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과제정보

과제명, 기관명, 담당부서, 전화번호, 연구기간, 연구분야, 과제개요의 정보를 제공합니다.
과제명 간병서비스의 사회제도화 방안
기관명 여성가족부 담당부서 여성정책국 여성인력개발과
전화번호 연구기간 2005-07-02 ~ 2006-04-19
연구분야
과제개요 간병서비스의 사회제도화 방안

계약정보

수행기관, 수행연구원, 계약일자, 계약방식, 계약금액의 정보를 제공합니다.
수행기관 한국보건사회연구원
수행연구원 황나미 계약일자  
계약방식 수의 계약 계약금액 12000000원

연구결과정보

제목, 연구보고서, 공개제한근거, 비공개사유, 연구보고서, 목차, 주제어, 공헌자, 제작일, 발행년도의 정보를 제공합니다.
제목 간병서비스의 사회제도화 방안
연구보고서 12- 의료기관 간병서비스 사회제도화방안.pdf
목차
    요 약 ············································································································· 1
    Ⅰ. 서론 ········································································································· 18
    Ⅱ. 연구내용 및 방법 ······················································································ 23
    1. 연구추진체계 ··································································································· 23
    2. 연구내용 ········································································································· 24
    3. 연구방법 ········································································································· 25
    4. 연구의 제한점 ································································································· 29
    Ⅲ. 선진국의 의료기관 간병서비스 공급체계 ···················································· 30
    1. 일본 ··············································································································· 30
    2. 미국 ··············································································································· 36
    3. 독일 ··············································································································· 41
    4. 영국 ··············································································································· 43
    Ⅳ. 의료기관 간호?간병서비스 지불보상체계 ···················································· 45
    1. 입원환자 간호행위에 대한 지불보상체계 ·························································· 45
    2. 의료기관 간호사 1인당 담당병상수 ··································································· 49
    3. 요양병원형 간호지불보상체계 ··········································································· 50
    Ⅴ. 의료기관 간병인 활용 현황 ······································································· 51
    1. 병원급 이상 의료기관의 간병인 활용 및 관리 ·················································· 51
    2. 간병인의 특성 및 수행업무 ·············································································· 66
    3. 입원환자 및 가족의 간병인 이용 실태 및 만족도 ············································ 72
    4. 환자가족 및 환자 개인고용 간병인이 간병하지 않는 ‘보호자 없는 병동’ 운영사례 ··· 83
    Ⅵ. 의료기관 간병인력 수급 현황 ···································································· 84
    1. 간병인력 양성 및 공급 실태 ············································································ 84
    2. 의료기관 간병서비스 수요 추계 ······································································· 91
    Ⅶ. 의료기관 간병서비스 제도화 방안 ····························································· 99
    1. 기본방향 ········································································································· 99
    2. 의료기관 간병서비스 인력 요건 ······································································ 101
    3. 의료기관 간병서비스 적용방안 ······································································· 108
    참고문헌 / 122
    부 록 / 127
    부록 1. 조사표 ···································································································· 129
    부록 2. 자활근로 간병인력의 시장 진입형 인건비 ················································· 151
    부록 3. 의료기관 간병서비스 개선을 위한 토론내용 ·············································· 152
초록
    1. 연구 필요성 및 목적
    ? 저출산, 핵가족화 등 사회변화로 가족기능은 축소되고 있는데 반해, 인구 고령화와 만
    성질환자의 증가로 환자 간병 수요는 증가되고 있음
    ○ 간병서비스는 최첨단 의과학 및 생산기술의 혁신적 발달로 대체될 수 없는 휴먼서
    비스로서 초저출산 및 고령사회의 진입으로 지속적인 수요증대가 예상됨.
    ? 현 의료체계에서는 전인간호(total care)를 제공하기 어려운 상황이어서 간병은 환자 가
    족이나 개인고용에 의한 유료간병인에 의해 수행될 수밖에 없는 상황으로 가족간 갈등
    과 환자 비용부담 초래, 그리고 이들 활동으로 인하여 감염 및 안전사고에 대한 위험
    이 상존하고 있음.
    ? 이에 따라, 보건의학적 지식에 근거한 서비스 제공으로 간호서비스의 질 향상과 아울
    러 환자에게는 경제적 부담을 감소시킬 수 있는 돌봄의 사회화 및 보호자가 간병할 필
    요가 없는 병동구축의 필요성이 대두됨.
