제1차 국민건강보험종합계획 2021년 시행계획(안)20.11.27

제1차 국민건강보험종합계획 2021년 시행계획(안) 20.11.27 보건복지부

목 차
Ⅰ. 수립 개요 ·······················································································1

□ 수립 근거
○『국민건강보험법 제3조의2』에 근거
- 보건복지부장관이「국민건강보험종합계획」에 따라 매년 연도별 시행계획을 수립하고, 매년 시행계획에

  따른 추진실적을 평가
- 시행계획은 건강보험정책심의위원회 심의를 거쳐 수립하고, 국회(소관 상임위원회)에 보고
□ 2021년 시행계획 개요
○ ｢제1차 국민건강보험종합계획(2019~2023)｣수립(’19.5.1)에 따라 3차년도 시행계획인 2021년도

   추진내용 및 추진일정 등 마련
○ 2021년 시행계획 추진실적은 ’22년에 평가하여, 그 결과를 다음번 종합계획(2024~2028) 및 2023년

   시행계획에 반영 검토
Ⅱ. 세부 추진 과제 ··············································································3
1. 평생건강을 뒷받침하는 보장성 강화 ······································5
1-1. 국민의료비 부담 경감 ································································7
1-1-1. 비급여의 단계적 급여화······························································· 9

1. 과제 개요
○ (기본방향) 치료에 필요한 항목은 급여화하되, 필수적인 분야‧항목부터 단계적으로 추진
- 치료에 필요하지만, 일부비용효과성이 불확실한 비급여는 본인부담을 높여(50~90%) 예비적으로

  급여화(예비급여)
* 3~5년 주기 재평가를 통해 급여 또는 비급여로 전환, 예비급여 유지 등 결정(’19~), 안정성‧유효성 등

  의료기술 평가 필요시 심층평가 실시(보건의료연구원)(’20~)
○ (필수검사 비급여) MRI 및 초음파는 의학적으로 필요한 모든 경우에 보험이 적용되도록 단계적으로

   확대(~’21)
○ (의학적 비급여) 비급여 의료행위, 소모품(치료재료) 등을 점검하고, 치료에 필요한 의학적 비급여는

   ’22년까지 단계적으로 급여화 추진
○ (상급병실 비급여) 국민 수요도, 의료기관 종별 기능, 병원급 의료기관간 형평성 등을 고려하여 병원

   (의과·한방) 2·3인실 보험 적용(’19)
- 1인실은 감염 등으로 불가피한 경우에 제한적 적용 추진(’20)
○ (보장성 모니터링 및 대응) 보장성 강화대책 추진으로 빠른 지출 증가가 예상되는 항목 중심으로

   이용량, 청구경향 등 모니터링 강화

비급여의 급여화 추진 계획           1] (MRI) ’19년(두경부, 복부, 흉부 등) → ’20년(척추) → ’21년(근골계) 2] (초음파) ’19년(하복부, 비뇨기, 생식기) → ’20년(흉부, 심장) → ’21년(근골격, 두경부, 혈관) 3] (상급병실) ’19년(병원[의과·한방] 2·3인실 보험 적용) 4] (등재비급여) ’19년(응급실·중환자실 등) → ’20년(척추) → ’21년(근골격, 만성질환)                      → ’22년(안·이비인후과 질환 등) 5] (기준비급여) ’19년(암환자, 뇌혈관 질환 등) → ’20년(척추, 근골격, 재활 등)                       → ’21년(정신질환, 영유아질환 등) → ’22년(안·이비인후과 질환 등)          * 추진 일정 및 분야 등은 시행계획 수립과정에서 변경 가능

2. 추진 경과
○ (MRI·초음파 급여화) 비급여의 급여화 추진계획에 따라 질병진단에 필수적인 분야에 건강보험

   적용 완료
- 상복부 초음파(’18.4월), 하복부‧비뇨기 초음파(’19.2월), 남성생식기초음파(’19.9월), 여성생식기

   초음파(’20.2월), 안과 초음파(’20.9월)
- 뇌혈관 MRI(’18.10월), 두경부 MRI(’19.5월), 복부‧흉부 MRI(’19.11월)
○ (상급병실 급여화) 상급병실료 부담완화를 위한 단계적으로 건강보험 적용 확대 완료
- 종합병원급 2‧3인실(’18.7월), 병원급 2‧3인실(’19.7월)
○ (등재‧기준비급여) 사회적 요구도가 큰 필수적 의료분야 건강보험적용 확대 및 급여 기준 확대 완료
- 신경인지검사, 난청검사, 수면장애 검사 등 총 566개 항목 급여화 및 기준확대(’20.9월 기준)
3. 2021년도 추진 계획
□ 추진내용
○ (MRI·초음파 급여화) 비급여의 급여화 추진계획에 따른 ’21년도 주요 항목의 건강보험 적용
- 척추 분야 MRI, 심장 분야 초음파 건강보험 적용 확대 추진 : 21년상반기 의견수렴후  하반기 적용
* 불필요한 오남용 방지를 위한 통제장치를 마련하여 병행 추진
** 초음파, MRI 건강보험 적용 과정에서 의료기관 손실‧왜곡이 발생하지 않도록 예상진료량을 고려

   하여 수가 수준 논의

○ (의학적 비급여 급여화) 신경계질환 분야 건강보험 적용 및 정신질환 분야 급여기준 확대 추진  

21년 상반기	21년 하반기
· 생물학적 드레싱류 건강보험 적용 · 정신질환, 심장질환 분야 급여기준 확대	· 신경계질환 건강보험 적용 추진 · 영유아질환 분야 급여기준 확대

