Restructuring tertiary hospitals into institutions specializing in treating severely ill patients is the fastest-progressing project among the Yoon Suk Yeol administration’s healthcare reforms.

On Dec. 24, the three remaining hospitals—Samsung Medical Center, Ulsan University Hospital, and Inha University Hospital—decided to participate in the project, meaning all 47 of the nation’s tertiary hospitals have jumped in.

Through the restructuring project, the government plans to strengthen the large hospitals’ ability to focus on treating severe, urgent, and rare diseases, establish a strong cooperation system with secondary hospitals and other medical partners, and normalize the medical delivery system that provides intensive training for junior doctors.

The government has mandated the reduction of general beds so that hospitals can focus on treating critically ill patients. The 47 tertiary hospitals reduced 3,625 general beds to participate in the project, accounting for 8.6 percent of their total general beds.

The health authorities also presented a direct figure to verify whether a hospital has focused on treating critically ill patients—achieving a critical care ratio of 70 percent or more. According to the Ministry of Health and Welfare, the tertiary hospitals’ critical care ratio stood at an average of 50 percent, meaning that they must treat 20 percent more critical patients to reach the target.

However, the government also acknowledges that it is not easy to increase the share of severely ill patients by more than 20 percent from the current level. Therefore, the government promised to “expand the recognition criteria to complement the limitations of the severity classification criteria so that no case is classified as non-severe despite the need for treatment at tertiary institutions.”

In other words, even if a disease is classified as mild in the disease classification system, the government will provide criteria to recognize it as a severe patient who needs to be treated at tertiary hospitals, considering the patient's condition. However, even though all 47 tertiary hospitals have decided to participate in the project since it began last October, the government's promise is not being kept.

Orthopedics, which takes a large patient portion in tertiary hospitals, takes a hit

With the critically ill patient classification criteria unchanged, hospitals that are required to increase the proportion of critically ill patients by about 20 percent are doing so by reducing the treatment of mild cases. Orthopedics is the department hit hardest by this practice.

Orthopaedics has been hit hard (by the restructuring project). Rehabilitation medicine and plastic surgery departments also maintain large shares of mild patients at tertiary  hospitals, but these departments do not have a large patient portion,” a senior official at the Korean Orthopaedic Association told Biomedical Review over the phone. “On the other hand, orthopedics is the top department in the hospital in terms of performance and sales, but it is unable to treat mild patients (due to the hospitals’ move to increase the share of severe patients in the restructuring project).”

“Severe diseases account for about 25 percent of patients at the orthopedic department, but they must jack up the rate to 70 percent,” the official said. “They've gotten to the point where they can't do surgery because hospitals don’t allocate operating rooms or staff to orthopedics (to reduce the number of patients).”

“In the U.S., there are about 2,000 classifications of musculoskeletal diseases, subdivided according to the difficulty of surgery. However, Korea has only 200 classifications,” he said. “We should have started with additional classification but skipped it and are recklessly speeding up the conversion of tertiary hospitals in line with the expansion of medical students, and this is what is happening.”

The official also expressed concern that patients will bear the brunt of the reduction in orthopedic care at tertiary hospitals.

“The government tells us to treat mild cases at general or specialized hospitals, not in tertiary hospitals, but there are many cases that we can't do,” he said. “Patients with joint or musculoskeletal infections are typical, and these patients are not welcome in general or specialized hospitals. They come to tertiary hospitals, which can't accept them because of their low severity and lack of profit.”

To solve this problem, he emphasized that orthopedic patients with comorbidities, including diabetes, heart disease, cerebrovascular disease, those with musculoskeletal infections, artificial joint infections, and patients over 80 old should be classified as severe patients.

“The sooner, the better (recognizing some milder patients as severely ill). The evaluation for compensating restructured tertiary hospitals is scheduled for the end of the year, so the reclassification must be completed in the first half of the year,” he said. “The government began the restructuring project with too little preparations.”

Even pediatrics and internal medicine, the most avoided departments, are no exceptions

Departments avoided by physicians, which are supposed to benefit most from the government’s healthcare reforms, are also struggling to expand the share of severely ill patients for the restructuring of tertiary hospitals.