    ? 본 연구는 의료현장에서 수요?공급관계가 꾸준히 형성되어 온 간병수요(demand)를 파
    악하여 보건의학적(health science) 지식에 근거한(evidence- based) 간병서비스를 규명하
    고, 가족의 경제적 부담 및 사회적 부담을 감소시킬 수 있는 간병서비스 보장 메커니
    즘을 개발하는 데 그 목적이 있음. 구체적 목적은 다음과 같음.
    첫째, 병원급 이상 의료기관 간병인 활동실태 파악 및 문제점 도출
    둘째, 의료기관 간병수급 현황 분석 및 간병비용 추계
    셋째, 간병서비스 규명 및 표준화된 간병교육 프로그램 개발
    넷째, 양적?질적 간병서비스 보장을 위한 제도적 메커니즘 개발
    다섯째, 간병비의 재원조달 방안 및 지불보상 방식 제시
    2. 연구방법
    ? 국내외 관련 법 및 문헌고찰, 인터넷을 이용한 국내외 관련 정보검색
    ? 우리나라 간호행위 관련 보험책정 및 2005년 4/4분기 요양급여 신청 병원급 이상 의료
    기관 자료 분석
    ? 의료기관의 간병인 활동실태조사 실시
    ○ 표본 선정방법
    ① 의료기관종별 선정 규모: 비비례층화표출법(disproportional stratified sampling)
    ② 조사대상 의료기관 선정: 계통적 표출법(systematic sampling)
    ○ 조사대상 및 자료수집 결과
    - 총 311개 조사대상 기관 중 112개 기관(종합전문요양기관 22개소, 종합병원 50개
    소, 요양병원 19개소, 병원 21개소)의 자료수집(회수율 36.0%)
    ? 입원환자 및 의료기관 간병인 활동조사 실시: 간병인 이용환자 및 간병인 대상
    ○ 표본 선정방법: 목적표출법(Purposive sampling)을 통한 의료기관 및 간병단체 선정
    후 조사대상자 무작위 추출
    ○ 조사대상: 간병인 50명, 간병인 이용환자(또는 가족) 50명
    ? 주요 정보 제공자 면담 (Key Informants interview)
    ? 학계 및 보건의료계 전문가, 간병 교육?알선단체의 의견수렴
    3. 의료기관 간호서비스 지불보상체계
    가. 우리나라 간호행위에 대한 지불보상체계
    ? 간호사의 간호업무에 대해서는 의료법(제2조)에 ‘상병자 또는 해산부의 요양상의 간호
    또는 진료의 보조 및 대통령령이 정하는 보건활동에 종사함’이라고 규정하고 있을 뿐
    구체적인 업무를 규정하고 있지 않고 있음.
    ? 건강보험에서 지불보상이 이루어지고 있는 간호행위는 680여개 간호행위 중 37개에 불
    과하며 나머지 650여개 간호행위는 ‘입원료’에 포함된 ‘입원환자 간호관리료’로 지불보
    상됨(‘병원간호사회’에서의 구분 기준).
    ○ 입원료 = 입원환자 간호관리료(25%)+병원관리료(35%)+의학관리료(40%)
    ? 입원환자 간호관리료는 종합전문요양기관, 종합병원, 병원, 의원으로 구분하여 일반병
    동의 간호사 확보정도에 따라 1~6등급으로 분류, 등급별로 입원료의 10%를 가산하여
    책정되어 있음.
    ○ 병상 대 간호사수로 차등되는 (간호)등급은 종합전문요양기관의 경우 2:1~4:1, 종합
    병원급 이하 기관은 2.5:1~4.5:1을 여섯 등급으로 나누어 2006년 종합전문요양기관
    의 경우 1등급은 22,890원, 6등급은 7,630원이며, 병원은 1등급 18,605원, 6등급
    6,202원의 차등수가가 적용됨.
    ? 병원급 이상 의료기관의 간호등급(2005년 4/4분기)을 살펴보면 총 1,449개소 중 종합전
    문요양기관 2개소와 병원 1개소만이 1등급임. 종합전문요양기관의 경우 64.3%가 4~6
    등급(4등급 52.4%, 5등급 9.5%, 6등급 이하 2.4%), 종합병원, 병원 및 요양병원은 6등급
    또는 6등급 기준인력도 충족시키지 못하는 경우가 각 60.7%, 96.7%, 100%로 파악됨.
