As the finances of the national health insurance rapidly deteriorate, National Health Insurance Service President Jeong noted that overtreatment is increasing the fiscal burden. The service has rolled out stronger management measures under the banner of appropriate care, but observers say it is still hard to gauge the actual impact on finances.
On the 5th, President Jeong held the "2026 first-half policy briefing" and said, "The key to a sustainable healthcare system ultimately is expenditure management," adding, "In a country where the population is not increasing, diseases are not rising significantly either, yet services are increasing and expenditures are growing. We need to closely examine whether those services have justifiably increased."
According to the service, last year's current-account surplus for health insurance plunged 88% in two years from 4.1 trillion won in 2023. The Ministry of Economy and Finance projects that health insurance will swing to a deficit this year and that even the accumulated reserve will be fully depleted by 2033. As of last year, the accumulated reserve stood at 30.2217 trillion won.
To establish appropriate care, the service plans to strengthen benefit analytics. To that end, in 2024 it reorganized the existing Appropriate Care Inducement Team and launched the Appropriate Care Promotion Group (NHIS-CAMP) in Feb. last year.
The core tool is statistics. Using big data, the service previously built a dashboard that shows prescription patterns by hospital, disease, and physician at a glance. The Appropriate Care Promotion Group uses this dashboard to identify medical institutions where the implementation rate is excessive among services with low necessity or utility by diagnosis.
It then takes follow-up actions for medical institutions suspected of overtreatment—such as sending inquiries, conducting on-site inspections, processing appeals, and proposing improvements—after expert consultations and literature reviews.
By Dec. last year, 74 analyses had been completed. Of these, 46 had follow-up actions completed and 28 were underway. President Jeong said, "We are not yet at a stage where every process is perfectly meshed," adding, "We are working to ensure it does not end with analysis alone."
A representative case is managing the deferral rate of breast cancer screening determinations. The service selected the top 100 institutions with deferral rates of 12% or higher and conducted on-site and written inspections, followed by change-tracking analyses. This is because the higher the deferral rate, the more the rate of ultrasound tests tends to rise. Among 3,530 breast cancer screening institutions nationwide, the average deferral rate of determinations is 10.9%.
President Jeong said, "As a result, we saved 352 million won in breast ultrasound test costs," adding, "It is not a large amount, but if these efforts accumulate, the health insurance finances will also improve."
He said, "Ultimately, the goal is to disclose to the public information that shows which hospitals provide appropriate care."
However, it has not yet been calculated when and by how much the health insurance finances will be eased by the activities of the Appropriate Care Promotion Group. He said, "A current-account deficit of several hundred billion won is expected this year," adding, "Appropriate care must take root to achieve significant savings."
Sanctions for medical institutions that engage in overtreatment also remain insufficient. President Jeong said, "A task is how to define the scope of overtreatment," adding, "There are clinical practice guidelines (CPG) that physicians follow, but they are not legal standards. If those are excessively deviated from, we are considering sanctions through cooperation with the Health Insurance Review & Assessment Service (HIRA), but there is no concrete plan."