의료행위 원가와 보상 정책에 기초한 상급종합병원 진료량 관리 : 의료전달체계 확립을 중심으로

Despite of policy for controlling medical demand by charging expensive medical cost and high copayment rate, the not severe outpatient visit for tertiary hospital has been increasing. This is the contradiction of the function of tertiary hospital which has a role to take care of severe inpatients and to do research based on healthcare delivery system. When medical treatment is delivered, the hospital bill is made from RVS and a hospital type remuneration rate. This billing is to give a financial reward on the investment made by hospital to take care of a patient with critical or serious condition. But there are critics that not only the ground of a different remuneration rate are ambiguous but also it fails to reflect the quality of care and actual medical cost incurred. This paper suggested supply side policy that could induce the behavioral adjustment by changing a financial rewards instead of imposing restriction on patient’s accessibility or budget burden. This paper dealt the conceptual framework of incentives so as to mitigate the cohesion of outpatient to tertiary hospital and to reallocate medical resources by regaining the inpatient focused hospital. For this purpose first above all, the data related to the increase of medical revenue of tertiary hospital and family doctor were reviewed. The introduction of the family doctor should only be considered in the long term plan. To find an applicable short term way within current medical setting, physician work based on clinical concept, medical expense for practice, and medical cost accounting are reviewed. To set a reasonable schema, medical cost calculation is very important factor for determining RVU. A RVU of specific medical treatment shows cost coverage ratio and revenue of medical treatment. The revenue of hospital depends on the type of practice, the change of RVU, remuneration and incentives. So the management of outpatient volume needs the adjustment of these factors. It can be thought that if cost coverage ratio is lower than other practice, the frequency of other practice will be increased and if fees for outpatient are higher than fees for inpatient service, the volume for ambulatory care will be increased. To manage outpatient volume of tertiary hospital, five alternatives are considered. Firstly, high copayment rate imposed to outpatient is excluded because there exists a high limitation for low income family to visit hospital. Patient oriented policy should be supplemented by healthcare provider oriented policy. Secondly, if hospital’s medical revenue increases rapidly because of volume effect, an introduction of the floating conversion factor can be considered for restricting the rapid growth of outpatient revenue. Thirdly, the reconsideration of a consultation fee is proposed to correct the possible imbalance of RVU between healthcare type. Fourthly, this paper suggested new remuneration policy for controlling outpatient patient visit for a tertiary hospital. The current single hospital-type based incentive system was introduced to repay a initial investment by hospital and to balance the cost recovery rates between hospital type. But the current single hospital-type incentive system should be divided into the outpatient and inpatient type or the non-severe and severe patient-type based on ambulatory care sensitive conditions. Finally this paper recommended the incentives based on the quality of medical care and the managerial efficiency of resource utilization be introduced. Quality oriented reimbursement to reflect demands of value-based care can be achieved by the new adjusted remuneration rate and two newly introduced incentives. It is expected that the conceptual framework which is based on medical cost proposed in this paper could not only be able to reflect the current healthcare reform but also stimulate the behavioral change and attain efficient medical cost management. The limitation of this paper is expected to be cured in the next research which can be developed based on the concepts proposed in this paper. The role of accountant and academic scholar are much more anticipated than before for the cost analysis and setting cost calculation system to get the proper medical cost for healthcare policy setting. So collaboration of both professional can find the way to normalize the current entangled medical delivery system and to control the increase of non severe outpatient to the tertiary hospital which should focus on taking care of the inpatients and medical research.