Gov’t raises service fee for difficult surgeries

breaks away from uniform fee pricing structure

The Ministry of Health and Welfare explains its plans at its health reform progress briefing...will conduct overall reform, including service fees, non-reimbursed items, and indemnity insurance

The government is promoting a plan to completely reform the unbalanced structure of Korea’s fee-for-service system.

 

For this, the government is reviewing whether to raise the compensation level for severe surgeries and reforming the relative value system and conversion index used to calculate medical service fees.

 

Kyung-sil Jeong, Head of the Healthcare Reform Promotion Team at MOHW explained so at a briefing on the progress of Korea’s healthcare reform on the 13th.

 

"Korea's reimbursement system is based on a 'fee-for-service system' that sets a unit price for every individual act of service," Jeong said, pointing out that "among the types of services, basic medical treatment, surgery, and treatment have lower fee levels, while testing, imaging, and functional type services have higher fee levels." The system has constantly been criticized as it incentivizes more tests than serious, high-risk surgeries.

 

"We are promoting an overall reform to increase the compensation level in low-compensated areas and decrease the compensation level in high-compensated areas," Jeong said, adding, "First of all, we are considering raising the compensation level of about 1,000 severe surgeries, which are mainly performed at tertiary hospitals and general hospitals but have low fees." The government has established a 'Medical Cost Analysis Committee' within the Health Insurance Policy Review Committee to establish a system where medical fees can be quickly adjusted based on scientific evidence.

 

The committee is also looking to reform the relative value system and conversion index, which are the basis of the fee-for-service system.

 

"The committee has identified 6 priority areas that require concentrated investment: severe disease treatment, difficult essential medical treatment, emergency treatment, night and holiday treatment, pediatrics and childbirth, and vulnerable regions," Jeong said, adding, "In consideration of these priorities, we plan to more systemically introduce the public policy fee.” Furthermore, the government plans to transform the fee-for-service system into a "value-based payment system" to fundamentally improve the problem of how the current fee-for-service system increases the volume of procedures rather than improves the outcome of treatment.

 

"The current system, which applies a uniform 15% premium to the reimbursement rate for services provided at tertiary general hospitals without distinguishing between severe and mild cases, will be converted to a system in which hospitals will be rewarded more for treating severe cases and less for treating mild cases," said Jeong, adding, "To this end, we will select and apply ‘appropriate disease groups' that are suited to the functions of each medical institution." Discussions are also underway to reform the management of non-reimbursed items and indemnity insurance.

 

In July, the government formed a non-reimbursement and indemnity insurance subcommittee within the Specialized Committee for Essential Healthcare and Fair Compensation under the Special Committee on Healthcare Reform to discuss non-reimbursed management and indemnity insurance reform.

 

During subcommittee discussions, it was suggested that non-reimbursed items with obvious excessive use concerns, such as manual therapy, cataract surgery with non-reimbursed lenses, and non-valve reconstruction, should be restricted, and that a management system should be established using the current positive listing system to set standard prices for non-reimbursed items that bring concerns over excessive use based on the non-reimbursed item status monitoring result and continuously manage the items through data analysis and re-evaluation.

 

Regarding the reform of indemnity insurance, the role of the indemnity insurance as a complement to health insurance should be clarified and the system should be improved in line with this principle.

 

During subcommittee discussions, an opinion was raised that the statutory coinsurance rate of the national health insurance should be adjusted to a reasonable level to minimize some of the negative impacts of indemnity insurance on the healthcare delivery system and access to healthcare.

 

In particular, Jeong explained that there were suggestions that the scope of non-reimbursed coverage should be rationalized in conjunction with the government’s non-reimbursed item management measures to improve the issue of insufficient examination and follow-up due to the nature of indemnity insurance, where an agreement is made only between the insurer and the patient, and to reinforce the review and management system for proper use and supply of healthcare, "In order for the healthcare reform to succeed, we need to change the way people use healthcare, different to what they have been accustomed to," Jeong said, adding, "If you have relatively minor symptoms, please refrain from visiting emergency rooms of tertiary hospitals to make room for severe and urgent patients."