    ○ 종합병원급 이하 병원의 6등급의 간호사 1인당 담당병상수는 4.5병상 이상으로 1일
    3교대 등으로 실질 근무 담당병상수를 환산하면 14병상 이상을 담당하는 것임.
    ○ OECD(2005) 자료에 의하면 종합병원급 이상 의료기관의 간호사 1인당 담당병상수
    는 2.7로 미국 0.71, 영국 0.56, 프랑스 1.85 등 선진국에 비해 담당병상수가 높은 실
    정임.
    ? 현 수가체계 하에서 간호사 인건비 보전율은 종합병원의 경우 간호등급수준에 따라 39~
    67%로 간호사인력 투입의 유인책이 없는 상태임.
    ○ 의료기관에 대한 낮은 간호관련 수가 때문에 환자 간병은 환자가족의 몫으로 당사
    자인 환자가족 또는 개인 고용 유료간병인에 의해 해결되고 있는 실정임.
    나. 일본의 의료기관 간병서비스 확보를 위한 개선 실태
    ? 일본은 1970년대 부터 급증한 환자 개인고용에 의한 간병인의 활동을 폐지하고 간호의
    질을 향상시키고자 1994년 간호료 지불보상체계를 개선하여 일명 ‘신간호체계’를 수립함.
    ○ 즉, 사회보험 지불보상체계에 ‘간호보조료’ 수가를 별도로 신설하여 병상에 투입된
    간호보조자(‘간호조수’로 지칭) 비율에 따라 8단계(3:1~15:1)로 구분된 수가를 책정,
    추가로 차등지급함.
    ○ 또한 입원기본료의 간호료(신간호료)는 환자 대 간호인력의 비율을 7단계(2:1~6:1)
    로 세분화하여 간호인력 투입수준에 따라 최고 2배의 간호료를 추가 지불보상함으
    로써 서비스 질 향상을 유도함.
    ? 일본 정부는 개인 고용 간병인 활동의 폐지를 위해 간병인이 활동하는 기관에 대해서
    는 보험의료기관의 지정을 취소하는 등 적극적인 조치를 취함.
    ○ 이에 1995년 환자를 시중하는 간병인의 활동을 허용하던 병원의 약 80%가 간병인
    활동이 폐지됨.
    ○ 개정된 지불보상 기준으로 인하여 간호보조료가 포함된 전체 간호료는 1997년 이전
    보다 약 20% 상승하게 되었으며 이는 총의료비의 전년도 대비 증가분 5% 중 2.6%
    에 해당된 것으로 파악됨.
    4. 의료기관 간병인력 활용 실태
    가. 간병인 고용방식 및 관리
    ? 전국 표본 추출된 병원급 이상 의료기관(112개소)의 간병인 활용 또는 환자알선 방법은
    병원이 요청환자에 대해 간병인 단체로 연결하고 각 간병인단체가 간병인 관련 업무를
    전담하는 경우가 가장 많아 46.3%, 단체에서 파견된 간병인을 병원에서 관리?담당하는
    경우 24.4%, 병원에서 공식적으로 인력을 채용한 경우가 17.1%이었음.
    ? 조사대상 병원의 17.9%(종합전문요양기관 22.7%, 종합병원 22.0%, 병원 19.0%)는 소속
    기관에서 활동하는 간병인을 대상으로 교육을 실시한 바 없다고 응답하였는데, 무응답
    기관이 29.5%임을 고려하면 47.4%의 기관이 간병인에 대한 교육을 실시하지 않은 것
    으로 추정됨.
    나. 간병인 이용 현황 및 문제점
    ? 2005년 12월 말 현재 병원급 이상 의료기관에서 활동하고 있는 1일 평균 유료 활동간
    병인 수는 총 30,861명으로 추정
    ? 입원환자 중 11.7%는 유료 간병인을 이용하고 있었음(종합전문요양기관 10.1%, 종합병
    원 8.4%, 요양병원 19.3%, 병원 9.0%).
    ○ 병원 간호관리자의 의견을 토대로 일반병동의 간병서비스가 필요한 환자의 비율을
    파악한 결과, 요양병원이 91.4%로 가장 높았고, 종합병원 54.2%, 종합전문요양기관
    48.3%, 병원 44.2%이었음.
