의료급여 사례관리 고위험군과 선택의료급여기관 적용군의 의료이용 비교

Abstract

본 연구는 전북 J시 W구의 의료급여 1종 수급권자를 대상으로 의료급여 사례관리 고위험군과 선택의료급여기관 적용군의 의료이용을 비교, 분석한 연구이다. 연구 대상은 전라북도 J시 W구의 사회보장정보시스템에 등록된 의료급여 1종 수급권자 중 2014년 1월 1일부터 2014년 12월 31일까지 의료급여 사례관리 중재를 실시한 사례관리 고위험군 149명과 2014년에 선택의료급여기관을 지정한 적용군 416명을 최종 선정하여 분석하였다. 본 연구의 종속변수는 의료이용으로 의료이용의 변수에는 실급여일수, 외래일수, 입원일수, 투약일수, 진료비(기관부담금), 약국을 제외한 의료급여기관수 등 6개이며 국민건강보험공단 의료급여통계시스템상의 개인별 질환별로 구축된 자료를 활용하였다. 수집된 자료는 SPSS/win 14.0통계 패키지를 이용하여 실수와 백분율, 평균과 표준편차, X²-test와 t-test 를 사용하여 분석하였으며 의료이용의 차이를 보기 위한 Wilcoxon signed-rank test 및 의료이용 변화에 차이가 있는 지를 살펴보기 위해 Mann-Whitney U test와 Kruskal wallis 검정을 실시하였다.

연구결과를 요약하면 다음과 같다. 첫째, 연구대상자인 사례관리 고위험군의 일반적 특성은 연령이 30대 이하가 34.9%, 40대 26.2%, 50대 20.1%, 60대 이상 16.1%로 나타났고 여성이 61.1%, 학력은 중학교졸업 이하의 학력이 87.9%였으며 미혼이거나 이혼, 사별인 결혼형태가 69.8%, 장애가 있는 대상자가 43%였고 의료급여 유형은 91.3%가 기초생활수급자로 조사되었다. 선택의료급여기관 적용군의 일반적 특성은 사례관리 고위험군과 비슷한 구성분포를 보여 두 군 간의 유의미한 차이는 없었다. 둘째, 연구대상자인 사례관리 고위험군의 질병특성에서는 중증과 희귀질환의 경우 21.5%의 유병률로 선택의료급여기관 적용군과 비슷한 구성분포를 보여 두 군 간의 유의미한 차이는 없었으며 중복응답이 많은 고시질환과 기타질환은 각 질환별로 유병률의 차이는 있으나 비슷한 순위의 복합질환을 가지고 있었다. 셋째, 사례관리 고위험군의 일반적 특성에 따른 의료이용 비교에서 실급여일수 및 외래일수와 투약일수는 연령에 따른 의료이용에 차이가 있었으며 40대가 가장 많이 감소하였고, 입원일수는 배우자 유형에 따른 배우자가 있는 대상자가 더 감소하였다. 진료비(기관부담금)는 남성, 배우자가 있는 대상자, 중증 및 희귀질환이 있는 대상자가 더 감소하였고 의료기관이용수의 의료이용은 배우자가 있는 대상자와 40대 연령에서 가장 많이 감소하였다. 선택의료급여기관 적용군의 의료이용 비교에서 실급여일수는 대상자 유형에 따라서만 유의미한 변화를 보여 국가유공자는 감소한 반면 기초생활수급자는 증가하였고 입원일수, 외래일수, 투약일수는 장애유무에 따라서만 변화를 보여 장애가 없는 대상자의 입원일수가 더 증가하였고 외래일수와 투약일수는 더 감소하였다. 진료비(기관부담금)와 의료기관이용수에서는 모든 대상자 특성에서 유의미한 변화를 보이지 않았다. 넷째, 사례관리 고위험군은 중재 전에 비해 실급여일수, 입원일수, 외래일수, 투약일수, 진료비(기관부담금), 의료기관이용수에서 모두 통계적으로 유의미한 감소를 나타내었고 선택의료급여기관 적용군은 입원일수와 진료비(기관부담금)에서만 유의미한 증가를 보였으며 다른 의료이용에서는 유의미한 변화가 없었다.

