2015 재난적의료비경험률과추이 Catastrophic Health Expenditure Status and Trend of Korea in 2015 저자저널명발행기관 NDSL URL 김우림 ; 박은철 Health policy and management = 보건행정학회지한국보건행정학회 http://www.ndsl.kr/ndsl/search/detail/article/articlesearchresultdetail.do?cn=jako201715262464511 IP/ID 128.134.207.84 이용시간 2017/09/20 13:50:53 저작권안내 1 NDSL 에서제공하는모든저작물의저작권은원저작자에게있으며, KISTI 는복제 / 배포 / 전송권을확보하고있습니다. 2 NDSL 에서제공하는콘텐츠를상업적및기타영리목적으로복제 / 배포 / 전송할경우사전에 KISTI 의허락을받아야합니다. 3 NDSL 에서제공하는콘텐츠를보도, 비평, 교육, 연구등을위하여정당한범위안에서공정한관행에합치되게인용할수있습니다. 4 NDSL 에서제공하는콘텐츠를무단복제, 전송, 배포기타저작권법에위반되는방법으로이용할경우저작권법제 136 조에따라 5 년이하의징역또는 5 천만원이하의벌금에처해질수있습니다.
hpm 보건행정학회지 2017;27(1):84-87 ISSN 1225-4266 Health Policy and Management Vol.27 No.1, 84-87 https://doi.org/10.4332/kjhpa.2017.27.1.84 DATA OBSERVATION 2015 재난적의료비경험률과추이 김우림 1,2 ㆍ박은철 2,3 1 연세대학교대학원보건학과, 2 연세대학교보건정책및관리연구소, 3 연세대학교의과대학예방의학교실 Catastrophic Health Expenditure Status and Trend of Korea in 2015 Woorim Kim 1,2, Eun-Cheol Park 2,3 1 Department of Public Health, Yonsei University Graduate School; 2 Institute of Health Services Research, Yonsei University; 3 Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Korea Catastrophic healthcare expenditure refers to out-of-pocket spending for healthcare exceeding a certain proportion of a household s income and can lead to subsequent impoverishment. The aim of this study was to investigate the proportion of South Korean households that experienced catastrophic healthcare expenditure between 2006 and 2015 using available data from the Korea Health Panel, National Survey of Tax and Benefit, and Household Income and Expenditure Survey. Frequencies and trend tests were conducted to analyze the proportion of households with catastrophic healthcare expenditure. Subgroup analysis was performed based on income level. The results of the Household Income and Expenditure Survey revealed that around 2.88% of households experienced catastrophic healthcare expenditure in 2015 and that this proportion was highest in the low income group. Results also showed a statistically significant increasing trend in the number of households with catastrophic healthcare expenditure (annual percentage change = 0.92%, p-value < 0.0001). Therefore, the findings infer a need to strengthen public health care financing and to particularly monitor catastrophic healthcare expenditure in the low income group. Keywords: Catastrophic healthcare expenditure; Trend; Income 서론재난적의료비 (catastrophic health expenditure) 는의료비로인한가구의경제적부담을측정하는개념으로서한가구의의료비지출이일정수준을넘어서는경우를의미한다 [1]. 세계보건기구는가구의지불능력중 40% 이상을의료비로지출한경우재난적의료비가발생한것으로정의하고있으며, 각국가의상황에맞게 10% 40% 사이의값을사용할수있다 [2]. 재난적의료비측정은한국가의의료제도가경제적위험에서국민을보호하는기능을하고있는지확인하고, 의료비로인해빈곤계층으로추락하는취약계층을파악할수있는장점이있다. 우리나라는중증질환자의진료비본인부담률을점진적으로낮추고비급여를급여로전환하는등의노력을하였으나, 급여가확대된만큼비급여진료비도빠르게상승하여의료비 가점차증가하는추세이다 [3]. 