간호관리료 차등제 기준 변경(2024년)의 정책효과 분석: 논리모형 적용
Policy Impact of the 2024 Revision of Differential Nursing Fee System: Using a Logic Model
- 주제(키워드) 도움말 간호사 , 간호관리료 차등제 , 간호사 확보수준 , 간호등급 , 정책효과 , 논리모형 , 혼합효과모형
- 발행기관 국립강릉원주대학교 일반대학원
- 지도교수 도움말 정수용
- 발행년도 2025
- 학위수여년월 2025. 8
- 학위명 박사
- 학과 및 전공 도움말 일반대학원 간호학과
- 실제URI http://www.dcollection.net/handler/kangnung/000000012234
- UCI I804:42001-000000012234
- 본문언어 한국어
초록/요약 도움말
2024년 1월, 보건복지부는 ｢간호관리료 차등제｣를 전면 개편하면서, 간호등급 산정기준을 기존의 ‘병상 수 대 간호사 수’에서 ‘환자 수 대 간호사 수’로 일원화하 였다. 이와 함께 S·A등급이 신설되고, 간호등급 미신고 기관에 대한 감산률을 50%로 확대 적용하는 등 간호등급 관련 수가 산정체계 전반에 구조적 변화가 이 루어졌다. 본 연구는 환자 수 대 간호사 수의 기준 변경이 마지막 단계에서 적용된 정책 실험군(상급종합병원 및 서울 소재 종합병원·병원)을 중심으로, 간호사 확보수준 과 간호관리료 청구금액에 미친 영향을 분석하였다. 이를 위해 논리모형을 분석 틀로 적용하여, 2024년 간호관리료 차등제 기준 변경의 도입에 따른 간호등급 분 포, 간호사 확보수준, 간호관리료 청구금액의 변화를 통해 제도 개편의 효과를 검 토하였다. 분석대상은 전국 병원급 이상 의료기관 전수(n=1,744)이며, 제도 개편 전후(전: 2023년 3·4분기, 후: 2024년 1·2분기) 총 4개 분기 데이터를 비교·분석하였다. 정책실험군은 2024년 1월부터 병상 수 기준에서 환자 수 기준으로 전환을 최종적 으로 적용받은 상급종합병원 및 서울 소재 병원급 이상 의료기관 총 308개소이며, 정책대조군은 이미 병상 수 기준에서 환자 수 기준으로 전환을 완료하여 2024년 개편 시점에는 추가 변경이 없었던 의료기관 총 1,436개소이었다. 주요 분석 변수는 간호등급 분포, 병상 수 대 간호사 수, 환자 수 대 간호사 수, 간호사 총 수, 간호관리료 청구금액 등이며, 제도 효과의 통계적 유의성을 검 증하기 위해 Difference in Differences(DID) 모형과 혼합효과모형(mixed effects model)을 적용하였다. 분석결과, 간호등급 산정기준의 상향 재편은 S·A·1·2등급의 적용 확대를 통 해 등급 분포에 유의한 변화를 유도하였으며, 특히 병원에서 간호관리료 청구금액 의 유의미한 증가(β=+24.681, p<.001)가 확인되었다. 그러나 종합병원(β=–19.230, p=.482)과 상급종합병원(β=–485.100, p=.049)에서는 청구금액이 증가하지 않거나 오히려 유의하게 감소하였다. 간호사 확보수준은 병상 가동률 구간에 따라 상이하 게 나타났는데, 30–50% 가동률 구간에서는 간호사 1인당 병상 수가 유의하게 증가 (β=+9.15, p=.014)하여 간호사의 업무 부담이 심화된 반면, 고가동률(≥70%) 구간 에서는 감소(β=–5.25, p=.008)하여 업무 부담이 일부 완화되는 경향이 관찰되었다. 이상의 결과는 간호관리료 차등제의 기준 개편이 간호등급 구조 및 간호관리료 청구금액에는 일정한 변화를 유도하였으나, 간호사 인력의 확보수준 증가에는 큰 영향을 미치지 못했음을 보여준다. 제도 효과는 의료기관의 종별, 병상 가동률 등 구조적 특성에 따라 상이하게 나타났다. 본 연구는 혼합효과모형과 DID 분석을 활용하여 2024년 간호관리료 차등제의 기준변경의 단기 효과를 정량적으로 평가하였다. 분석 결과, 정책이 간호등급과 수 가 인센티브에 긍정적인 영향을 주었으나, 간호사 확보수준의 증가로까지 이어지진 못했다. 정책 수용도와 제도의 실효성을 높이기 위해서는 간호사 인건비, 병원 재 정 구조, 간호사 배치 기준, 환자 중증도 등을 고려한 구조적 지원과 제도적 보완이 병행될 것을 제언한다.
