• 보건행정학회지
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• 제30권2호
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• pp.192-198
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• 2020

Background: Korea National Health Insurance Service (NHIS) is operated as a social insurance system in which people pay a portion of their monthly income as insurance premiums and receive benefits when they experience illness or injury. Since 2005, the national health insurance remained surplus accumulating cumulative reserves each year. However, as of 2018, NHIS revenue recorded 62.11 trillion won and spending of 62.29 trillion won. The deterioration of NHIS finances is expected to accelerate with the aging population, income growth, new medical technology development, and enhanced security policies. Methods: To examine the financial health and sustainability of NHIS, we estimated the future revenue and spending until 2030 using the data from Korea Health Insurance Review and Assessment Service statistical yearbook. 2004-2018 average percentage change in NHIS revenue and spending was calculated. We estimated the future NHIS financial status using two methods. In the first method, we calculated the revenue and spending of the future NHIS by applying the 2004-2018 average percentage change to the subsequent years consecutively. In the second method, we estimated the future NHIS financial status after adjusting for the predicted demographic changes such as the aging population and declining birth rate in South Korea. Results: The estimates from this study suggest that the NHIS's cumulative reserves will run out by 2024. Conclusion: In terms of spending on current health insurance, there should be a search for ways of more efficient spending and funding options.

• Annals of Occupational and Environmental Medicine
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• 제35권
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• pp.35.1-35.11
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• 2023

Background: Cardio-cerebrovascular diseases (CVDs) are the most common cause of death worldwide. Various CVD risk assessment tools have been developed. In South Korea, the Korea Occupational Safety & Health Agency (KOSHA) and the National Health Insurance Service (NHIS) have provided CVD risk assessments with health checkups. Since 2018, the KOSHA guide has stated that NHIS CVD risk assessment tool could be used as an alternative of KOSHA assessment tool for evaluating CVD risk of workers. The objective of this study was to determine the correlation and agreement between the KOSHA and the NHIS CVD risk assessment tools. Methods: Subjects of this study were 17,485 examinees aged 20 to 64 years who had undergone medical examinations from January 2021 to December 2021 at a general hospital. We classified subjects into low-risk, moderate-risk, high-risk, and highest-risk groups according to KOSHA and NHIS's CVD risk assessment tools. We then compared them with cross-analysis, Spearman correlation analysis, and linearly weighted kappa coefficient. Results: The correlation between KOSHA and NHIS tools was statistically significant (p-value < 0.001), with a correlation coefficient of 0.403 and a kappa coefficient of 0.203. When we compared risk group distribution using KOSHA and NHIS tools, CVD risk of 6,498 (37.1%) participants showed a concordance. Compared to the NHIS tool, the KOSHA tool classified 9,908 (56.7%) participants into a lower risk category and 1,079 (6.2%) participants into a higher risk category. Conclusions: In this study, KOSHA and NHIS tools showed a moderate correlation with a fair agreement. The NHIS tool showed a tendency to classify participants to higher CVD risk group than the KOSHA tool. To prevent CVD more effectively, a higher estimation tool among verified CVD risk assessment methods should be selected and managements such as early intervention and treatment of risk factors should be performed targeting the high-risk group.

• 의료법학
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• 제16권2호
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• pp.131-157
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• 2015

국민건강보험공단은 의사가 요양급여기준을 위반하여 처방을 함으로써 국민건강보험공단이 약국에 약제비를 지급하게 된 것은 의사가 국민건강보험공단에 대해 민사상 불법행위를 한 것이라고 주장하며 손해배상청구를 하였다. 대법원이 이를 인정하는 판결이 잇따르자, 국민건강보험공단은 의사들이 의료법을 위반하여 진료를 하여 약국에 지급하게 된 약제비나 해당 의료기관에 지급하게 된 요양급여비용에 대해서도 모두 국민건강보험공단에 대한 민법상 불법행위라고 주장하며 손해배상을 청구하였으며, 대법원은 이를 모두 인정하였다. 그러나 우리나라 국민건강보험제도에서 보험급여의 주체는 국민건강보험공단이며, 환자가 의료기관에 진료를 요청하여 의료기관이 행하는 요양급여 역시 보험급여이므로 이러한 요양급여를 행하는 주체 역시 국민건강보험공단이다. 그리고 국민건강보험법은 의사의 의료법위반행위를 규제하기 위해 만든 법이 아니므로 의사의 의료법 위반행위를 국민건강보험공단에 대한 민법상 불법행위책임에서의 위법성으로 포섭할 수 없다. 그렇다면 환자가 보건복지부장관으로부터 부여 받은 면허를 가진 의사에 의해 요양급여기준에 맞는 진료를 받은 경우에는 국민건강보험공단은 민법상 환자에게 요양급여를 해 줄 의무를 면하는 이득을 얻었으므로 설사 해당 의사가 진료를 하는 과정에 의료법을 위반한 행위를 하였더라도 국민건강보험공단으로서는 손해가 없다. 대법원이 의료법위반으로 진료를 한 행위를 모두 국민건강보험공단에 대한 민법상 불법행위책임으로 인정하는 것은 국민건강보험공단이 보험급여의 주체로서 보험급여를 해 줄 의무를 면하였다는 이득은 고려하지 않고, 오로지 의사에게 요양급여비용을 지급하였다는 측면만을 고려한 것으로서 민법 제750조의 법리에 어긋난다. 의사가 의료법을 위반하였다면 의료법에 따라 제재를 받을 일이지, 국민건강보험법으로 규율할 일이 아니며, 대법원이 위와 같이 판결한 것은 국민건강보험법의 법리와 민법의 법리를 혼동한 탓으로 생각된다.