높은의료비본인부담률은재난적의료비의원인이될수있는데, 특히우리나라는의료급여의보장성이낮아소득이적을수록과부담의료비지출을할확률이높아진다 [4]. 따라서저소득층에서의재난적의료비발생은빈곤화로이어질가능성이크며이에대한현황파악이필요하다. 이연구는우리나라의 2006 2015년재난적의료비지출가구의비율을파악하고소득에따른재난적의료비발생률을제시하고자한다. 방법 1. 연구자료이연구는재난적의료비에대하여조사한한국의료패널 (2011 2013년 ), 재정패널조사 (2011 2014년) 및통계청가계동향조사 Correspondence to: Eun-Cheol Park Department of Preventive Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1862, Fax: +82-2-392-8133, E-mail: ecpark@yuhs.ac Received: March 8, 2017 / Revised: March 13, 2017 / Accepted after revision: March 15, 2017 Korean Academy of Health Policy and Management This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 84 https://kshpa.jams.or.kr/co/main/jmmain.kci
한국의재난적의료비현황 김우림외 (2006 2015년 ) 를자료원으로사용하였다. 한국의료패널, 재정패널조사, 가계동향조사는표본추출가구의연 ( 월 ) 평균상세소득과가계직접부담의료비및식료품비를포함한지출에대한정보를담고있다. 한국의료패널, 재정패널조사, 가계동향조사에포함된총연구대상은각각 7,234, 7,094, 9709가구였다 [5,6]. 가계직접부담의료비혹은식료품비에대해무응답한경우는분석에서제외하였다. 2. 변수정의및측정방법재난적의료비는세계보건기구의 Xu가정의한방법을기준으로측정하였다 [2]. 가구소비지출, 식료품비지출, 가계직접부담의료비를바탕으로빈곤선, 가구생계비및지불능력을계산한후가구의지불능력중가계직접부담의료비지출비중을산출하였다. 빈곤선은생활비대비식료품비의비율이 45 55분위이내인가구들의가구원수보정식료품비의가중평균을의미한다. 이연구에서는지불능력대비의료비지출이 40% 이상일경우재난적의료비지출이있는것으로가정하였다. 을측정하였으며, 연구대상가구를소득 5분위별로나누어소득별재난적의료비발생률을산출하고비교하였다. 또한우리나라의인구구조를반영하기위해각자료가제시하는가구횡단가중치를이용하여가중치가반영된재난적의료비발생비율을함께살펴보았다. 소득은균등화소득을바탕으로분류하였는데, 균등화소득은경제협력개발기구제곱근지수방법을이용하여가구소득을가구원수의제곱근으로나누어산출하였다. 각데이터의연도별재난적의료비지출가구의추이가통계적으로유의한지검정하기위해추세분석 (trend test) 을시행하였으며, 이는율의변화를보여주는 annual percentage change (APC) 로제시하였다. 이를위해 log-binomial 모델을바탕으로종속변수는재난적의료비경험여부, 독립변수는연도로지정하여회귀분석한뒤산출된회귀계수에지수함수를취하여 [(exp(β)-1) 100] 관찰기간동안의평균퍼센트변화율을측정하였다 [7]. 결과 3. 통계분석방법 각데이터를이용하여연도별재난적의료비지출가구의비율 2015 년재난적의료비지출가구의비율은 2.88% 였다 (Table 1). 모든결과해석은가중치가부여된값을기준으로하였다. 연도별 Table 1. Percentage of households with catastrophic healthcare expenditure at nearest year Variable No. Unweighted CHE no. (%) Weighted CHE (%) Korea Health Panel 2013 Total 7,234 244 (3.37) 3.06 Low 1,447 145 (10.02) 8.78 Low-middle 1,449 63 (4.35) 3.93 Middle 1,447 22 (1.52) 1.45 Middle-high 1,448 7 (0.48) 0.69 High 1,443 7 (0.49) 0.42 National Survey of Tax and Benefit 2014 Total 7,094 209 (2.95) 3.39 Low 1,517 118 (7.78) 8.88 Low-middle 1,334 40 (3.00) 2.85 Middle 1,425 16 (1.12) 1.35 Middle-high 1,593 16 (1.00) 0.9 High 1,225 19 (1.55) 1.59 Household Income and Expenditure Survey 2015 Total 9,709 330 (3.40) 2.88 Low 1,942 199 (10.25) 9.56 Low-middle 1,942 76 (3.91) 3.63 Middle 1,942 24 (1.24) 0.64 Middle-high 1,942 19 (0.98) 0.65 High 1,941 12 (0.62) 0.74 CHE, catastrophic healthcare expenditure. 보건행정학회지 2017;27(1):84-87 https://kshpa.jams.or.kr/co/main/jmmain.kci 85