- (등재비급여) 신경계질환 분야 등 급여화 추진
  * 기립성혈압검사 등 검사행위 및 생물학적 드레싱 등 치료재료 건강보험 적용 추진
- (기준비급여) 영유아질환, 정신질환, 심장질환관련건강보험급여기준확대
  * 경피적관상동맥 시술관련 행위 및 치료재료, 인공심폐기 인정기준 등 검토 예정

○ (새로운 가격제도 도입) 일정 기간 정부 관리체계 하에 자유가격 유지하며 의료제공을 허용하되

   주기적으로 재평가하여 조정(요양급여 기준규칙 개정)
   * 로봇수술 등 고가의 비급여 또는 신의료기술 대상
○ (모니터링 및 관리) 급여화항목에 대한 모니터링 실시로 청구량 급증 등 비정상적인 의료이용 경향에

   대한 점검 및 대응 추진
* 매월 의료기관 종별로 이용량 확인을 통해 이상 징후 모니터링 후 급여기준 개선 등 조치

□ 세부추진일정

구분	추진일정
1/4분기	- 척추 MRI 협의체 운영(1월) - 심장 초음파 협의체 운영(3월)
2/4분기	- 정신질환 분야 급여기준 확대 적용(6월) - 생물학적 드레싱류 건강보험 적용(6월)
3/4분기	- 심장 초음파 건강보험 적용(9월) - 신경계질환 분야 건강보험 적용(9월)
4/4분기	- 척추 MRI 건강보험 적용(12월) - 영유아 분야 급여기준 확대 적용(12월)

* 과제별 세부추진일정은 정책 추진 과정에서 변동가능

1-1-2. 의약품 보장성 강화······································································13
1-1-3. 구강건강 보장성 강화·································································· 16
1-1-4. 한의약 보장성 강화······································································18
1-1-5. 간호·간병통합서비스 확대 및 제도화········································20
1-1-6. 임·출산 및 어린이 의료비 부담 경감········································24
1-1-7. 보완적 의료비 지원 내실화·························································27
1-1-8. 비급여 관리 강화··········································································30
1-2. 환자 중심 통합서비스 제공 ····················································33
1-2-1. 입원-퇴원-재가복귀 연계 강화···················································· 35
1-2-2. 환자 중심의 협진 활성화·····························································38
1-2-3. 조기 사회 복귀를 위한 재활의료 제공체계 구축···················· 40
1-2-4. 거동불편 환자의 재택의료 활성화············································· 43
1-3. 예방중심 건강관리 기능 강화 ················································47
1-3-1. 국가건강검진 효과성 제고 등·····················································49
1-3-2. 일차의료 중심의 포괄적 만성질환 관리강화···························· 53

1-3-3. 교육·상담 활성화···········································································56
1-3-4. 장애인 건강관리 강화·································································· 59
2. 의료 질과 환자 중심의 보상 강화 ········································61
2-1. 의료 질 제고 ·············································································63
2-1-1. 의료 질 평가 및 보상 내실화·····················································65
2-1-2. 질과 성과 중심의 심사체계 개편··············································· 70
2-1-3. 전자적 진료정보 교류 및 관리 강화········································· 73
2-2. 적정 진료 및 적정 수가 보상 ················································77
2-2-1. 3차 상대가치 개편 추진·······························································79
2-2-2. 의료 질 향상을 위한 인력 투입·················································82
2-2-3. 필수의료에 대한 지원 강화·························································85
2-2-4. 포괄·묶음 방식의 수가제도 확대················································90
3. 건강보험의 지속가능성 제고 ·················································95
3-1. 건강보험 재정 관리 강화 ························································97
3-1-1. 재원조달 안정화············································································99
3-1-2. 보험재정 관리·운영 체계 개선·················································· 101
3-2. 의료이용 적정화 ·····································································103
3-2-1. 가입자의 합리적 의료이용 지원··············································· 105
3-2-2. 공·사 의료보험 연계 강화························································· 108
3-3. 합리적인 지출구조 설계 ·······················································111
3-3-1. 의료기관 기능에 적합한 보상체계 마련·································· 113
3-3-2. 보험급여 재평가를 통한 급여체계 정비 강화························ 116
3-3-3. 약제비 적정 관리········································································ 120
3-3-4. 보험급여 사후관리 강화····························································· 122

3-4. 통합적･효율적인 노인의료 제공 ··········································125
3-4-1. 합리적 이용 지원을 위한 노인의료 제공체계 개편··············· 127
3-4-2. 존엄한 임종 지원 강화······························································· 130
4. 건강보험의 신뢰 확보 및 미래 대비 강화 ························133
4-1. 공평한 보험료 부과 ·······························································135
4-1-1. 보험료 부과체계 개편 지속 추진············································· 137
4-1-2. 소득에 대한 부과기반 강화······················································· 139
4-2. 가입자 자격･징수 관리 제도 개선 ······································141
4-2-1. 체계적인 진단을 통한 자격기준 정비······································ 143
4-2-2. 부담수준을 고려한 보험료 경감제도 정비······························ 145
4-2-3. 납부능력에 따른 체납관리 차별화··········································· 147
4-2-4. 내·외국인 가입자 간 형평성 제고············································ 149
4-3. 통계･정보 관리 강화 ·····························································151
4-3-1. 원가자료 조사체계 구축····························································· 153
4-3-2. 평가정보 관리체계 구축····························································· 156
4-3-3. 진료비 실태조사 및 보장률 지표 개선···································· 158
4-3-4. 데이터 활용 고도화···································································· 160
4-4. 건강보험 운영체계 개선 ·······················································163
4-4-1. 건강보험 의사결정 과정 개선··················································· 165
4-4-2. 효율적인 건강보험제도 운영 기반 구축·································· 169
4-4-3. 건강보장 국제 공조 강화··························································· 172
Ⅲ. 재정 투입 및 관리 방안 ··························································175