• 보건행정학회지
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• 제28권3호
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• pp.210-216
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• 2018

National Health Insurance Service (NHIS) has put a great effort on extending life expectancy, for last 40 years. The system has also made remarkable outcomes in achieving universal health coverage. However, it is facing challenges of low health insurance benefits and sustainability risk due to low birth rate and aging society at the same time. To overcome the difficulties and build a lifelong health security system for the nation, it is required for NHIS to make multilateral changes in its roles. Based on the quantitative growth achieved so far, NHIS needs to strive for the growth in quality by not only increasing coverage and reforming contribution imposition system, but also reorganizing the relevant systems such as lifelong health management support, rational adjustment to the medical fee, and benefit costs monitoring. In addition, it's important for NHIS to restructure the organizational culture by having specialty and communicating with people for high quality of administration and health insurance sustainability.

• Archives of Plastic Surgery
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• 제45권3호
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• pp.239-245
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• 2018

Background Breast reconstruction has become more common as mastectomy has become more frequent. In Korea, the National Health Insurance Service (NHIS) began covering breast reconstruction in April 2015. This study aimed to investigate trends in mastectomy and breast reconstruction over the past 10 years and to evaluate the impact of NHIS coverage on breast reconstruction. Methods Nationwide data regarding mastectomy and breast reconstruction were collected from the Korean Breast Cancer Society registry database. Multiple variables were analyzed in the records of patients who underwent breast reconstruction from January 2005 to March 2017 at a single institution. Results At Seoul National University Hospital, the total number of reconstruction cases increased 13-fold from 2005 to 2016. The proportion of immediate breast reconstruction (IBR) cases out of all cases of total mastectomy increased from 4% in 2005 to 52.0% in 2016. The proportion of delayed breast reconstruction (DBR) cases out of all cases of breast reconstruction and the overall number of DBR cases increased from 8.8% (20 cases) in 2012 to 18.3% (76 cases) in 2016. After NHIS coverage was initiated, the proportions of IBR and DBR showed statistically significant increases (P<0.05). Among the IBR cases, the percentage of prosthesis-based reconstructions increased significantly (P<0.05), but this trend was not found with DBR. Total mastectomy became significantly more common after the expansion of NHIS coverage (P<0.05). Conclusions Over the last decade, there has been an increase in mastectomy and breast reconstruction, and the pace of increase accelerated after the expansion of NHIS coverage. It is expected that breast reconstruction will be a routine option for patients with breast cancer under the NHIS.

• Journal of Korean Medical Science
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• 제33권44호
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• pp.276.1-276.10
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• 2018

Background: The National Health Insurance Service (NHIS) established a healthcare claim database for all Korean citizens. This study aimed to analyze the NHIS data and investigate the patterns of breast cancer treatments. Methods: We constructed a retrospective female breast cancer cohort by analyzing annual incident cases. The annual number of newly diagnosed female breast cancer was compared between the NHIS data and Korea National Cancer Incidence Database (KNCIDB). The annual treatment patterns including surgery, chemotherapy, radiation therapy, endocrine therapy and targeted therapy were analyzed. Results: A total of 148,322 women with newly diagnosed invasive breast cancer during 2006-2014 was identified. The numbers of newly diagnosed invasive breast cancer cases were similar between the NHIS data and KNCIDB, which demonstrated a strong correlation (r = 0.995; P < 0.001). The age distribution of the breast cancer cases in the NHIS data and KNCIDB also showed a strong correlation (r = 1.000; P < 0.001). About 85% of newly diagnosed breast cancer patients underwent operations. Although the proportions of chemotherapy use have not changed during 2006-2014, the total number of chemotherapy prescriptions sharply increased during this period. The proportions of radiotherapy and anti-hormonal therapy increased. Among the anti-hormonal agents, tamoxifen was the most frequently prescribed medication, and letrozole was the most preferred endocrine treatment in patients aged ${\geq}50$ years. Conclusion: Along with the increased breast cancer incidence in Korea, the frequencies of breast cancer treatments have increased. The NHIS data can be a feasible data source for future research.

