서면평가, 현지조사

1년 국고지원 시설장비

보강사업 지원-

4 응급의료기관평가 응급의료에관한법률17조

보건복지부 국립중앙 의료원

중앙응급의료센터

서면평가, 현지평가

1년 수가 (응급의료수가)

O

5 의료질평가지원금 평가

의료질평가지원금 산정을 위한 기준

보건복지부 건강보험심사평가원

서면평가 1년 수가(입원료, 외래진찰료)

-

6 전문병원 의료질평가지원금

평가

의료질평가지원금 산정을 위한 기준


서면평가 1년 수가(입원료, 외래진찰료)

-

7 자격 평가

상급종합병원 지정평가

상급종합병원의 지정 및 평가에 관한 규칙 3조



3년 수가(종별가산) O

8 전문병원 지정평가 전문병원의 지정 및 평가 등에 관한 규칙 3조



3년 수가(전문병원 관리료)

O

9 연구중심병원 지정평가

보건의료기술진흥법 15조

보건복지부 한국보건산업진흥원


3년 R&D예산 지원 O

10 수련환경평가 전공의의 수련환경 개선 및 지위향상을 위한

법률 제14조

보건복지부 대한병원협회 서면조사, 현지평가

1년 수련규칙 이행여부에 따른 과태료 부과, 인력(전공의 정원 책정)

-


평가사업별 평가영역 및 대상

구분 평가영역 평가대상

요양급여적정성평가

14개 영역, 35개 항목, 61개 세부항목(영역: 정신건강영역, 진료영역, 급성질환,

만성질환, 암 질환, 약제, 정액수가, 중환자실, 진료량, 일반질, 감염질환, 환자중심의료, 환자안전,

치과)

항목별 해당되는전체 의료기관

의료질평가지원금5개 영역, 58개 지표

(영역: 의료질과 환자안전, 공공성, 의료전달체계, 교육수련, 연구개발)

종합병원

의료기관인증평가4개 영역, 91개 기준, 520개 조사항목

(영역: 기본가치 측면, 환자진료 측면, 조직관리 측면, 성과관리 측면)

병원급 이상

상급종합병원지정평가

6개 영역(영역: 진료기능, 교육기능, 인력·시설·장비, 질병군 별 환자구성비율, 의료서비스 수준, 의료 권역별

소요병상 충족도)10개 진료권역별로 상급종합병원

지정 신청한 상종병원

전문병원지정평가7개 영역

(영역: 환자구성비율, 진료량, 필수진료과목, 의료인력, 병상, 의료질, 의료서비스 수준)

종합병원, 병원, 요양병원, 한방병원

연구중심병원지정평가 연구 기본역량 5개, 연구역량 8개

종합병원, 병원, 요양병원, 한방병원

지역거점공공병원지정평가

4개 영역, 62개 평가기준(영역: 양질의 의료, 공익적 보건의료서비스, 합리적

운영, 책임운영)지방의료원, 적십자병원

응급의료기관평가7개 영역, 112개 지표

(영역: 필수, 안전성, 효과성, 환자중심성, 적시성, 기능성, 공공성)

전국 응급의료기관(권역·전문·지역응급의료센터,

지역응급의료기관)

수련환경평가6개 영역, 11개 부문

(영역: 병원운영체계, 수련지원체계, 수련규칙이행평가, 수련전문과목, 인턴수련환경,

전공의만족도조사)인턴 및 레지던트 교육을

담당하는 수련병원

가. 평가대상

⧠ 평가별 대상 기관(종별)을 살펴보면, 적정성 평가는 (평가항목마다 조금씩 그 대상이 상이하나) 전반적으로 모든 의료기관을 포괄, 그 외 성과평가 사업들은 주로 종합병원급 이상 의료기관이 해당○ 민간병원과 요양병원, 의원의 질 관리 기전은 요양급여적정성평가만이 의무사항에 해당


의료기관 대상 평가사업 현황: 평가대상 기관

구분 평가명 의무/자발평가대상기관(자격기관)

상급종합병원

종합병원 병원 요양병원 의원

인증평가 의료기관인증평가 자발 O O O O

(질) 성과 평가

요양급여적정성평가 의무 O O O O O

지역거점공공병원 운영평가 의무 O(공공) O(공공) O(공공)

응급의료기관평가 의무 O O

의료질평가지원금 평가 자발 O O

전문병원 의료질평가지원금 평가 자발 O O

자격 평가

상급종합병원 지정평가 자발 O O

전문병원 지정평가 자발 O O

연구중심병원 지정평가 자발 O O O

수련환경평가(수련병원 지정평가) 의무 O O

의료기관인증평가 참여기관 수(2017년 말 누계)

구분 인증 조건부 불인증 계 전체 참여율

계 337 3 3 343 2,353 14.58 상급종합병원 43 　　 43 43 100.00

종합병원 173 1 1 175 301 58.14 병원 121 2 2 125 1,466 8.53

치과병원 16 　　 16 231 6.93 한방병원 22 　　 22 312 7.05

*인증기관 중 중복되는 재인증기관은 누계실적에서 제외*출처: 의료기관평가인증원(2018), 2017년도 사업실적보고서; 2017년 건강보험 통계연보(국민건강보험공단)

의료질평가지원금 평가 참여 기관 수(2019년 평가)

