Towards universal coverage: an evaluation of the benefit enhancement plan for four major conditions in Korean National Health Insurance

Owing to low contributions and a limited benefits design, the Korean National Health Insurance (NHI) took only 12 years from its establishment to achieve universal population coverage. However, the NHI has been facing critical challenges like high out-of-pocket payment rates and catastrophic health expenditures because of low contributions and a limited benefits design. In response to these challenges, in 2013, as a major move towards universal coverage, the Korean government declared a plan to radically enhance the benefit coverage for four major conditions, including cancers, cardiovascular and cerebrovascular diseases, and rare diseases. This study aimed to evaluate the benefit enhancement plan for these four major conditions and identify key success factors. Four major strategies were adopted to enhance benefit coverage: 1) covering almost all previously non-covered medical services either as essential or discretionary benefits, except for definite non-essential services such as cosmetic surgery; 2) improving conditions for benefit coverage corresponding to current scientific knowledge; 3) reducing high out-of-pocket payments considering income level; 4) reducing the financial burden from three major non-covered services including physician surcharges, private room charges, and private charges for custodial care. Despite impaired equity in financial protection across conditions, the plan is expected to reduce out-of-pocket payments by 10% in four major conditions. The actual impact of the plan should be evaluated after implementation. For the successful implementation of the plan, we need to strengthen the NHI's strategic purchasing by establishing a new benefit management system, improving claims review processes, and providing financial incentives rewarding quality and efficiency of care.

How to develop social consensus for the uninsured benefit in the social insurance system

The current national health-insurance system of the Republic of Korea uses the negative-list method to determine benefit coverage, which includes most medical services. However, financial limitations have led to frequent conflicts between medical-service providers and the Health Insurance Review and Assessment Service (HIRA) about the inclusion of specific service-providers' practices within benefit coverage. The role of HIRA is to determine whether payments claimed by service providers are clinically valid and formulated in a cost-efficient manner. This article describes the present state and structure of the benefit system in the Korean national health-insurance system. We focus on issues of arbitrary uninsured benefits that may arise when service providers request patients to pay in full (with their approval) for a service that is not included in the benefits, according to the National Health Insurance Act. We also consider the legal treatment of arbitrary uninsured benefits in Korea and other countries. We suggest measures to improve the payment system for arbitrary uninsured benefits in Korea. Laws and regulations should be revised to cover these arbitrary uninsured benefits in a manner that can be agreed upon by HIRA, service providers, and patients.

Changes in Medical Practice Pattern before and after Covering Intraocular Lens in the Health Insurance / 예방의학회지

This study is to find out changes in medical practice at a university hospital before and after covering intraocular lens (IOL) from the health insurance benefit. The coverage started on March 1, 1993 and a total of 596 cases who were discharged from July 1 to December 31, 1992 and 580 cases who were discharged from July 1 to December 31, 1993 were analyzed. Since the standard reimbursement scheme was changed from March 1, 1993, the charges for 1992 were transformed into 1993 scheme. Major findings are as follows: Average length of stay was statistically significantly decreased from 8.24 days in 1992 to 6 86 days in 1993. Charges except IOL has been statistically significantly decreased from 501,000 won in 1992 to 444,000 won in 1993. Charges for drugs and injection have been reduced. However, charge per day for them was not much different. This is due to decrease in length of stay. Charges for laboratory tests and radiologic examination were quite the same. charges which are not covered by the insurance remained the same. The revenue of the hospital was reduced as expected. However, the hospital reduced the length of stay and increase the turnover rate in order to compensate the potential loss of revenue due to the difference of reimbursement between the out-of-pocket expense and the insurance coverage. By introducing the IOL benefit in the insurance, the insured pays less, hospital generates more revenue through shortening the hospital stay, and the total medical care cost becomes less nationwidely.