현안보고서 2014-02
건강보험 의사결정기구의 개편 방안
A plan to re-organize the health insurance policy determination body
신 영 석·김 소 운·김 은 아
==========================
요약 ···················································································································· 1
제1장 건강보험 의사결정기구의 역사 및 현황 ······························································ 3
제1절 건강보험 의결 관련 법 및 의사결정기구의 변천 ··················································· 3
제2절 건강보험 의사결정기구의 기능 및 구성 ······························································ 6
제2장 건강보험 의사결정기구의 문제점 및 외부시각 ·················································· 10
제1절 건강보험정책심의위원회의 성과 및 한계 ··························································· 10
제2절 건강보험정책심의위원회관련 외부 시각 ··························································· 12
제3절 건강보험정책심의위원회 개편관련 논의 ··························································· 16
제3장 국외 건강보험관련 의사결정기구의 특성 ··························································· 25
제1절 일본의 건강보험 관련 의사결정기구 ································································· 25
제2절 독일의 건강보험 관련 의사결정기구 ································································· 28
제3절 대만의 건강보험 관련 의사결정기구 ································································· 30
제4절 그 외 국가의 건강보험 관련 의사결정기구 ·························································· 33
제5절 소결 및 시사점 ····························································································· 35
제4장 건강보험 의사결정기구의 개편원칙 및 개편안 ····················································37
제1절 개편원칙 ·····································································································37
제2절 개편안 ·········································································································38
참고문헌 ··············································································································41
=====================================
본 연구에서는 우리나라 건강보험 의사결정 기구인 건강보험정책심의위원회의 현황 및 문제점을 분석하고 국외 건강보험관련 의사결정 기구의 특성을 살펴봄으로써 건강보험 의사결정 기구 개편을 위한 원칙과 방안을 제시하였다.
건강보험 의결과 관련된 법의 변화에 따라 건강보험 의사결정기구의 명칭, 심의 사항과 위원구성의 변화가 존재하였다. 현재 우리나라의 건강보험 의사결정 기구는 국민건강보험법 제 4조에 의거하여 건강보험정책에 관한 중요사항을 심의 및 의결하기 위하여 보건복지부 장관하에 설치된 건강보험정책심의위원회로 요양급여의 기준, 요양급여 비용, 지역가입자와 직장 가입자의 보험료, 건강보험과 관련된 주요 사항을 의결하는 기능을 수행하고 있다. 이러한 건강보험정책심의위원회에 관해서 권한의 과도한 집중, 책임구조의 결여, 위원 구성의 중립성의 부족, 위원회의 전문성 결여 등 많은 문제점이 논의되었다. 또한 위원회의 위상이나 권능만큼 위원 구성, 위원회 운영방법, 논의 내용 등에 대한 논란이 지속되고 있으며 정부편향적 위원구성, 의사결정의 절차적 불공정함 등에 대한 지적이 제기된 바 있다.
주요 국가의 의사결정 기구 특성을 살펴 본 결과, 국가마다 건강보험 운영방식과 보험급여 및 수가 설정 방식이 상이하여 건강보험 관련 의사결정 기구의 구성과 역할의 범위가 국가마다 다양한 특성을 보였다. 하지만 공통적으로 정부가 최종적인 결정권을 갖고 있거나 위원회 등에서 결정된 사항에 대해 거부권을 행사할 수 있도록 제도화함으로써 제도운영의 책임성을 높이고 있다.
책임성, 중립성 및 객관성, 전문성의 개편원칙을 토대로 2가지의 개편방안이 모색되었다. 현행 체계에 정부의 책임성을 강화하면서 조정과 중재의 역할을 실질화할 수 있도록 공익대표의 선정과정을 투명하게 하는 1안과 향후 건강보험 운영의 지향을 포함하여 전문성을 강화하는 방향의 2안이 제시되었다.
