정부가 지역·필수의료 강화를 위해 연 3조6천억원의 건강보험 재정을 투입하기로 하면서 휴일·야간 응급수술 수가를 대폭 강화한다.

임신·분만과 관련된 수술·처치의 수가를 높이고 고위험분만 제왕절개 수가 가산을 신설하는 한편, 소아 일차진료와 소아 중증·응급수술에 대한 보상도 강화한다.

보건복지부는 25일 건강보험정책심의위원회를 열어 이러한 내용을 담은 '건강보험 수가 구조 혁신방안'을 확정했다고 밝혔다.

수가는 정부가 건강보험 재정에서 의료기관에 지급하는 의료서비스의 대가다. 그간 응급수술이나 고위험분만 등의 경우 수가가 낮은 반면 의료진의 당직 부담이나 의료분쟁 가능성이 높아 기피현상이 벌어지며 수가 개편 필요성이 지적돼 왔다.

복지부는 우선 응급진료 강화를 위해 종합병원 이상 의료기관의 중증 수술·시술 수가를 20% 높이기로 했다.

심뇌혈관 등 응급 관련 수술·시술, 암 등 중증 수술, 복합골절이나 선천성 기형 관련 시술처럼 난도가 높고 숙련된 인력 투입이 많은 1천600가지 수술·시술이 대상이다.

휴일·야간에 권역응급의료센터를 통해 응급으로 입원한 환자에 대해서는 수술 수가를 5.5배로 상향해 같은 중증 수술이어도 야간·휴일과 응급상황의 보상 수준을 높여 중증응급 환자에 대한 최종치료 역량을 강화한다.

종합병원 이상 의료기관의 전신마취 수가 수준은 현재보다 50% 상향하는 등 최종치료에 수반되는 행위에 대한 보상도 대폭 확대한다.

고위험 산모·신생아를 위한 모자의료 보상과 소아진료에 대한 보상도 강화한다.

지금까지는 분만에 대해서는 최대 176만원의 공공정책수가가 지원됐는데 모든 분만에 일률적으로 적용돼 고위험 분만과 조산아 치료에는 부족한 수준이라는 지적이 제기됐다.

이에 복지부는 산모 중증도, 신생아 상태(주수, 체중 등), 지역 등을 종합적으로 고려해 중증모자센터와 권역 모자센터 등을 중심으로 보상을 대폭 조정한다.

특히 신생아가 중환자실에서 치료받는 기간에 대해서도 가산수가를 신설해 고위험 분만과 신생아 중환자를 치료하는 모든 과정에 대한 보상을 강화한다는 방침이다.

이에 따라 28주 미만 조산아를 중증모자센터에서 분만한 경우 기본 분만 수가에 약 440만원을 가산하고, 비수도권 모자센터의 경우에는 약 506만원을 가산한다.

신생아 중환자의 경우 24주부터 28주까지 약 4주간 신생아 중환자실에서 치료할 경우 4주간은 기본 입원료(1일당 약 96만원)에 120%(1일 당 115만원)의 가산금을 추가해 입원료를 2.2배 수준으로 높이고, 비수도권 모자센터의 경우는 150%(1일 당 144만원)의 가산금을 추가해 입원료를 2.5배 수준으로 보상한다.

기본적인 임신·분만 수가 수준도 20% 상향하고, 고위험 분만에 대해서는 자연분만과 제왕절개 모두 일반 분만의 100∼200% 수가를 가산한다.

소아에 대한 일차진료를 강화하기 위해 진찰료 가산 연령을 현행 0∼5세에서 0∼7세로 상향하고, 가산 수준도 높인다.

또한 종합병원 이상에서 중증·응급 수술 1천600가지의 수가를 20% 상향하는 과정에서, 6세 미만 소아 수술은 난도와 위험도가 높은 점을 고려해 50%를 추가로 가산한다.

소아중환자실(상급종합병원 및 소아중환자실이 있는 종합병원 대상) 중증 처치 보상은 50%(비수도권과 수도권 취약지는 100%) 가산하고, 소아·청소년 야간 진료를 담당하는 달빛 어린이병원(현재 151곳)의 경우 소아전문관리료를 신설(약 5만원)하는 한편, 소아 인구가 적은 시군구의 121개 달빛어린이병원에는 야간진료 수가를 30%를 가산한다.

cindy@yna.co.kr

Sambil pemerintah memutuskan untuk mengalokasikan 3,6 triliun won dari anggaran asuransi kesehatan per tahun untuk memperkuat layanan medis regional dan penting, tarif bedah darurat di hari libur dan malam hari ditingkatkan secara drastis.

Tarif untuk operasi dan prosedur terkait kehamilan dan persalinan akan ditingkatkan, dan tunjangan tarif baru untuk operasi caesar persalinan berisiko tinggi akan didirikan, sementara kompensasi untuk perawatan primer anak-anak dan operasi anak-anak yang berat dan darurat juga akan diperkuat.