    ○ 이에 따라 간병이 요구되는 환자이나 비용부담 등으로 가족에 의해 간병이 이루어
    지거나 간병할 가족이 없어 방치되고 있는 환자의 비율은 전체 입원환자 중 35%~
    72%(종합전문요양기관 38%, 종합병원 46%, 병원 35%, 요양병원 72%)임.
    ? 간병인 이용 사유는 ‘간병가족이 없어 가족의 일상생활 지장과 가족간 갈등이 초래될
    것 같아’ 30.0%, ‘병원 치료과정상 환자가 이동하고 환경이 복잡하여 보호자 상주가 필
    요할 것아’ 25.6%, ‘간병을 해보니 간병하는 일이 정신적?육체적으로 부담이 커’ 24.4%
    로 나타남.
    ? 병원담당자들이 지적한 간병인 문제는 ‘간호사 또는 보호자의 지시에 응하지 않고 불
    손’이 가장 많아 전체 병원 중 48.2%(문제발생건이 거의 매일 2.7%, 주 1~3회 9.8%,
    월 1~2회 35.7%), ‘환자를 잘 돌보지 않아(동료간 잡담, 외출 등) 환자가 불편 호소’가
    41%(거의 매일 1.8%, 주 1~3회 7.1%, 월 1~2회 32.1%), 그리고 25.9%가 ‘간병인 부주
    의로 환자가 다치거나 간병 기초상식 부족’을 지적함.
    ○ 그 외 환자 질환 및 기타 비밀을 누설한 경우, 간병인의 불량한 개인위생을 문제로
    지적함.
    ? 한편, 간병인들은 24시간 또는 12시간 근무형태, 환자로부터의 감염, 근로조건 불이익
    등에 대해 애로사항을 토로함.
    ? 2005년 병원급 이상 의료기관 입원환자가 간병인 이용비용으로 환자가족이 지출한 비
    용부담액은 연간 414,772(간병인 조사기준)~612,822백만원임(간병인이용환자 기준).
    ○ 간병인 고용에 따른 가족의 지출비용은 1주당 평균 381,875원이며, 암환자가 1주당
    45만원, 사지마비환자 42만원, 척수 및 관절손상 등 근골격계 질환 40만 5천원, 뇌
    혈관질환 35만 5천원임
    ○ 여기에 환자 가족들에 의해서 이루어진 간병에 대한 사회적 비용(직장인 휴가(직)시
    인건비, 식사비, 교통비, 간병 필요물품 구입비 등)까지 포함한다면 그 비용은 더 높
    아질 것임.
    ○ 간병비용에 대해 환자가족의 약 65%는 부담을 가지고 있으며, 부담을 갖지 않는다
    는 경우는 10.2%에 불과함.
    ? 간병인 이용 전후 환자 가족의 환자 방문빈도는 간병인 이용 전 하루 종일 병원에 상
    주한 비율이 44.0%이었으나 간병인 이용 이후에는 4.1%로 감소하였고 거의 매일 방문
    하거나(40.8%), 주 1~2회 방문하는 경우가 많았음(24.5%).
    다. ‘보호자 없는 병동’에 대한 환자가족의 의견
    ? 향후 간호인력의 팀접근을 통해 간호?간병서비스가 병원차원에서 전부 제공되는 이른
    바 ‘보호자 없는 병동’이 마련될 경우, 환자가족에게 이용여부를 파악한 결과, 이용하
    겠다는 대상은 72.9%, 이용하지 않겠다는 대상은 18.8%, 판단유보 또는 병동여건 또는
    간호사 수준을 보고 결정하겠다는 경우가 8.3%이었음.
    ○ 보호자 없는 병동을 이용하는 사유는 전문적이고 신뢰할 수 있는 간병을 받을 수
    있을 것 같아서 35.1%, 병원이 책임질 것이므로 가족들이 안심하고 가사나 생업에
    종사할 수 있기 때문 28.6%, 간병비용 부담이 크기 때문이 23.1%로 나타남.
    ○ 보호자 없는 병동 이용을 원하지 않는(또는 판단을 유보한) 이유는 환자인 가족을
    혼자 둘 수 없기 때문에 35.2%, 환자가 원하지 않기 때문에 27.8%로 나타남.