more초록/요약 도움말
Backgroud: In January 2024, the Ministry of Health and Welfare im plemented a major reform of the nursing grade-based fee system. The reform targeted tertiary hospitals and inpatient care facilities in Seoul, transitioning the standard from a “bed-to-nurse ratio” to a “patient-to-nurse ratio.” Additionally, new S and A grades were introduced, and a 50% reduction rate was expanded for institutions that do not report their nursing grades. These changes reflect a structural revision of the nursing fee calculation system. This study quantitatively analyzed the impact of the system reform on nurse staffing levels and nursing fee claim amounts. Methods: This study used data from the Health Insurance Review and Assessment Service, including nursing grade reports, health insurance claims da ta, and provider information from the third quarter of 2023 to the second quar ter of 2024. A logic model served as the analytical framework to assess changes in nurs ing grade distribution, staffing levels, and fee claims before and after the reform. The analysis covered all hospital-level inpatient care facilities in Korea (n=1,744), with 308 tertiary hospitals and facilities based in Seoul assigned to the intervention group and 1,436 institutions to the control group. T-tests were conducted to examine key outcome variables, and Difference- in-Differences (DID) and mixed-effects models were applied to estimate the re form’s impact, adjusting for institutional factors. Results: The introduction of S and A grades in January 2024, along with the shift to the bed-to-patient standard across all institutions, resulted in a sig nificant change in the distribution of nursing grades. According to the t-test analysis, staffing levels in tertiary hospitals and Seoul-based inpatient care facilities did not show statistically significant changes after the standard revision, but the fee claim amounts showed statistically sig nificant differences. Even after adjusting for institutional characteristics using DID and mixed-ef fects model, the number of beds per nurse did not significantly change follow ing the reform. However, the mixed-effects model showed that nursing fee claim amounts significantly decreased in tertiary hospitals and in the overall sample, whereas they increased only in general hospitals. Conclusion and Policy Implications: The reform had a measurable impact on nursing grades and the fee system, but did not lead to a substantial in crease in actual staffing levels. During the first and second quarters of 2024, ongoing medical-political con flicts may have hindered efforts by institutions to secure additional nursing staff, thereby limiting the observable short-term effects. For meaningful staffing improvements, structural support and institutional compensation strategies should accompany policy changes. Long-term evaluation is also essential.
more목차 도움말
Ⅰ. 서 론··································································································1
1. 연구의 배경 및 필요성···················································································1
2. 연구 목적·········································································································6
3. 용어의 정의·····································································································7
Ⅱ. 이론적 배경·····················································································10
1. 간호관리료 차등제의 도입배경과 발전과정·················································10
2. 2024년 간호관리료 차등제 개편의 주요 내용과 정책적 함의···················21
3. 간호사 확보수준 개념 및 국외 제도 현황··················································27
4. 간호관리료 차등제 관련 선행연구·······························································49
5. 논리모형의 개념 및 보건의료정책 적용······················································58
Ⅲ. 연구 방법·························································································66
1. 연구의 개념적 틀··························································································66
2. 연구 가설·······································································································68
3. 연구 설계·······································································································69
4. 연구 대상·······································································································70
5. 자료구축 방법································································································72
6. 분석 변수·······································································································74
7. 자료분석 방법································································································77
Ⅳ. 연구 결과·························································································80
1. 연구대상의 일반적 특성···············································································80
2. 개편 전후 간호사 확보수준의 변화·····························································83
3. 정책실험군의 개편 전후 간호등급 변화······················································86
4. DID 모형에 따른 정책효과의 분석·····························································94
5. 혼합효과모형에 따른 정책효과의 분석······················································101
Ⅴ. 논 의······························································································107
1. 간호관리료 차등제 개편의 정책효과··························································107
2. 정책 제언 및 함의······················································································110
3. 연구의 한계 및 향후과제············································································113
Ⅵ. 결 론······························································································115