Kementerian Kesehatan dan Kesejahteraan Sosial mengumumkan bahwa pada tanggal 25, ia menetapkan 'Rencana Inovasi Struktur Tarif Asuransi Kesehatan' yang memuat konten ini melalui komite kebijakan asuransi kesehatan.

Tarif adalah kompensasi untuk layanan medis yang dibayarkan oleh pemerintah dari anggaran asuransi kesehatan kepada fasilitas medis. Selama ini, dalam kasus operasi darurat atau persalinan berisiko tinggi, tarifnya rendah sementara beban on-call staf medis atau kemungkinan sengketa medis tinggi, menyebabkan fenomena penghindaran, dan kebutuhan akan revisi tarif telah ditunjukkan.

Kementerian Kesejahteraan memutuskan untuk meningkatkan tarif untuk operasi dan prosedur berat di fasilitas medis tingkat rumah sakit umum atau lebih tinggi sebesar 20% untuk memperkuat layanan darurat.

Sasarannya adalah 1.600 jenis operasi dan prosedur dengan tingkat kesulitan tinggi dan memerlukan banyak tenaga terampil, seperti operasi dan prosedur terkait darurat jantung dan pembuluh darah, operasi berat seperti kanker, dan prosedur terkait fraktur kompleks atau cacat bawaan.

Untuk pasien yang dirawat darurat melalui pusat perawatan darurat regional selama hari libur dan malam hari, tarif operasi meningkat 5,5 kali lipat, meningkatkan tingkat kompensasi untuk situasi malam, hari libur, dan darurat bahkan untuk operasi berat yang sama, memperkuat kapasitas pengobatan akhir untuk pasien darurat berat.

Tingkat tarif anestesi umum di fasilitas medis tingkat rumah sakit umum atau lebih tinggi ditingkatkan 50% dari saat ini, dan kompensasi untuk tindakan yang menyertai pengobatan akhir juga diperluas secara signifikan.

Kompensasi untuk perawatan ibu-anak untuk ibu hamil berisiko tinggi dan bayi baru lahir, serta kompensasi untuk perawatan anak-anak juga akan diperkuat.

Sejauh ini, untuk persalinan, tarif kebijakan publik maksimum 1,76 juta won telah didukung, tetapi diterapkan secara seragam untuk semua persalinan, dan telah dikemukakan masalah bahwa itu tidak memadai untuk persalinan berisiko tinggi dan perawatan bayi prematur.

Menanggapi hal ini, kementerian kesejahteraan menyesuaikan kompensasi secara signifikan, berpusat pada pusat ibu-anak berat dan pusat ibu-anak regional, sambil mempertimbangkan secara komprehensif tingkat keparahan ibu, kondisi bayi baru lahir (minggu gestasi, berat badan, dll.), dan wilayah.

Khususnya, untuk periode ketika bayi baru lahir menerima perawatan di unit perawatan intensif, tarif tambahan baru akan didirikan, dan kebijakan adalah untuk memperkuat kompensasi untuk semua proses pengobatan persalinan berisiko tinggi dan pasien bayi baru lahir yang kritis.

Sesuai dengan ini, ketika bayi prematur kurang dari 28 minggu dilahirkan di pusat ibu-anak berat, sekitar 4,4 juta won ditambahkan ke tarif persalinan dasar, dan untuk pusat ibu-anak di luar wilayah Seoul, sekitar 5,06 juta won ditambahkan.

Untuk pasien bayi baru lahir yang kritis, jika dirawat di unit perawatan intensif bayi baru lahir selama sekitar 4 minggu dari minggu ke-24 hingga ke-28, selama 4 minggu, 120% (sekitar 1,15 juta won per hari) ditambahkan ke biaya rawat inap dasar (sekitar 960.000 won per hari), meningkatkan biaya rawat inap ke tingkat 2,2 kali lipat, dan untuk pusat ibu-anak di luar wilayah Seoul, 150% (sekitar 1,44 juta won per hari) ditambahkan untuk kompensasi biaya rawat inap pada tingkat 2,5 kali lipat.

Tingkat tarif dasar untuk kehamilan dan persalinan juga ditingkatkan 20%, dan untuk persalinan berisiko tinggi, 100-200% tarif persalinan umum ditambahkan untuk persalinan normal dan operasi caesar.

Untuk memperkuat perawatan primer untuk anak-anak, kelompok usia untuk tunjangan biaya pemeriksaan ditingkatkan dari 0-5 tahun saat ini menjadi 0-7 tahun, dan tingkat tunjangan juga ditingkatkan.

Juga, dalam proses meningkatkan tarif untuk 1.600 jenis operasi berat dan darurat di rumah sakit umum atau lebih tinggi sebesar 20%, operasi anak-anak di bawah 6 tahun ditambahkan 50% tambahan dengan mempertimbangkan tingkat kesulitan dan risiko yang tinggi.

