한국과 일본의 진료비 상한제도 비교: 제도 실효성을 높이기 위한 방안모색을 중심으로

초록

Background and Objective Korea’s Out-of-Pocket Limit Policy provides for a maximum amount of out-of-pocket payments for health care with the medical expenses exceeding that limit covered by insurer. This policy has been an object of continuous discussion due to recurring reports of catastrophic health expenditure. In contrast, the High-Cost Medical Care System, a similar policy in Japan, is thought to be functioning stably. Therefore, this study was conducted to discuss the structural problems of Korea’s Out-of-Pocket Limit Policy and compare it with Japan’s High-Cost Medical Care System with a view to deriving implications for the future direction of improving the current policy. Comparison of the policy 1) Governing body: In both Korea and Japan, public health insurers are responsible for the management and operation. 2) Insurance coverage: Both systems offer a benefit package, but there is a significant difference in the scope of coverage between the two systems, the major differences being more uninsured benefits and higher co-insurance for the coverage benefits in Korea. 3) Ceiling calculation unit: As the basis for setting the payment limit, Korea applies an annual cap, and Japan a monthly cap. 4) Criteria for the threshold: While the ceiling is determined according to income in Korea, Japan applies both income and age as criteria for determining the ceiling. Evaluation of the policy: Korea’s policy is well-established in terms of system itself, but receives a negative evaluation because of its limited scope of coverage and high rate of catastrophic health expenditure ascribable to high ceiling despite its income-dependent differentiated levels. In contrast, Japan’s policy is evaluated to be a pragmatic and effective system attributable to various supplementary schemes such as “application on the household unit,” application of a lower ceiling for “frequent users” and “specific types of disease requiring high-cost and long-term care.”Conclusion In order to enhance the effectiveness of Korea’s policy, there is a need to overcome the limitations of the current policy through continuous monitoring and its effects and to progressively adopt the operational strategies of the Japanese system.

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