결론적으로 의료급여 사례관리 고위험군은 급여일수, 입원일수, 외래일수, 투약일수, 진료비(기관부담금), 의료기관이용수에서 모두 통계적으로 유의미한 감소를 나타내어 사례관리가 의료이용의 감소에 효과가 있었으며 선택의료급여기관 적용군의 경우 외래일수와 의료기관이용수에서만 의료이용에 감소를 보였고 사례관리 고위험군 보다 감소효과가 적었으며 의료이용의 감소에 유의미한 효과가 없이 오히려 입원일수 및 투약일수와 진료비(기관부담금)가 증가한 것으로 조사되었다.

|The study was conducted to compare health care utilization between in high risk group case management of Medicare and the designated doctor system group in W-gu, J-city, Jeonbuk, South Korea. Total of 149 high risk people who had received case management of Medicare and 416 people in the designated doctor system were included and analyzed in the current study. Data was collected from the Social Security Information System of W-gu, J-city, Jeonbuk. Health care utilization was measured in 6 domains; – actual medical use day, outpatient day, inpatient day, medication day, medical expenses(paid by organizations), and the number of medical institutions that were used such as hospital or clinics except for drug store. The individual and disease-specific data of Medical Aid Comprehensive Information Support System of National Health Insurance Corporation were utilized in this study. The collected data was analyzed by using the actual number and percentage ratio which utilize the SPSS/win 14.0 statistical package, mean and standard deviation, and X²-test and t-test. In addition, Wilcoxon signed-rank test was conducted to see the difference of health care utilization, Mann-Whitney U test and Kruskal wallis test also were conducted in order to see if there are difference of health care utilization change The research findings can be summarized as follows; First, as to the general characteristics of high risk group case management, 34.9% of them was aged 30s or under; 26.2%, in their 40s; 20.1%, in their 50s; and 16.1%, in their 60 s or over. 61.1% were females. Concerning their educational background, 87.9% of them graduated middle school or under. As for the marital status, 69.8% were found to be not married, divorced or bereaved. 43% had some physical disability. As for the medical aid type, 91.3% were basic living beneficiaries. The designated doctor system group showed similar characteristics to the high risk group case management without a significant difference. Second, concerning the disease characteristics, 21.5% of the high risk group showed serious cancer or rare diseases, showing a similar composition to the designated doctor system group to represent no significant difference. There were many multiple answers regarding notice diseases and etc diseases. Although the prevalence rates of each of them had a difference, their complicated diseases were ranked in similar orders. Third, in the comparison of health care utilization depending upon the general characteristics of the high risk group case management, actual medical use day, outpatient day and medication day showed differences in health care utilization according to ages. Those in their 40s showed the largest reduction among all age groups. As for the inpatient day, those with a spouse showed a larger reduction than those without. Medical expense(paid by organizations) showed a larger reduction in male participants, those with a spouse, and those with serious cancer or rare diseases. Health care utilization concerning the number of medical institutions, decreased the largest in those with a spouse and in their 40s. In the comparison of health care utilization with the designated doctor system group, actual medical use day showed significant change only according to the type of the participants. National merit showed reduction whereas the basic living beneficiaries showed increase. Inpatient day, outpatient day and medication day showed increasing changes only depending upon the status of physical disability. The participants without a physical disability showed increasing inpatient day while their outpatient and medication day decreased. The medical expense (paid by organizations) and the number of medical institutions showed no significant change in all characteristics of the participants. Forth, the high risk group case management showed statistically significant decrease in all of the items – actual medical use day, inpatient day, outpatient day, medication day, medical expense (paid by organization) and the number of medical institutions, compared to the status before the intervention herein. The designated doctor system group showed significant increase only inpatient day and medical expenses(paid by organizations) while showing no significant change in any other dimensions. In conclusion, the high risk group case management was found to have statistically significant reduction in all of the domains - actual medical use day, outpatient day, inpatient day, medication day, medical expenses(paid by organizations), the number of medical institutions, demonstrating the effectiveness of case management on reducing health care utilization. The designated doctor system group showed reduction only outpatient day and the number of medical institutions. The designated doctor system group was found to experience less effectiveness than the high risk group case management and receive no significant effect in reducing health care utilization while rather experiencing increasing inpatient day, medication day and medical expense(paid by organizations); The study was conducted to compare health care utilization between in high risk group case management of Medicare and the designated doctor system group in W-gu, J-city, Jeonbuk, South Korea. Total of 149 high risk people who had received case management of Medicare and 416 people in the designated doctor system were included and analyzed in the current study. Data was collected from the Social Security Information System of W-gu, J-city, Jeonbuk. Health care utilization was measured in 6 domains