Kompensasi untuk perawatan berat di unit perawatan intensif pediatri (ditargetkan untuk rumah sakit umum tingkat lanjut dan rumah sakit umum dengan unit perawatan intensif pediatri) ditambahkan 50% (100% untuk wilayah non-Seoul metropolitan dan daerah rentan di wilayah Seoul metropolitan), dan untuk Rumah Sakit Anak Cahaya Bulan (saat ini 151 lokasi) yang menangani perawatan malam hari untuk anak-anak dan remaja, biaya manajemen spesialis pediatri baru akan didirikan (sekitar 50.000 won), sementara untuk 121 Rumah Sakit Anak Cahaya Bulan di kota/kabupaten/distrik dengan populasi anak rendah, tarif perawatan malam hari ditambahkan 30%.

cindy@yna.co.kr

As the government invests 3.6 trillion won in health insurance finances to strengthen regional and essential medical care, it significantly strengthens medical fees for emergency surgeries on holidays and nights.

It raises medical fees for surgeries and procedures related to pregnancy and childbirth and newly establishes a surcharge for high-risk cesarean deliveries, while also strengthening compensation for pediatric primary care and pediatric severe/emergency surgeries.

The Ministry of Health and Welfare held a Health Insurance Policy Deliberation Committee on the 25th and announced that it confirmed the "Healthcare Insurance Medical Fee Structure Innovation Plan" containing these details.

Medical fees are compensation for medical services that the government pays to medical institutions from health insurance finances. In the past, medical fees for emergency surgeries and high-risk deliveries have been low, while the on-call burden on medical staff and the possibility of medical disputes are high, leading to avoidance phenomena and the need for medical fee restructuring has been pointed out.

The Welfare Ministry decided to raise the medical fees for severe surgeries and procedures at general hospitals and above by 20% to strengthen emergency care.

The targets include 1,600 surgeries and procedures with high difficulty levels and requiring a large number of skilled personnel, such as emergency-related surgeries and procedures for cardiovascular diseases, severe surgeries for cancers, and procedures related to complex fractures or congenital malformations.

For patients who are admitted as emergencies through regional emergency medical centers during holidays and nights, the surgical fees are raised 5.5 times, raising the compensation level for the same severe surgery during night, holidays, and emergency situations to strengthen the final treatment capacity for severe emergency patients.

The compensation for actions accompanying final treatment is also greatly expanded, such as raising the level of general anesthesia fees at general hospitals and above by 50% from the current level.

Compensation for mother-child medical care for high-risk mothers and newborns and compensation for pediatric care are also strengthened.

Until now, childbirth has been supported with a maximum public policy fee of 1.76 million won, which was uniformly applied to all deliveries, and it was pointed out that it was insufficient for high-risk deliveries and premature infant treatment.

Accordingly, the Welfare Ministry comprehensively considers the mother's severity, newborn status (gestational age, weight, etc.), and region, and significantly adjusts compensation centered on severe mother-child centers and regional mother-child centers.

In particular, a surcharge is newly established for the period during which newborns receive treatment in the intensive care unit, strengthening compensation for all processes of treating high-risk deliveries and newborn patients in the ICU.

Accordingly, for premature infants born before 28 weeks at a severe mother-child center, approximately 4.4 million won is added to the basic delivery fee, and for non-Seoul metropolitan mother-child centers, approximately 5.06 million won is added.

For newborn ICU patients, if treated in the newborn intensive care unit for approximately 4 weeks from 24 weeks to 28 weeks, a 120% surcharge (approximately 1.15 million won per day) is added to the basic hospitalization fee (approximately 960,000 won per day) for 4 weeks, raising the hospitalization fee to 2.2 times the level, and for non-Seoul metropolitan mother-child centers, a 150% surcharge (approximately 1.44 million won per day) is added, compensating the hospitalization fee at 2.5 times the level.

The basic pregnancy and childbirth medical fee level is also raised by 20%, and for high-risk deliveries, a 100-200% surcharge to the standard delivery fee is added for both natural delivery and cesarean section.

To strengthen primary care for children, the age range for consultation fee surcharges is raised from the current 0-5 years to 0-7 years, and the surcharge level is also increased.

Additionally, in the process of raising the medical fees for 1,600 types of severe and emergency surgeries at general hospitals and above by 20%, an additional 50% surcharge is added for pediatric surgeries under 6 years of age, considering the high difficulty and risk levels.

A 50% surcharge (100% for non-Seoul metropolitan areas and vulnerable areas in the Seoul metropolitan area) is applied to severe treatment compensation in pediatric ICUs (for teaching hospitals and general hospitals with pediatric ICUs), and for Moonlight Children's Hospitals (currently 151 facilities) that provide pediatric and adolescent night care, a new pediatric specialized management fee (approximately 50,000 won) is established, while for 121 Moonlight Children's Hospitals in counties and districts with small pediatric populations, a 30% surcharge is added to night care fees.

cindy@yna.co.kr