건강보험의 관리체계 개선방향 = Reform Measure on Financing Management of Social Heath Insurance in Korea

다국어 초록 (Multilingual Abstract)

This report suggests an effective financing management of social health insurance(SHI) to meet both access to basic care and long-term sustainability, and an efficient administration of SHI related organizations.The financial soundness had been once collapsed since the introduction of separation policy of prescribing and dispensing, and now the financial balance has been almost recovered in the end of 2004. However, the future of financing cannot be optimistic against the planned expansion of service coverage, income growth, and rapid ageing. The effective insurance coverage is estimated 52 percent of a whole medical cost, but the ruling party announced the coverage should reach 70 percent till 2008. If this plan would be realized, the contribution rate will be expected to rise from 4.21 percent of income up to 7.61% in 2020. When the government subsidy to SHI is abolished in 2006 as scheduled in the Special Act, the contribution rate will be 8% in 2020. These projections imply SHI must prepare a well designed financing strategy.The principle for a good financial management is thought to be a well designed combination of a comprehensive access to care, a protection against catastrophic diseases, and an effective control of health care cost. To accomplish this, the Guaranteed Health Care Package(GHCP) should be established for the basic protection of patients, and the total expenditure accruing from GHCP must be controled for the affordable financing. We suggest the total expenditure should be contained according to `sustainable growth rate` which is calculated based on the macro-economic growth rate, medical price inflation, changing structure of ageing, and expansion of service coverage, and etc. This kind of cost control mechanism could be successful with the control of increasing provision of doctors and beds and the control of service quality.Considering a constrained resource in the short stage, a major risk such as catastrophic and disastrous chronic care should be covered, while a minor risk would be recommended to depend on the hand of patients` responsibility like coinsurance and `deductible`. On the other hand, we suggest the government support the private health insurance take a role to supplement the non-GHCP services, and patients to buy `Medical Saving Account(MSA)` to prepare in advance against unexpected medical costs.Tax financing should be reviewed as an alternative. Tax financing would be a solution against the conflict of equitable burden between corporate workers` insurance and residence-based insurance, and an answer to solve the under-reporting problem of income in a large informal sector. However, negative side effects of tax financing should be cautiously reviewed. Moreover the transition from insurance financing to tax financing means that SHI is managed in the framework of government budget, in which the flexibility of financial management will tend to be harmed.Another suggestion in the way of financial management is the introduction of `managed competition` under the rule of centralized financing. A reform of administrative system would be recommended such that as the single insurer, National Health Insurance+ Corporation(NHIC) takes a role of subscription, financing, claim review and reimbursement. The evaluation for medical services should be separated and independently operated like the organization such like Center for Medical Services(CMS) in USA. Furthermore, we recommend to consider to establish a Bureau of National Health Service as a government agency, and let the National Tax Agency collect health insurance premium or tax. Especially the electronic networking between insurer and providers must be built, and a smart card must be possessed by each policy holder, through which the transparency of medical informations and the efficiency of management will be improved.