• 의료법학
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• 제15권1호
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• pp.123-164
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• 2014

Under the new system of 'Separation of pharmaceutical prescription and dispensing' in Korea, which was implemented in 2000, physician could not dispense a medicine, and outpatient should have a physician's prescription filled at a drugstore. After pharmacist makes up outpatient's prescription, National Health Insurance Service(NHIS) pay for outpatient's medicine to pharmacist, except an outpatient's own medicine charge. And NHIS only pay for outpatient's prescription fee to physician and, physician doesn't derive profit from dispensing medicine in itself. Nevertheless, if physician writes out a prescription with violation of 'Criteria for the Medical Care Benefits', NHIS clawed back the payment of outpatient's prescription and medicine from the physician or the medical institution which the physician belongs to. In the past, NHIS's confiscation was in accordance with 'the National Health Care Insurance Act, Article 52, Clause 1'. But, since 2006 when the Supreme Court declared that there was no legal basis on the NHIS's confiscation of outpatient's medicine payment, NHIS had put in a claim for illegal prescriptions on the basis 'the Korean Civil law, Article 750(tort)'. So, Many medical institutions filed civil actions against NHIS. The key point of this actions was whether the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits constitute of the law of tort. On this point, the first trial and the second trial took different position. Finally the Supreme Court acknowledged the constitution of the law of tort in 2013. In this paper, the author will review critically the decision of the Supreme Court, and consider the relativeness between the legal effect of Criteria for the Medical Care Benefits and the constitution of the issuing outpatient prescriptions with violations of Criteria for the Medical Care Benefits as the law of tort.

• 의료법학
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• 제23권4호
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• pp.3-28
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• 2022

공단과 제약사 간 협상은 제도 도입 이후 지속적으로 범위와 대상을 확대하여 왔고, 최근에는 품질관리에 관한 사항 등이 협상 대상으로 추가되었다. 그에 따라 복지부의 상한금액 고시가 아닌 공단과의 협상만으로도 제약사들의 법익이 침해될 우려가 제기되었고, 그로 인해 협상의 법적 성격과 법익 침해에 대한 구제방법 등의 검토 필요성이 대두되었다. 복지부장관이 공단 이사장에 대한 협상'명령'을 내리면, 공단이 제약사에 이를 '통보'하여 '협상'이 진행된다. '명령'은 행정권 내부의 행위로서 항고소송의 대상이 되는 처분성이 부인된다. 이에 반해 '통보' 내지 '협상'은 제약사를 상대방 당사자로 하는 행위로서, 협상 결렬에 대한 불이익이 존재한다면 그 자체를 '처분'으로 볼 여지도 있을 것이다. 협상은 '대상(보험급여목록에 등재되어 있는지 여부)'과 '목적(협상대상이 가격인지 조건 부여인지)'에 따라 4개 유형으로 세분할 수 있다. 조건 부여에 관한 협상은 협약을 통해 부담(부관)을 설정하도록 하는 합의가 된다. 신규 등재 또는 가격 인상 약제 협상의 경우에는 수익적·재량적 행정행위에 부담을 부착하는 경우로서 조건 부여 협상이 적법할 것이지만, 기등재 약제의 가격 조정은 대부분 가격을 인하하는 침익적 처분으로서 협상을 통해 부담을 부착할 경우 위법할 여지를 배제하기 어렵다. 따라서 부담의 설정이 필요하다면 인센티브 등의 부여를 통해 협상에 따른 고시가 수익적·재량적 행정행위가 될 수 있는 길을 열어놓을 필요가 있을 것이다.

• 대한치과보철학회지
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• 제57권1호
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• pp.37-41
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• 2019

치과 임플란트는 상실된 치아의 수복에 효과적이고 예측 가능한 치료 방법이다. 하지만 임플란트 사용이 증가함에 따라 합병증도 증가하고 있다. 이 중 기계적 합병증은 발생 빈도가 높을 뿐 아니라 임플란트의 수명이 길어질수록 더 많이 발생하므로 이에 대한 대책이 필요하다. 이에 임플란트의 가장 흔한 기계적 합병증인 지대주 파절과 지대주 나사 파절의 증례에서 파손된 부위만 재제작하여 파손되지 않은 구성요소를 최대한 보존할 수 있는 방법을 소개하고자 한다.

• 대한치과의사협회지
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• 제54권6호
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• pp.457-467
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• 2016

The National Health Insurance Service(NHIS) has been selectively covering the elderly on the dental implant and removable denture treatment and gradually expanding the eligibility criteria. Every dentist needs to have a good understanding of the insurance policy to provide qualified dental service to the beneficiaries and to avoid confusions and complications. In order to help dentists understand the NHIS requirements, the definitions, categories, and procedures of dental implant and conventional denture treatment are suggested.