President Moon Jae-in has announced a policy to drastically expand health insurance coverage but left concrete action plans to further debates, making it inevitable for the government and medical community to bicker over details.
The Ministry of Health and Welfare (MOHW)보건복지부 said it would discuss the concrete plans over key factors, such as the classification of standby benefits and compensation plans for the medical community after the across-the-board coverage.
As the ministry will not be able to accept all demands from the medical community, however, some conflicts appear inevitable, industry watchers say.
|President Moon Jae-in announces the “measure to enhance health insurance coverage at Seoul ST. Mary’s Hospital Wednesday.|
How should they categorize uncovered treatments and to what extent?
President Moon Wednesday stressed the need to turn “all uncovered treatments into covered ones except for beauty treatments and cosmetic surgeries. He said he would turn part of uncovered treatments into covered ones, and, in the case of treatments whose safety, validity and cost-effectiveness are in doubt, turn them into preparatory coverage, which differentiates patients’ burdens into 50 70, 90 percent of total costs.
If all uncovered treatments are turned into covered ones, and customary payments are acknowledged, there would be few problems, but there is no chance of that. Accordingly, clashes between the medical community and the government are unavoidable in the process.
Already, the two sides have been bickering over the process in administering selected coverage for some uncovered treatments.
“We cannot leave the decisions on medical necessity to doctors alone,” Jung Tong-ryung정통령, director of the Insurance Payment Division at the Ministry of Health and Welfare, told Korea Biomedical Review. “Objective basis should be in place. The Drug Reimbursement and Evaluation Committee will decide on patients’ payment share.”
“Representatives from civil groups will take part in the committee. They have their principles to classify,” he said. “It is also difficult to classify uncovered treatments which are treatments entirely unrelated to medical care. Medical checkups and Lasik eye surgery belong to these controversial categories.”
There is a bigger problem: the total expense of uncovered treatments amounting to 69 trillion won ($61 billion) as calculated by the government are based on figures at 15 general hospitals in 2014, and did not include injections mostly administered in neighborhood clinics.
“We think these are acts unrelated to treatments,” Director Jung said. “If we grasp uncovered treatments at clinics, the number of treatments subject to preparatory coverage will increase. We will announce the schedule for them by the end of this year.”
Is preparatory coverage just wordplay?
Many uncovered treatments that the government promises to turn into covered ones are taking the form of preparatory coverage. This raises criticism that “the government is expanding the “selected coverage,” and repackaging it as full coverage of uncovered treatments.” If patients have to shoulder 90 percent of costs, it should be seen as uncovered treatments, critics say.
Most of all coverages that the government is talking are included as the type of primary uncovered drugs. Accordingly, some criticize ‘the government has already expanded selected coverage, but it is talking about all coverages of uncovered drugs’. Even drugs are included as primary uncovered drugs, if the individual payment is 90 percent, they are uncovered drugs.
In response, Jung said, “The ministry would turn what’s needed medically into the selective coverage of 50 percent, and into fully-covered ones as soon as possible once verification process is completed.” He said the ministry would hear people’s views and unveil the administrative road map before the conversion of uncovered treatments into covered ones.
The ministry will prohibit treatments with problems in safety and efficiency that keep them from being belonging to preparatory coverage while leaving some treatments with proven safety and validity but low effectiveness as uncovered ones.
If there are treatments left as uncovered acts, the ministry will adjust the payment of treatments substitute them, leaving alternatives for medical institutions and naturally discarding the uncovered acts. Behind these steps are the government’s thinking that the preparatory coverage system is a prerequisite for deciding which should be covered and which are not.
How to lift restrictions on the frequency of MRI and ultrasonic waves?
The most noteworthy point in this policy is how the government improves the existing uncovered treatments, such as lifting the restrictions on the number of MRI and ultrasonic waves as well as that of heart stents. However, the ministry has worked out steps to prevent their reckless use.
“We will remove the limits of frequency and number in treatments. For example, if the current rule limits heart stents to three, our goal is to allow four or five for people who need it,” Jung said. “But we will adjust it in reasonable ways. We will make a medical guideline everyone admits.”
Government adheres to expanded DRG
The government has come up with the “expansion of new Diagnosis Related Group (DRG)” to prevent the influx of uncovered treatments, thinking it would naturally reduce medical institutions’ use of uncovered treatments.
“It needs much effort to grasp every uncovered treatment. We need to manage them on institutional levels, and so needs to introduce the new DRG,” Direct Jung said. “However, we will not make it a mandatory system but leave it to hospitals while excluding neighborhood clinics from its application.”
“What is important is to set a goal, induce them to reduce medical costs, and provide incentives in proportion to it. The implementation of the DRG doesn’t mean disadvantages for suppliers. We can make a compensation model for autonomy and appropriate medical costs. We will make the model that the medical field can accept,” Jung said.
Biggest battlefield -- appropriate levels of coverage and compensation
The biggest battleground between the government and the medical community are levels of insurance benefits and compensation plans resulting from the conversion of uncovered treatments into covered ones. The most interesting point is how the government sets the insurance benefits. Conflicts appear inevitable as the government would not make up for 100 percent of the existing costs.
“We have not calculated the exact compensation rate of original costs. Given that the rate has been low for covered treatments and high for uncovered ones thus far, however, the medical community would lose nothing if we set the uncovered costs at covered ones. But the current uncovered costs are set at too high a level,” Jung said. “That means if uncovered treatments are turned into covered ones, their costs can’t help but go down.”
“However, we are considering making up for the lowered costs in uncovered treatments from the hitherto undervalued costs,” the official said. “We have a clear intention to make up for medical institutions.”
The government’s compensation plan is to give appropriate benefits and expand incentives after strengthening the evaluation of medical service quality. And it will prevent people who mostly use large hospitals through price standardization, but stopped short of presenting how.
Roh Hong-in 노홍인, director general of the Health Insurance Policy Bureau said, “We think we will give the greatest benefit to people, and, at the same time, will go along with suppliers. They aren’t separated. We have talked much about low medical costs. We will solve the problem, too, this time.”
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