    5. 의료기관 간병인력 수급 현황
    가. 간병인력 양성
    ? 간병인력은 ‘노인복지법’, ‘국민기초생활보장법’ 및 ‘산재보험법’ 등에 따라 양성되는
    간병인력과 이와 유사한 업무와 교육내용을 갖는 간병인, 케어복지사 등 민간자격제도
    로 양성되는 인력으로 다원화되어 있음
    ※ 민간 간병인력 양성 또는 알선 단체는 대부분 열악한 수준으로 전국에 약 5,000여
    개소로 추정
    ? 현재 간병 및 요양보호 인력의 양성?관리체계의 미비로 민간기관에서 전문성이 부족한
    인력이 양산됨에 따라 서비스 질 저하 초래
    ○ 간병인력 역할과 업무범위가 미정립되어 있어 표준화된 커리큘럼이 부재함.
    나. 의료기관 간병서비스 수요추계
    ? 병원 간호관리자의 간병요구(need-based)에 기초할 경우 특수병원(정신?결핵?한센 병
    원)을 제외한 병원급 이상 의료기관(1,449개소)에서 적정 수준의 간병을 제공하는데 필
    요한 총간병인력 수요는 최소 134,341명으로 추계됨.
    ○ 2005년 4/4분기 간호등급 요양급여 신청 병원급 이상 의료기관종별 간호등급 기준
    총간병인력 수요: 134,341명
    ○ 2005년 4/4분기 간호등급 요양급여 신청 병원급 이상 의료기관 가동병상 규모에 따
    른 총간병인력 수요: 166,385명
    ? 특수병원(정신?결핵?한센 병원)을 포함한 병원급 이상 의료기관(1,552개소)에서 적정
    수준의 간병을 제공하는데 필요한 총간병인력 수요는 약 20만명으로 추계됨.
    6. 의료기관 간병서비스 제도화 방안
    가. 기본방향
    ? 간병은 의료기관의 간호서비스 전달체계 내에서 팀 접근을 통해 공급되어 궁극적으로 보
    호자가 상주하지 않는 ‘보호자 없는 병동’시스템 구축으로 사회적 수요에 부응하도록 함.
    ? 최근 사회 양극화 현상의 심화 및 근로빈곤층(working poor)이 증가하고 있는 우리나라
    현실적 상황과 사회적 비용부담을 고려하여 장단기로 구분, 사회적으로 유용한 간병서
    비스 공급기전을 마련함.
    ○ 단기적으로는 현재와 같은 일시적, 임시직, 비전문적 서비스라는 한계를 극복하고
    인증된 기관에서 간병교육을 이수한 간호보조인력의 간병서비스 제공 및 ‘간호보조
    료’ 수가 신설을 통해 사회적 요구에 부응한 공익사업으로 자리매김할 수 있도록
    함.
    ○ 장기적으로 급성기 병동에서는 간호사 인력이 간호 및 간병서비스를 제공하도록 지
    불보상체계를 마련하고, 재활 및 요양병동에서 간호보조인력이 활동, 지불보상화하
    여 보호자가 상주할 필요가 없는 병동 시스템을 구축하도록 함.
    나. 의료기관 간병서비스 제도적 요건
    1) 간호보조인력 교육 및 양성 프로그램
    ? 2008년 도입될 노인수발보험제도하에서 양성, 배출되는 수발(시설?재가간병)인력의 자
    격(인력 명칭 포함)과 호환되도록 함.
    ? 교육?훈련 시간과 내용 중 간호보조인력의 경우, 의료인의 지시?감독이 필요한 간병서
    비스(급성기 환자의 특성 및 이에 적절한 위생관리, 환자상태 관찰 등)에 대한 기술이
    더 요구됨.
    ○ 시설?재가간병의 경우, 만성질환자 특성, 가정간병(취사?청소?세탁, 지역사회 연계
    등)의 업무가 더 요구됨.
    2) 간호보조인력 양성교육 및 알선?파견기관
    ? 간호보조인력 양성 및 교육기관은 ‘노인수발보험제도’에서 양성되는 수발요원 양성교육
    인증기관 조건에 준함.
    ○ 간호보조인력 알선기관은 사회적 기업의 조건인 조직의 목표를 이윤보다는 구성원과
    지역사회의 공익을 우선하여야 하고 민주적인 의사결정 과정 시스템이 형성되어야 함.
    ? 간호보조인력 교육 및 일자리 알선?파견 유형과 각 유형별 장단점은 <표 2>와 같음.
    ○ 제도화 초기에는 제2안, 제3안의 형태일 것이나 차후 제 1안이 형태의 참여 가능성
    이 높음.
