Government to ban mixed treatment of reimbursed and unreimbursed care, sparking medical opposition

The government has decided to incorporate the "ban on mixed treatment," strongly opposed by the medical community, into its plan for managing unreimbursed medical care.

The ban targets reimbursed treatments performed in parallel with unreimbursed care provided for aesthetic and cosmetic purposes. If a treatment is included in the banned mixed care, its accompanying medical fees and material and drug costs are considered unreimbursed.

The Special Committee on Healthcare Reform, which is under direct presidential jurisdiction, held a policy debate on Thursday at the Korea Press Center on how to “reform the management of unreimbursed treatment and actual cost insurance to normalize the healthcare system.”

Seo Nam-gyu, head of the Unreimbursed Treatment Management Office at the National Health Insurance Service (NHIS), presented the “plan to improve the management of unreimbursed treatment,” which called for strengthening the role of health insurance, enhancing the control of using unreimbursed treatment, strengthening the daily management system of unreimbursed treatment, and innovating the basis for managing unreimbursed treatment.

Specifically, Seo said the government would promote converting essential but unreimbursed treatments into reimbursed ones to strengthen the role of health insurance while introducing the “managed reimbursement system” targeting unreimbursed treatments requiring extensive management.

Managed benefits refer to converting unreimbursed treatments prone to abuse into reimbursed ones, with specific treatment standards and prices. It will prioritize “unreimbursed treatment with wide gaps in medical expenses, treatment volume, and prices, applying 90-95 percent co-payment rates to these unreimbursed treatments.

To strengthen the management of unreimbursed treatment, the government will reassess unreimbursed treatment and limit benefits for unnecessary parallel treatments while clarifying or eliminating their scope of use.

Restricting reimbursement for unnecessary parallel treatments means limiting the benefits of reimbursed treatments provided in parallel with unreimbursed treatments, which is fiercely opposed by the medical community. It will be limited to “items with low necessity and high abuse potential.”

For example, it will be applied to “reimbursed treatment given in parallel with unreimbursed treatment for aesthetic or cosmetic purposes to make claims for actual cost insurance,” Seo said.

The government plans to announce the unreimbursed items restricted for parallel treatment separately and apply the non-reimbursement principle to all parallel reimbursed treatments, such as treatment fees, materials, and drugs.

The government aims to standardize the system, enhance monitoring, increase transparency, and improve patient choice to ensure consistent management of unreimbursed treatment.

The perennial unreimbursed treatment management system will start by standardizing the optional unreimbursed name codes and making them mandatory for unreimbursed treatment reporting. For example, “Cinderella injections” would be standardized to “thioxene injections.” The government will also consider making this standardization mandatory for medical receipts.

Other initiatives include expanding sample organizations for medical expense surveys, expanding the unreimbursed treatment reporting system, and strengthening monitoring after selecting items that exceed specific management standards.

Lastly, reforms have been proposed to improve the legal framework for managing unreimbursed treatments and to review institutional-level management plans.

The main contents of the legal system overhaul included selecting automatic management targets for intensive management and preparing management plans, expanding the unreimbursed treatment reporting system to include new unreimbursed treatments for monitoring, establishing the obligation to explain unreimbursed treatment in advance, and giving written consent for patient choice, establishing the basis for price management for major unreimbursed treatments for price management, establishing the basis for removing problematic items through a periodic reassessment of reimbursement treatments for their removal and establishing the authority to require submission of unreimbursed treatment-related data for data submission.

Differentiated compensation will be introduced based on the proportion of unreimbursed treatments provided by each institution. This means that the conversion index calculation method will be reviewed from the perspective of medical institutions' total revenue, including unreimbursed treatment, and institutions with high revenues from unreimbursed treatments will be penalized in the conversion index calculation.

Seo said the policy is expected to ensure that necessary treatments are covered by health insurance and create a healthy healthcare supply ecosystem.