“Pediatrics has always been at a disadvantage (in the classification of critically ill patients) because there are no different codes for each age group (in the patient classification system),” said an official at the Korean Pediatrics Society in a telephone interview with Korea Biomedical Review. “Therefore, even when there was no restructuring project, we were told not to admit patients when the government evaluates tertiary hospitals yearly.”

“For example, arrhythmia in children looks like a serious condition, but there is no code separation from adult arrhythmia,” the official said. “So, we have requested that the society recognize it as a specialized disease by differentiating patients’ ages.”

“To be classified as a disease, the number of patients must be a certain size, and the medical expenses must be different from the group before the separation, but it is difficult to meet the requirements because the pediatric population is small and the fees are low,” he said. “Considering these things, the situation at the pediatric department is very frustrating.”

Not severe diseases should be transferred to local general or specialized hospitals, as changing the structure of tertiary hospitals is difficult for the pediatric department to do.

“Tertiary hospitals are supposed to fill 70 percent of the patients with severe conditions and transfer the rest to local medical centers. However, in regions with a pediatric department at tertiary hospitals, they must treat both severe and mild cases,” he said. “If the pediatric department at these tertiary hospitals treat only severe cases and refuses to treat mild cases, mild patients have nowhere to go.”

“Setting the proportion of severe patients at 70 percent means that patients needing general procedures cannot come to tertiary hospitals,” said an official at the Patient Classification System Committee at the Korean Association of Internal Medicine. “It is right to increase the fees (for severe patients) through restructuring the tertiary hospitals, but we must take a closer look at the areas where patients who must come to tertiary hospitals cannot do so.”

“For example, asthma is not categorized as a severe illness, but when it becomes severe, it should go to tertiary hospitals through the emergency room,” he said. “Pneumonia is also a very complicated case, and if left untreated, patients die. Heart failure patients are also not well categorized by code alone.”

When will the search for ‘hidden’ severely ill patients begin for restructuring?

The Ministry of Health and Welfare also recognizes that hospitals will face challenges in meeting the 70 percent critically ill rate for restructuring.

Therefore, it will be included as a supplementary indicator in the evaluation to monitor the situation for about a year. During this period, patients who are transferred through secondary hospitals or treated through emergency rooms, even if they are not seriously ill, will be recognized as severely ill so that the 70 percent ratio of severely ill patients can be met as much as possible.

The ministry is also preparing to keep its promise to expand the recognition criteria so that no cases are classified as non-critical despite the need for advanced medical treatment by complementing the limitations of the severe classification criteria.

Yoo Jeong-min, head of the Healthcare System Innovation Division at the ministry's Healthcare Reform Promotion Team, told Korea Biomedical Review, “We are forming an internal task force to start discussions to ensure that there are no cases that are classified as non-severe even though they need advanced medical treatment. All relevant divisions, such as the Medical Institution Policy Division, Insurance Benefits Division, and Insurance Policy Division, will participate,” he said.

Although the task force has yet to be activated, Yoo noted that the team has received feedback from the field.

“Once the task force is operational, we plan to continue communicating with the field and developing the discussion. In the meantime, we have contacted individual societies to collect their opinions,” Yoo said. “There were many opinions that patients with severe disabilities and patients who require advanced anesthesia, including general anesthesia, should be classified as severe patients even if they are mild.”

“When the task force starts full operation, we will formally ask the relevant societies to participate. It's not easy politically (to discuss), but I think there will be a lot of input from the field,” he said. “However, rather than announcing a final content through complete consensus, we will try to publicize agreed parts and implement them quickly.”

“The restructuring project was launched in October last year, and the goal is to achieve a 70 percent severe patient ratio. We are not ready, but I hope all parties involved will consider that it requires much study to find solutions to problems raised for more than 10 years,” Yoo said.

“It's not just a matter of improving the criteria. It's a completely different categorization that considers patient condition,” Yoo said. “We are preparing internally to start the discussion, and we will communicate with the field to try to come up with a good solution.”