    3) 간호보조인력 업무범위
    ? 환자의 치료 및 처치와 관련된 수가화되지 않은 간호서비스에 대해서는 간호사가 제공
    하도록 보험수가화하고, 환자상태에 대한 의료인의 판단에 의해 다음의 서비스 범위
    내에서 환자의 수발서비스를 간호보조인력이 제공하도록 함.
    ○ 간호보조인력은 의료인의 지시와 감독 하에 신체관리(전신, 상체, 하체, 손?얼굴 씻
    기), 샤워하기 돕기, 단순 구강?의치 및 치아 관리, 머리빗기, 면도, 배설(소변, 대변,
    의복상태 준비, 소변후 귀저귀 교체, 대변후 귀저귀 교체), 영양섭취(먹기에 알맞은
    음식 준비?차리기, 구강영양), 기동성 돕기(기상?취침, 이동, 걷기, 서 있기, 계단 오
    르내리기), 의복 갈아입기 등의 업무를 수행함.
    다. 의료기관 간병서비스 적용방안
    1) 수혜대상
    ? 원칙적으로 모든 입원환자. 단, 요양병원의 노인수발보험제도 수혜자 제외
    ○ 조기퇴원 후 가정간호 이용환자에 대해서도 입원과 동일하게 간병서비스를 제공하
    여 간병서비스 제공으로 퇴원하지 않고 불필요한 입원이 증가되는 부작용 방지
    2) 간병서비스 관련행위 보험수가
    ? 현 수가화 되지 않은 ‘환자에게 전적 식사 보조행위’, ‘전신억제대 적용’, ‘피부간호(성
    인)’ 등의 간호행위에 대해 수가화함.
    ○ 장기적으로 급성기 병동은 간호관리료 수가 개선을 통해 간호사에 의한 간호?간병
    서비스가 제공되도록 함.
    ? 수가화되지 않은 기본간호 행위 중 위임 가능한 행위와 수발서비스를 가칭 ‘간호보조
    료’로 지칭하여 수가 신설
    ○ 원칙적으로 정액 수가 적용
    ○ 간호보조인력 인건비(연 1168만원) 보전율 75% 기준: 원가보전 수준이 낮을 경우
    간호보조인력 투입을 기피할 것이 우려되나, 높을 경우 간호사 인력 배치를 기피하
    고 간호보조인력으로 대체할 수 있으므로 두 인력의 인건비 보전율을 유사한 수준
    으로 유지(간호관리료 수가 상향조정하여 인건비 보전비율 75% 예상시)
    ? 간호보조료 수가: 건강보험제도의 재원조달체계를 적용함.
    ○ 재원은 보험료 및 이용자부담으로 구성되며, 현행 건강보험의 재원분담비율이 그대
    로 적용됨
    ? 간병서비스의 법정본인부담률은 20%로 함. 다만, 법정 본인부담률을 시행초기에
    50%를 적용하고, 시행과정상 문제점을 보완한 후에 20%를 적용하는 방안을 검토함.
    ? 의료급여대상자는 정부부담(국가와 지자체 분담)으로 함
    ○ 행위료에 적용되는 요양기관종별 수가가산율은 ‘간호보조료’에는 적용하지 않도록 함.
    라. 소요비용 추계
    ? 소요비용
    ○ 소요비용은 간병서비스 적용대상을 병원 입원환자 전원에게 적용할 경우에 소요되는
    간병서비스 인건비를 기준으로 산정함.
    ○ 의료기관의 유형은 일반병원, 요양병원, 특수병원으로 구분하되, 특수병원은 간병서
    비스 비용추계에서 제외함. 특수병원은 정신병원, 결핵병원, 한센병원 등으로서 일반
    간병서비스가 어려울 것으로 판단되기 때문
    ? 소요비용의 계산
    ○ 소요비용은 간병인 1인당 연간 인건비를 기준으로 앞서 추계한 간병소요인력수를 곱
    하여 산정
    마. 재원조달
    ? 재원조달 유형 및 분담
    ○ 병원 입원환자의 간병서비스 비용을 제도화하게 되면 건강보험제도, 의료급여제도,
    산재보험제도 및 자동차보험에서 분담하게 됨.
