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KMID : 1812620210010010016
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HIRA Research
2021 Volume.1 No. 1 p.16 ~ p.22
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Management of Health Services Uncovered by National Health Insurance
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Jeong Hyoung-Sun
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Abstract
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In December 2020, a provision for medical institutions to report items, amounts, and details of uncovered medical expenses to the Minister of Health and Welfare was newly established in the Medical Law. This paper aims to estimate the scale and trend of out-of-pocket expenditures for uncovered medical items; to review the government’s plans as well as related literatures for the management of uncovered medical items; and to gather opinions at expert meetings. Of the total current health expenditures in 2019, household out-of-pocket was 47.5 trillion won (30.3%), and “out-of-pocket excluding cost-sharing” was 26.3 trillion won (16.8%). The decrease in household out-of-pocket burden over the past 2 decades has been replaced by the increase of private health insurance premiums, suggesting that the policy has not been sufficiently connected to the burden relief of low-income households. Whether covered or uncovered, a medical item is located at a point in the continuous spectrum between necessity and selectivity. It is most logical to classify medical items according to the size of “necessity of treatment,” and determine the level (height) of co-payment rate accordingly. A medical item changes its position on the necessity-selectivity spectrum. It is a limitation in terms of classification. Suggestions: First, “medical items for which the treatment necessity is confirmed” should be covered by public health insurance, subject to quality management and differential co-payment rates. Second, “items with relatively weak treatment necessity”, currently not covered, should be switched to coverage once their therapeutic natures are confirmed, though their co-payment rates are set high in order to induce “cost-conscious” medical use of patients. Third, even in the case of “items remaining uncovered”, policy measures as follows are required from the perspective of consumer protection: informed consent, data submission, and monitoring when they are provided together with covered items, etc.
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KEYWORD
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Management of uncovered items, Treatment necessity, Differential cost-sharing, Consumer protection
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