Kim W, et al. Catastrophic Health Expenditure in Korea % of CHE Korea Health Panel (APC= -6.05, p-valule=0.8329) National Survey of Tax and Benefit (APC=5.13, p-value< 0.0001) Household Income and Expenditure Survey (APC=0.92, p-value<0.0001 3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 2.0 2007 2008 2009 2010 2011 2012 2013 2014 2015 재난적의료비지출가구의비율을살펴보면 2006 년가계동향조사 기준 2.46% 였으며, 2011 년의경우한국의료패널기준 3.45%, 재정 패널조사 2.95%, 가계동향조사 2.63% 였다. 동일하게 2012 년재난적 의료비발생률은한국의료패널 3.55%, 재정패널조사 3.06%, 가계 동향조사 2.55% 였으며, 2013 년발생률은한국의료패널 3.06%, 재정 패널조사 3.33%, 가계동향조사 2.77%, 2014 년발생률은재정패널 조사 3.39 %, 가계동향조사 2.40% 로측정되었다 (Figure 1). 따라서 각데이터간의편차는 1% 내외였다. 이외에도소득별로나누어분 석한결과소득계층이낮을수록재난적의료비지출가구의비율 이높았다 (Table 1). 연도별재난적의료비지출가구비율의증감추이를살펴보면, 추세검정결과한국의료패널 (p-value = 0.8329) 는통계적으로유의 한경향성을보이지않았다 (Figure 1). 하지만재정패널조사의결과 는최근 4 년간통계적으로유의하게 APC 가 5.13 (p-value < 0.0001) 로소폭상승하는경향성을보였으며가계동향조사의최근 10 년 추세도 APC 가 0.92 (p-value < 0.0001) 로소폭상승하는경향성을 보였다. Year Figure 1. Percentage of households with CHE experience by year. CHE, catastrophic healthcare expenditure; APC, annual percentage change. 고찰 2015 년재난적의료비발생가구의비율은 2.88% 였으며, 이는 2006 2015 년사이상승하는추세를보였다. 이는대부분의경제협 력개발기구국가들이보인 1% 미만의재난적의료비발생률에비 해높은수치이다 [1]. 다른동아시아국가들에비해서도우리나라 의재난적의료비발생률은상대적으로높았는데, 일본은 1.68%, 중국은 4.81%, 대만은 0.41% 의가구가재난적의료비를겪은것으 로보고되었다 [8,9]. 하지만베트남, 인도, 몽고등의개발도상국가 에비하면한국은대체로낮은발생률을보이고있다 [10-12]. 한국의의료체계가안정화되었음에도재난적의료비발생이비 교적높은이유는건강보험의보장성이낮기때문이다. 실제로우 리나라의가구소비대비의료비지출비용은 4.7% 로경제협력개발 기구국가들중가장높았고, 국민의료비중공공의료비백분율도 55% 로경제협력개발기구국가평균인 73% 보다낮다 [13]. 재난적 의료비는한국가의건강보장제도가그기능을충분히하고있는 지확인할수있는도구로, 이연구에서보여준우리나라의재난적 의료비발생비율은의료제도의보장성강화가필요함을암시한다. 과도한의료비지출은빈곤화의원인이될수있으며, 이는삶의 질하락으로이어질가능성이있다 [14]. 이연구에서는저소득층 및저 중소득층의재난적의료비발생가구비율이다른소득층에 서비해높았으며, 특히저소득층에서재난적의료비발생가구가 현저히많았다. 재난적의료비지출여부가빈곤화와빈곤지속에 영향을줄수있다는점을감안할때, 저소득층의재난적의료비발 생가구에대한지속적인모니터링이필요한것으로보인다 [15]. 한국의료패널, 재정패널조사및가계동향조사는가계직접부담 식료품비지출변수측정에서차이를보였는데, 재정패널조사와가 계동향조사는식료품비와외식비를별도로조사한반면한국의료 패널은이를분리하여조사하지않았다. 따라서이연구에서는가 계동향조사의식료품비및외식비비율을사용하여한국의료패널 의재난적의료비를산출하였다. 또한두패널조사는지난조사이 후현조사시점까지의의료이용을후향적으로수집하고있어의료 비지출액이부정확하거나의료이용자체의누락가능성을배제할 수없다. 조사주기역시한국의료패널과재정패널조사는연단위, 가계동향조사는월단위로가계동향조사의지출기록이상대적으 로정확할가능성이높다. 이외에도데이터별로사용된모집단과 모집단에서샘플링하는방식의차이가있는데, 이는모두결과의 차이로이어졌을수있다. 이연구에서는의료를이용하지않은경 우에대해서는고려하지않았다. 우리나라의 2015 년재난적의료비발생가구비율은 2.88% 로, 대 부분의경제협력개발기구국가들보다높았다. 또한재난적의료비 발생률은 2006 2015 년사이소폭상승하는경향을보였으며, 특히 저소득층의재난적의료비발생가구비율이높았다. 이는건강보 장체계개선이필요함을의미하며, 특히저소득층의재난적의료비 발생에대한모니터링이필요할것으로보인다. REFERENCES 1. Xu K, Evans DB, Kawabata K, Zeramdini R, Klavus J, Murray CJ. Household catastrophic health expenditure: a multicountry analysis. Lancet 2003; 362(9378):111-117. DOI: https://doi.org/10.1016/s0140-6736(03)13861-5. 2. World Health Organization. Distribution of health payment and catastrophic expenditures methodology: discussion paper no. 2-2005. Geneva: World Health Organization; 2005. 3. Organization for Economic Cooperation and Development. OECD 86 https://kshpa.jams.or.kr/co/main/jmmain.kci 보건행정학회지 2017;27(1):84-87
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