    ○ 간병서비스 비용을 각 제도별로 분담함
    ? 건강보험의 경우 보험료 및 국고, 환자본인부담으로 조달
    ? 의료급여의 경우 1종과 2종으로 나누어 환자본인부담을 제외한 나머지 비용은 국
    고 및 지방비 등 정부부담으로 조달
    ○ 이에 따라 건강보험의 경우 직장가입자 1인당 혹은 지역가입 세대당 매월 추가되는
    본인부담 보험료와 고용주 및 정부의 추가부담을 계산함
    ? 적용기관과 재원조달방식에 따라 건강보험 재원의 증가율은 다음과 같음.
    ○ 일반병원과 요양병원을 대상으로 건강보험 환자본인 부담률을 50% 적용할 경우 건
    강보험 재원의 증가율은 2.17%이며, 환자본인부담률 20%의 경우 건강보험 재원의
    증가율은 3.47%가 되어야 함.
    ○ 일반병원만을 대상으로 건강보험 환자본인 부담률을 50% 적용할 경우 건강보험 재
    원의 증가율은 1.69%이며, 환자본인부담률 20%의 경우 건강보험 재원의 증가율은
    2.70%가 되어야 함.
    ? 간병서비스 재원을 조달하기 위해 가입자 1인당 월평균 추가보험료는 건강보험환자 본
    인부담률에 따라 792~1,836원임(표 4).
    ? 입원환자의 1일 ‘간호보조료’ 수가 및 환자본인부담액
    ○ 간병 불필요 환자도 가족 또는 간병인에 의해 간병이 이루어지고 있다는 점을 고려
    하여 ‘보호자 없는 병동’의 구축을 위해 의료기관 입원환자 전원에게 간호보조료
    수가를 적용, 산정함.
    ○ 2000~2004년 기간 동안의 종합전문요양기관, 종합병원, 병원(한방, 요양병원 포함)
    의 총 연인원 입원일수에 대한 연 평균 증가분(7%)을 동 간병제도가 적용되는 2007
    년을 기준으로 추정하여 ‘간호보조료’의 환자본인부담액을 산출하면 일반병원과 요
    양병원 입원환자 적용시 1일 7,760원(50% 환자본인부담률 적용시), 3,105원(20% 환
    자본인부담률 적용시)임.
    ○ 이 경우, 본 연구에서 전문가가 평가한 간병이 불필요한 종합전문요양기관의 51.7%,
    종합병원 45.8%, 요양병원 8.6%, 병원 55.8%의 입원환자는 간호보조료의 본인부담
    액 지출에 따른 저항이 예상됨.
    바. 제도 도입 및 시행
    ? 시범사업 실시
    ㅇ 목적: 간병서비스 보장성 평가와 환자 중증도에 따른 간병요구도(need of care) 적합
    성 평가
    ? ‘간호보조료’ 수가 적용환자 및 급여범위에 대한 평가와 아울러 질적 서비스 제공
    을 위한 적정수가 모형 개발
    ? 환자의 건강상태 및 관리수준에 따라 의료기관-가정-시설 등으로 이동하는 환자의
    특성을 감안하여 간병서비스가 원활하게 제공되도록 continuity care의 확보를 위
    한 합리적 방안 마련
    ? 시범사업 운영 전반을 모니터링하고 평가한 후 이후 단계적, 또는 전면 확대 여
    부 등을 평가
    ? 입원환자의 간병서비스 보장으로 인한 사회적 입원의 증가 방지를 위한 정책적
    수단 개발: 입원건당 보험 적용일수를 제한하며(예: 입원진료 건당 20일까지), 동
    시에 연간 일정 간병보조료 요양급여일수 제한(예: 연간 총 100일 등) 등
    ○ 대상
    ? 지방공사의료원: 공공의료 강화를 위한 정부정책 부응 차원
    ? 종합전문요양기관(또는 일정 병동): 전문적 간병요구도 큰 급성기 중증환자가 입
    원하기 때문, 병원 자율적 판단에 의해 원하는 경우 지정
    ○ 기간: 2008년 노인수발보험제도 도입 이전(2007년) 실시
    ○ 간호보조인력수
    ? 지방공사의료원 (35개소): 총 6,009명
    ? 종합전문요양기관(42개소): 총 18,212명
    ○ 소요예산(국고 또는 보험재정)
    ? 지방공사의료원: 기관당 평균 연간 7억 4천만원
    ? 종합전문요양기관: 한 병상당 평균 연간 222만원
    ? 단계적 확대 도입
    ○ 시기: 시범사업 후 노인수발보험제도의 도입시기(’08년 7월 예정)와 같은 시기에
    각 병원의 실정에 따라 단계적으로 확대 추진
    ○ 간병서비스 보험적용전략: 의료기관 입원환자의 간병서비스 보장으로 인한 사회적
    입원의 증가를 방지하기 위해 연 간병보조료 급여일수 제한
    7. 향후 정책과제
    ? 간호사의 간호행위에 대한 지불보상체계의 개선
    ○ 입원진료의 질을 향상시키기 위해서는 간호사 인력을 확보할수록 병원경영에 적자
    를 초래하는 현 간호관리료 등의 지불보상체계의 개선이 선결되어야 할 것임.