구분 참여기관 수 전체 기관 수 참여율

계 337 353 95.47

상급종합병원

42 42 100.00

종합병원 295 311 94.86

*출처: 국민건강보험공단, 2018년 건강보험 통계연보, http://www.docdocdoc.co.kr/news/photo/201908/1071771_1130382_2658.jpg


나. 평가영역과 지표 유형

⧠ 요양급여적정성평가, 지역거점공공병원 운영평가, 전문병원 지정평가 및 전문병원의료질평가지원금 평가의 경우 재입원율, 합병증 발생률 등의 결과지표 활용 중, 단 요양급여 적정성 평가의 일반 질 지표 평가(위험도표준화사망비, 재입원비)는 종합병원 이상을 대상으로 하고 그 외 항목들은 결과지표 활용 수준이 상이함.○ 결과적으로 전문병원을 제외한 민간병원급 이하에 대한 의무적 결과지표 적용은 매우 낮은

수준구분 평가명 의무/자발 평가대상

지표 유형

구조 과정 결과

인증평가 의료기관인증평가 자발

상급종합병원

종합병원

병원

요양병원

(질) 성과 평가

요양급여적정성평가 의무

상급종합병원

종합병원

병원

요양병원

의원

지역거점공공병원 운영평가 의무 공공병원

응급의료기관평가 의무상급종합병원

종합병원

의료질평가지원금 평가 자발상급종합병원

종합병원

전문병원 의료질평가지원금 평가 자발 전문병원

자격 평가상급종합병원 지정평가 자발

상급종합병원

종합병원

전문병원 지정평가 자발종합병원

병원

수련환경평가(수련병원 지정평가) 의무상급종합병원

종합병원

⧠ 결과적으로 종합병원급 이상의 급성기 질환, 구조 및 과정 지표 위주의 평가 진행으로 국민건강 성과 향상에 한계 직면○ OECD에 보고되는 HCQI지표를 통해 국가 의료 질 수준을 영역별로 살펴보면, 평가체계에

서 지속적으로 관리 대상이 되었던 급성기 진료와 일차의료 영역에서 과정지표(당뇨병 지질저하제 처방률, 항고혈압제 처방률 등)는 비교적 좋은 수준을 보임 ⇒ 지금까지 요양급여 적정성 평가 등 주요 평가제도의 성과

○ 반면 일차의료의 결과(입원율)와 항생제 처방, 정신보건 영역에서는 OECD 평균보다 낮은 상황 ⇒ 평가의 의도하지 않은 결과(teaching to test), 결과지표의 활용 필요성과 항생제 지표의 지속적 관리 필요성을 보여줌


자료: 김경훈, 선정연(2018), p.56, 표 8


4. 주요 평가사업별 개요 및 그간의 논의사항

가. 요양급여 적정성 평가

⧠ (평가목적) 평가 결과 정보 공개를 통해 국민의 의료기관 선택권 보장, 요양기관에 평가결과를 제공하여 자율적 진료행태 개선을 통한 의료서비스 질 향상 유도, 정부의 보건의료 정책 지원 등

⧠ (평가방법) 심평원 청구자료와 요양기관 현황자료 및 의무기록자료, 행정안전부의 주민등록 전산자료 등이 평가에 이용

⧠ (수집방법) 수집된 행정자료만을 이용하거나 행정자료와 조사표를 함께 이용하는 방법이 있으며, 조사표는 요양기관에서 제출한 E-평가 자료 제출 시스템을 통해 수집

⧠ (평가절차) 평가후보 항목 선정 및 예비평가, 연간 평가계획 수립, 평가세부계획 공개, 평가 수행, 평가결과 분석 및 적용, 평가결과 통보 및 공개, 이의 신청의 단계의 절차를 걸쳐 수행

요양급여 적정성 평가 절차

단계 절차 내용

1 평가후보 항목 선정 및 예비평가신규 평가지표 개발국민, 의료계 등 이해관계자의 평가항목 제안

평가 기획단 검토 및 의료평가조정위원회 심의

2 연간 평가계획 수립평가계획 공개 의료평가조정위원회 심의, 복지부 승인

3 평가세부계획 공개평가지표, 평가기준, 평가방법 등 평가 2개월 전 공개

4 평가 수행자료조사 및 분석, 신뢰도 점검 등 필요 시 자료 청구(조사표 등)

5 평가결과 분석 및 적용 의료평가조정위원회 심의 후 복지부 보고

6 평가결과 통보 및 공개 가감지급 적용 시 복지부 승인 및 국민건강보험공단 통보7 이의신청 -


⧠ (평가프레임) 국가 수준 의료 질 기반의 6개 영역과 18개 목표로 구성됨.

요양급여 적정성 평가 프레임

영역 목표

1.환자안전 (Safety)1) 의료관련감염 발생 감소2) 의료관련감염 이외 영역의 환자안전사고 감소3) 적절한 의료서비스 제공으로 환자안전 향상

2. 효과적인 진료 (Effectiveness)

1) 주요 입원질환에서의 근거기반 의료서비스 제공2) 일차진료에서의 근거기반 의료서비스 제공3) 계획되지 않은 재입원 감소4) 주요 질환으로 인한 사망 감소5) 모성 및 신생아·아동의 건강 향상6) 노인 건강 향상7) 정

요양급여 적정성 평가를 통한 의료 질 관리 및 국민건강 성과...

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