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KMID : 0986720230310020061
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Korean Journal of Medicine and Law
2023 Volume.31 No. 2 p.61 ~ p.95
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Legal consideration of National Health Insurance medical care benefit standards
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Kwon Oh-Tak
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Abstract
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Korea, which chose national health insurance as a method of social security, made all citizens insured, designated all medical institutions as health care institutions, compensated costs through health insurance, and divided medical care benefits into covered and non-coverage benefits. As a result, the following issues are being raised regarding medical care benefit standards.
First, the standards for medical care benefits are uniform and cost review is arbitrary. However, universality of medical care benefits is recognized as a result of the collective intelligence of experts with medical expertise. In addition, which of the various treatment methods will be compensated by health insurance is not a medical issue, but a matter of policy choice based on expertise, universality, and financial conditions, and cost review based on those standards cannot be considered arbitrary.
Second, medical technology prior to new medical technology evaluation under the National Health Insurance Act can also be used for non-coverage benefits purposes. First of all, all medical services used in clinical settings must have proven safety and effectiveness, and under the premise of safety and effectiveness, medical care benefits and non-coverage benefits are distinguished depending on the degree of cost-effectiveness proven. However, due to the discrepancy between the development of science and technology and the timing of applying medical care benefits, the timing of use of new, unproven medical technology may become an issue. As a result, except for pharmaceuticals, medical practices and treatment materials are ultimately verified for safety and effectiveness through evaluation of new medical technologies. However, the relevant regulations are unclear and need to be clearly revised.
Third, after the application of ideologically expensive drugs to health insurance, controversy may arise regarding the scope of coverage of National Health Insurance, a social insurance policy. Considering the development of science and technology and the public's health needs, a new agreement on the minimum guarantee of social insurance is needed. Therefore, for the sustainability of health insurance, it is time to publicize and reach a social consensus on the plan to secure health insurance finances, the scope and target of compensation for medical care benefits, and the principles of applying medical care benefits for new future medical technologies.
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KEYWORD
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Medical Care Benefits standards, Review of the costs of health care benefits, National Health Insurance, Evaluation of New Medical Technology, Health insurance finance
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