The Society of Convergence Knowledge Transactions ISSN:2287-8920(Print) 융복합지식학회논문지

The clinic-level health insurance coverage rate has continued to decline to 55.5% as of 2021. Accordingly, this study was conducted to analyze the causes of the continuous decline in the health insurance coverage rate for primary care institutions, specifically clinic-level facilities, and to develop measures to enhance coverage. To achieve the research objectives, the study compared and analyzed the scale of medical expenses and cost compensation rates based on whether the services were covered by health insurance, using accounting data from 200 clinic-level medical institutions. As a result of the analysis, non-benefit income accounted for 34.8% (with benefit income making up 65.2%) of the total medical income. There was a significant variation depending on the medical department, ranging from 60.2% in dermatology to 16.4% in otolaryngology. The total cost-compensation rate was at the level of 107.3%, and there was also a significant difference between the health insurance benefit compensation rate (93.7%) and the non-benefit compensation rate (189.0%). A cross-tabulation of the cost-compensation levels of benefit and non-benefit services was created to analyze the relative position of each medical department in the four quadrants. The study confirmed the necessity of policy adjustments and control over non-benefit services for medical departments with high non-benefit compensation levels. Policy measures proposed to strengthen the coverage of clinic-level primary care institutions include the adjustment of health insurance fees to reflect reality, the public management of non-benefit services, the reformation of performance-based bundled payment systems, and the improvement of current coverage rate calculation indicators. To generalize future research results, it is necessary to secure a representative sample along with a detailed investigation of uncovered medical services by medical department.