As the government announced a reform plan for ‘non-covered management and private health insurance’ that centers on reducing coverage for non-severe and non-covered treatments and significantly increasing the out-of-pocket rate for insurance subscribers (patients), the medical community and financial consumers (patients) vehemently reacted.
During the policy debate held on the afternoon of the 9th at the Korean Press Center in Jung-gu, Seoul, organized by the Medical Reform Special Committee, protests from the audience erupted throughout the venue regarding the ‘management of non-covered treatments and reform plan for private health insurance for the normalization of the medical system.’
The government is promoting a plan to designate treatments such as physical therapy and nutritional injections as ‘managed benefits’ and to raise the out-of-pocket rate significantly from the current average of 20% to over 90%. It plans to establish a fifth-generation private health insurance that shrinks coverage for non-severe and non-covered treatments and increases coverage for severe cases, encouraging holders of first to third-generation private health insurance products to transition.
This is because there have been many cases of non-covered treatments being performed alongside covered items that are eligible for health insurance, leading to an increasing financial burden on health insurance. Therefore, the intention is to improve so-called medical shopping and over-treatment behaviors by raising the out-of-pocket rates for patients.
However, consumers and the medical community expressed concerns that this limits consumer rights and might lead to adverse effects of the policy.
An audience member who identified as a cancer patient and a first-generation private health insurance subscriber said, 'Insurance companies are currently reluctant to expand coverage for severe patients for more than a year,’ adding, 'I contract private health insurance products to receive economic benefits in case of unexpected accidents or serious illnesses, so why is the government leading the transition to fourth and fifth-generation insurance while limiting consumer rights and benefits?'
Members of the medical community raised questions about the government's classification of regulatory items as ‘overuse or abuse’ non-covered treatments.
Professor Ji Yong-geon from the Cardiovascular Medicine Department at CHA University noted, 'It would be odd to categorize items that help private health insurance companies as ‘abuse’ and include them as prohibited items for concurrent treatments when the criteria are not even firmly established.' He added, 'We need to strategically clarify why concurrent treatments are necessary and unnecessary, and what the criteria are, to avoid misunderstandings regarding items that were previously treated concurrently.'
Yang Mun-sul, president of Bupyeong Serim Hospital, pointed out, 'While the government cannot designate treatments like physical therapy, which it cited as a representative example, as essential medical care, we need to consider whether there is a genuine medical necessity.' He further stated, 'Our country has entered a super-aged society, and the concentration of musculoskeletal diseases at the top rankings of non-covered items is not merely a moral hazard; it also suggests that with the emergence of new treatments, there may be alternative approaches.'
Park Jong-hoon, insurance director of the Korea Oriental Medical Association, said, 'If the areas previously excluded, such as traditional medicine and dental non-covered treatments, are expanded to be covered, it could be a groundbreaking way to encourage enrollment in fifth-generation insurance.' He added, 'If the out-of-pocket rate for patients is set at 50% while excessively worrying about the overuse of non-severe and non-covered treatments, it could undermine the effectiveness of the policy.'