    ? 입원환자의 연 간병보조료 보험급여일수 제한을 위한 ‘국민건강보험 요양급여의 기준
    에 관한 규칙’ 개정
    ○ 입원환자에게 간병서비스가 보장됨으로써 초래되는 사회적 입원의 증가를 방지하기
    위해 환자 1인당 연간 간병보조료 총급여일수를 제한하는 제도적 장치를 마련함.
    ○ 연간 보험급여일수를 초과한 경우에는 초과한 날로부터 100% 환자 본인부담으로 함.
    ? 입원환자의 효과적인 간병서비스 제공을 위한 병동 운영모형 개발
    ○ 간병서비스 제도화의 목적이 환자가족이 안심하고 사회생활을 하거나 일상생활에
    지장을 받지 않도록 병원 차원에서 환자간호의 일환으로 양적, 질적 간병서비스를
    제공하는 데 있음.
    ○ 그러나 본 연구에서 환자의 25.6%가 치료과정 중에 병원시설 및 구조상 환자가 이
    동하여야 하고 병원환경이 복잡하여 간병인이 필요한 것으로 응답하여 ‘보호자 없
    는 병동’으로 발전시키기 위해서는 입원병동 및 진료과정에서 환자에게 무리가 되
    지 않는 시설 및 환경 개선 등이 뒤따라야 할 것임(시범사업 중 점검이 요구되는
    부분임).
    ○ 한편, 영유아 및 아동환아의 경우에는 부모의 정서적지지 및 참여가 환아의 신체?
    정신적 발달도모와 심리안정에 중요한 역할을 한다는 점은 주지의 사실인 바, 특히
    소아병동에 적정한 간호 및 간병서비스 제공전략이 요구됨.
    ? 질적 간병서비스 모니터링체계 구축
    ○ 세계보건기구(WHO, 1991)는 의료서비스의 질을 평가하는 지표로 기술수준, 효율성,
    위험대처관리, 그리고 환자의 만족도를 제시함. 이에 질적 간병서비스를 확보하기
    위해서는 팀 접근을 통한 간병서비스의 철저한 지도감독체계가 요구됨.
    ? 보호자가 간병을 하지 않아도 되는 ‘보호자 없는 병동’에 대한 국민 홍보 실시
    ○ 간병서비스 제도 구축 후 ‘보호자 없는 병동’ 시스템으로 발전시키기 위해서는 일차
    적으로 환자 간병을 목적으로 환자가족 또는 간병인이 병원에 숙박하는 현재의 관
    행을 특별한 환자를 제외하고는 금지하도록 하고, 일용직 유료간병인에 의존하는
    국민의 인식 전환을 위한 홍보 실시가 요구됨.
    ? 간호인력의 팀 접근에 의한 간병서비스 제공방안 검토
    ○ 본 연구결과, 간병인 이용환자 또는 가족의 8.3%는 교육인증기관에서 자격증을 받
    은 간병인력보다는 간호사가 간병서비스를 제공해주길 원하였고 27.1%는 간호조무
    사에 의한 간병서비스를 원하였음.
    ○ 간호조무사는 12개월간(6개월 이론)의 교육을 받고 간호조무사 자격시험을 통과하여
    자격인정을 받은 자임. 이들의 업무는 간호업무 보조와 진료보조에 관한 업무를 행
    하도록 되어 있음(간호조무사 및 의료유사업자에 관한 규칙). 이에 따라 제도 시행
    에 소요되는 재원이 동일할 경우, 간호사 및 간호조무사 인력을 포괄하는 간호팀
    접근을 통해 간병서비스가 간호서비스와 연계되어 제공되는 방안을 검토할 필요가
    있음.
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발행년도 2006

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