Korean ECMO experts criticize 'punitive cuts' in reimbursement

The Health Insurance Review and Assessment Service (HERA) is improving its criteria for recognizing ECMO (extracorporeal membrane oxygenation) therapy to save essential care. Still, the “fear of cuts” (in insurance benefits) among field physicians remains strong, according to the medical community.

All doctors who conducted ECMO therapy have experienced a reimbursement cut—not a partial cut but an entire cut. The medical fees are also problematic because they fail to compensate for the manpower and resources required to administer ECMO.

These were the problems that emerged from the “2024 Korea ECMO Society Opinion Leadership Summit,” which was held on Saturday at Kangbuk Samsung Hospital.

The Korean Academy of Tuberculosis and Respiratory Diseases’ Intensive Care Research Society, the Korean Society of Cardiology’s Korea Cardiogenic Shock Working Group, and the Korean Society for Thoracic and Cardiovascular Surgery’s ECMO Research Society of the Korean Society of Cardiovascular and Thoracic Surgery organized it jointly.

Many ECMO experts also participated in the “Collaborative Conference on ECMO Reimbursement” session to discuss ways to improve the system.

‘Dilemma’ of physicians worrying about coverage cut ahead of treating patients

Experts were generally positive about the proposed revisions to ECMO reimbursement criteria prepared by HIRA. Some called it “the most significant and forward-looking” since ECMO entered the reimbursement list in 2015. However, they said it doesn't address the “dilemma” of physicians who must worry about reimbursement cuts in the face of patients awaiting treatment.

“The health insurance fee review affects the clinical practice the most. It's not a cut of one- or two-day treatment. One- or two-weeks’ fees are cut in a lump sum,” said Professor Lee Su-hwan of the Department of Respiratory Medicine at Severance Hospital. “Such large cuts occur frequently when the patient dies after treatments.”

Professor Lee noted that ECMOs require a lot of manpower and money, so they are only performed on patients who need them. However, they are often cut just because the patient has died.

Dr. Bae Jang-whan, director of the Institute of Cardiovascular Interventional Procedures at Good Samsun Hospital, criticized the “punitive whole-lot cut.”

“One of the structural problems in Korea is the entire cuts of coverage,” Bae said. “Other countries also cut reimbursement when the treatments do not fit the indication. However, no countries have cut an entire device for related behavior. You would have to search the galaxy to find such a place. You would have to go to Pluto to find such a country,” Bae said. “Even worse, such cuts are punitive in Korea.”

Another expert also pointed out the dilemma of worrying about benefit cuts rather than providing the best care.

“If a patient with an ECMO has a brain hemorrhage or multiple organ damage, physicians are worried that benefits will be cut,” said Professor Chung Eui-seok of the Department of Cardiothoracic Surgery at Kangbuk Samsung Hospital.

Professor Chung recounted a 72-year-old patient he operated on 15 years ago who went into cardiac arrest and was saved by ECMO only to see his reimbursement cut because it was not one of the indications requiring the device. “I don't want doctors to be faced with a dilemma and regret doing an essential procedure,” Chung said.

​Experts raise the need for classifying ECMO fees in greater detail

Other participants pointed out that the current reimbursement system does not reflect the resources and costs of ECMO treatment. They suggested that the ECMO fee should be divided in greater detail, and a transfer fee should also be established.

Professor Jung Jae-seung of the Department of Cardiothoracic Surgery at Korea University Anam Hospital shared the U.S. reimbursement system, including a separate fee for removing the ECMO device, saying Korea “must segment it more.” Jung noted that the U.S. also has different fees for different patient ages. He emphasized that Korea also must set a separate fee for removing the ECMO device.

Dr. Bae agreed. “About 2-3 percent of patients get worse after removing the ECMO device. It's a riskier procedure than you think,” Bae said. “The overall fee should be expanded by separately charging for the removed part if the entire reimbursement is too big to let go.”

Professor Kim Jae-bum of the Department of Cardiothoracic Surgery at Keimyung University Dongsan Hospital pointed out the fees for ECMO patients’ transfer must be set.

Currently, hospitals bear the burden of transporting patients without a separate fee. Professor Kim explained that to transfer ECMO patients, the hospital where they are hospitalized must send a private ambulance to the transferring hospital and bring medical staff. The medical staff would then load the ECMO equipment onto the ambulance and go to the hospital to replace the equipment. This is because transferring a patient from one hospital to another is impossible with the existing ECMO equipment.

“The ambulance is small, so only one doctor and one extracorporeal circulator can accompany them. They carry the ECMO equipment, swap it with the existing equipment, check the patient's condition, and if it's okay, they transfer the patient,” Professor Kim said. “After powering up, they sometimes replace the ECMO consumables, depending on the patient's condition, but they can't charge for it. Since the old hospital charges the fee on the same day, the new hospital cannot charge for any additional ECMO-related activities.”

He emphasized that a separate fee system should be in place for ECMO patient transfers or that paramedics should be able to handle patient transfers.

HIRA acknowledges a ‘punitive whole-lot cut’ problem, vowing to find out ways

HIRA said it is trying to improve the criteria for reducing ECMO's medical expenses and fees, adding that the agency’s efforts alone have limitations.

“I think it's a very big problem. It's a huge blow to medical professionals because patients or guardians are notified that they have received 'unnecessary treatment in some form or another,'” said Chang Yang-soo, chief evaluator at HIRA’s Medical Review and Assessment Committee. “We asked the National Health Insurance Service not to give such guidance, and NHIS President Jung Ki-suk also promised not to do so.”

“However, we also must discuss whether we should pay for not indicated procedures,” Chang said. “We recognize that punitive cuts are a problem, so we will prepare measures.”

Chang said there are limits regarding calls for classifying the system, including establishing transfer fees.

“I think creating a code for the transfer fee is necessary. Still, the fee for inserting or removing (the ECMO device) is included in the description of the (ECMO) act on the act classification table,” Chang said, “To separate them, the Ministry of Health and Welfare must revise the notification.”

Chang continued, “It will take time to convince the ministry to separate the insertion and removal (from the existing act description). It's very difficult to revise the notice,” suggesting that ECMO-related societies gather to collect opinions and devise an alternative.