Children’s hospitals call for overhaul of nighttime and holiday care system

Although some policies aim to prevent gaps in pediatric care during nights and holidays, children's hospitals warn that without institutional reforms anchored in sustainability and clinical function, critical gaps in care and the safety net will persist.

A group representing children’s hospitals said that the government should divide “Moonlight Children's Hospitals” – referring to medical institutions that provide night and holiday pediatric care – into “clinic-type” and “hospital-type” according to their respective functions, and apply differentiated fees to them.

It also called for policymakers to supplement the pilot project for the regional cooperative network for pediatric care and convert it into a full-scale program.

The Korea Children’s Hospital Association (KCHA) held a news conference on Saturday titled “Current State of Pediatric Healthcare System Policies and Urgent Call for Substantive Improvement.” The KCHA released results of a member hospital survey about pediatric healthcare system policies.

Fifty-two children's hospitals participated in the survey; 27 are part of the Moonlight Children's Hospital program, and 26 among them are part of the network pilot project.

Of the 25 non-designated hospitals, 68 percent (17) reported effectively providing nighttime care, high-complexity tests, admissions, and emergency response just as Moonlight Children's Hospitals do.

However, they are not designated as Moonlight Children's Hospitals because they do not meet the “operating hours standard,” which requires hospitals to remain open until 11 p.m.

Regarding whether the current Moonlight Children's Hospital fee schedule sufficiently compensates for “standby costs,” the majority responded that improvement is needed: 29 hospitals (56 percent) answered “not at all,” and 17 hospitals (33 percent) answered “no.” Furthermore, 40 out of 52 pediatric hospitals (77 percent) responded that being excluded from system support for failing to meet the operating-hour criteria constitutes “institutional reverse discrimination.”

Forty children's hospitals (77 percent) responded that the Moonlight Children's Hospital system needs to shift its focus from “opening hours” to “treatment capabilities.”

Regarding the proposal to reorganize the Moonlight Children's Hospital system into two categories—Type 1 (clinic-based: minor outpatient care, rapid transfers, basic fees) and Type 2 (hospital-based: tests, admissions, emergency response, standby costs, specialist surcharges)—over 80 percent supported the idea, with 26 hospitals (50 percent) “strongly agreeing” and 16 hospitals (31 percent) “agreeing.”

Additionally, 78 percent of children's hospitals reported that the pediatric medical care cooperation network pilot project “helps” secure the golden time for moderate-to-severe pediatric patients. However, they noted that transfers from children's hospitals to general or tertiary hospitals after treatment are delayed, requiring institutional improvements.

Hospitals identified key needs to activate the pilot project. They want to expand tertiary hospital capacity (39 hospitals) and set referral and linkage fees within the network (35 hospitals). Computerizing the transfer system and establishing a regional transfer control tower (28 hospitals) are also needed. They also called for regional standard manuals for transfers and transport, adequate fee support for receiving hospitals (20 hospitals), and an information-sharing system between Moonlight Children's Hospitals and pilot project hospitals (14 hospitals). Deploying regional pediatric emergency administrative personnel (nine hospitals) was another key need.

The main reasons cited for not participating in the Moonlight Children's Hospital or network pilot projects were: difficulty securing nighttime/holiday staff (22 hospitals); insufficient reimbursement rates, including lack of compensation for constant standby costs (13 hospitals); and unfair designation criteria due to evaluation focused on operating hours (six hospitals).

“The Moonlight Children's Hospital criteria must be restructured around clinical capability—what can be achieved during that time, rather than simply ‘how late it stays open,’” KCHA President Choi Yong-jae said.

Choi explained that a function-based Moonlight structure (Type 1 and Type 2) is needed to institutionalize the medical cooperation network. He added that Type 1 should be clinic-based and Type 2 hospital-based, each with distinct compensation structures tailored to their medical functions.

Choi stated, “Children's hospitals capable of nighttime examinations, admissions, IV therapy, and emergency response should be incorporated into the system through ‘conditional Type 2 functional certification.’”

Choi cited examples: “One children's hospital had consistently provided high-complexity pediatric care but was excluded from Moonlight Children's Hospital designation due to evaluations focused solely on operating hours, forcing it to scale back emergency and inpatient services.”

Another hospital, structured as a medical cooperation hub capable of both testing and hospitalization, is incurring losses because its constant standby costs are not covered, he added.

“Pediatric hospitals already have the necessary personnel and equipment, so they can immediately expand patient capacity,” Choi said. “This is more realistic and efficient than building new infrastructure. Delays in transferring patients with time-dependent conditions like status epilepticus, intussusception, acute myocarditis, or pneumonia can be fatal. Securing the golden hour is not an extra expense; it is an investment in reducing societal costs.”

The KCHA head also emphasized the need to differentiate policy directions between metropolitan and non-metropolitan areas.

KCHA Vice President Lee Hong-jun remarked that the Seoul metropolitan region already has sufficient infrastructure, so a 'quality-focused transition' is needed. "Non-metropolitan areas still lack basic nighttime medical networks. Quantitative expansion and cultivating strong small hospitals must proceed in parallel," he said.

In some provinces, including North Gyeongsang and Gangwon, there are no pediatric nighttime care facilities within a 20–30 km radius. Lee said it is efficient to enhance quality in the metropolitan area and expand the foundation in the regions.