The government and the medical community agreed that a system to prevent the excessive use of medical services is needed.

The two sides agreed that various measures are needed, such as sharing information between medical institutions and allowing patients to check their medical service use while medical institutions manage it.

Experts expressed their concerns about the current state of medical use at a debate titled “Is indiscriminate medical shopping okay as it is?” hosted by Rep. Ahn Sang-hoon of the ruling People Power Party (PPP) at the National Assembly on Monday.

Park Jung-hye, head of the Review Operation Office at the Health Insurance Review and Assessment Service (HIRA), presented data on outpatient treatment in 2022 in her presentation titled “Problems in the current situation of medical overuse in Korea.”

According to HIRA, the average number of outpatient days per person per year in 2022 was 15.7, and the total number of people who visited a hospital at least once was 48,759,963.

When analyzing outpatient visits among patients with 150-365 visits and those with more than 365 visits, the number of visits was higher for general patients than those with severe diseases that fall under the special calculation category. A special calculation system reduces the co-payment rate to 10 percent if a person is diagnosed with a rare disease and applies to the National Health Insurance Service through registration.

Among patients with 150-365 visits, the average number of visits for general patients was 197, compared to 185 visits for patients needing special calculation. Among patients with more than 365 visits, the average number of visits was 455 for general patients and 447 for those with special calculation needs.

Patients mainly visit hospitals for musculoskeletal disorders, including back pain, knee arthritis, and spinal diseases. They tended to be treated repeatedly with physical therapy, nerve blocks, and the administration of the painkiller tramadol.

In a survey of patients with general diseases who visited a tertiary hospital for outpatient care over 150 times, more than 90 percent had received physical therapy, more than 50 percent had received nerve blocks, and more than 60 percent had been given tramadol.

The forum also revealed cases of overuse of healthcare.

The patient with the highest number of physiotherapy visits during the year had an average of 4.2 per day for 292 days, totaling 1,216 physiotherapy sessions. One patient received 670 treatments for nerve blocks, visiting 2.8 hospitals per day on average.

The highest tramadol dose was for a patient with 3,009 visits to a healthcare provider, totaling 2,249 doses. This patient had 11 visits per day and received 550 mg of tramadol per day, exceeding the Ministry of Food and Drug Safety (MFDS)’s maximum daily dose of 400 mg.

Regarding computed tomography (CT) scans, in 2018, the number of patients with CT scans was 492, and the frequency of scans was 810. In 2022, however, the number of patients with CT scans was 746, and the frequency of scans was 1,411, recording sharp increases from 2018.

Park said that excessive medical service use can adversely affect patient health, which also explains why it is necessary to control from the diagnosis stage.

“A single CT scan exposes a patient to 0.6 mSv to 10 mSv of medical radiation. However, the International Commission on Radiological Protection recommends that the general population should be exposed to only 1 mSv per year,” Park noted. “Tramadol is administered as a narcotic painkiller in the United States. Patients are exposed to this risk even before medical institutions realize it.”

“Starting this year, a 90 percent co-payment rate for mildly ill patients who receive more than 365 outpatient visits per year has been implemented, but it is an after-the-fact method of reimbursement, revealing blind spots. It is necessary to identify patients' medical service use status from the stage of treatment and manage it to prevent the overuse of medical care.”

Professor Ji Young-geon at the CHA University Graduate School of Health Industry said that a system that provides real-time medical information through information sharing between medical institutions and allows patients to check their medical service use.

“It is important to manage medical institutions after the fact, but we now need to create a proactive medical overuse monitoring system,” Professor Ji said. “We need to establish standards for items to be managed and a legal basis for establishing and monitoring a medical overuse management system.”

“It is necessary to introduce a system that checks the number of procedures performed on each patient in real-time from the treatment stage,” he said. “We must develop standards for checking each item and build an infrastructure for checking information between medical institutions nationwide. A system should also be established for patients to check and verify their medical service use.”

Kim Yoo-seok, head of the Review and Assessment Policy Institute at HIRA, said that since the Drug Utilization Review Service (DUR) is also in operation, “it is not a technically difficult issue,” adding that it is necessary to establish a legal basis for this and standards for overuse.

‘Don’t blame individuals and institutions for medical service overuse’

Seo In-seok, director of insurance at the Korea Hospital Association, said that the responsibility for the overuse of medical care should not be left to individuals or medical institutions.

“Raising patients' co-payment should be approached in stages. If we try to regulate patients' shopping for medical institutions, it will only cause friction between hospitals and patients,” he said.

“In the future, we should also activate information exchange between medical institutions,” he said. “However, there is also a problem of exposing patients’ personal information, so various methodologies are needed to prepare technical measures, such as setting a threshold for excessive medical care.”

Nam Eun-kyung, a director at the Citizens’ Coalition for Economic Justice, said that users should not be solely responsible for overtreatment as it is difficult for them to know whether they are mildly or severely ill.

“I don't understand why users should take full responsibility for medical care. So far, the government has used ways to make it harder for people to access healthcare by making it more financially burdensome for administrative expediency,” Nam said.

“In an emergency, the patient cannot determine whether they are mildly or severely ill, so the medical institution has to determine it. It is a problem that can be solved by a management system, not by forcing individuals to use it rationally,” Nam went on to say. “We must spread a system that manages medical care use in advance.”

In response, the government said it would establish a proactive management system appropriate for both providers and users to induce rational medical utilization.

Cho Chung-hyeon, head of the Insurance Policy Division at the Ministry of Health and Welfare, said, “Increasing medical expenditures will inevitably lead to higher health insurance premiums, so we need to think deeply about it. In February, the government announced the second Comprehensive National Health Insurance Plan.”

“For rational medical use, we will seek proactive cooperation from the provider’s side by strengthening bed management and self-inspection of medical institutions,” Cho said. “On the user side, we will try to induce rational use by making users aware of medical expenses through step-by-step notifications on medical usage.”