70% of orthopedic departments are not covered by actual loss insurance… The number of ophthalmology clinics that treat cataracts has plummeted.

Analysis of actual loss insurance premiums by treatment category of 5 non-life insurance companies… “Non-benefit price control is necessary”

(CG)

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(Seoul = Yonhap News) Reporter Sae-rom Chae = While the rapid increase in non-coverage treatment such as manual therapy and extracorporeal shock wave therapy is pointed out as the main cause of leakage of actual cost insurance, more than 70% of actual cost insurance for orthopedics and family medicine was paid for non-coverage treatment as of the first half of this year. It was found that it was done.

On the other hand, the ratio of non-covered medical expenses for ophthalmologists, which was well over 70% until 2022, plummeted to the 20% range.

According to the non-life insurance industry on the 5th, the actual loss insurance paid out in the first half of this year, compiled by five non-life insurance companies, including Samsung Fire & Marine Insurance, Hyundai Marine & Fire Insurance, KB Non-life Insurance, DB Non-life Insurance, and Meritz Fire & Marine Insurance, was KRW 4.9439 trillion, 8.3 trillion won more than the same period last year. % increased.

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Of these, salary payments were KRW 2.0875 trillion and non-salary payments were KRW 2.8564 trillion. The ratio of non-benefit insurance payments increased slightly from 57.6% in 2023 to 57.8% in the first half of this year.

Among the major medical departments, the departments with the highest ratio of non-covered medical expenses are orthopedics (71.0%) and family medicine (70.4%). The insurance money for these two subjects accounts for 22.5% of the total insurance money.

This is believed to be because non-covered physical therapy costs such as manual therapy, proliferative therapy, and extracorporeal shock wave therapy, which account for about 20% of actual loss insurance premiums, were concentrated in these subjects.

In particular, the Department of Family Medicine is a department that provides continuous and comprehensive treatment regardless of the type of disease, but the non-coverage rate is so high due to the extensive practice of manual therapy and non-coverage injection treatments.

Among other medical departments, medical departments with a high non-coverage ratio were found to have a high rate of increase in insurance premiums.

Insurance payments for orthopedics and family medicine increased by 12.7% and 5.7%, respectively, in the first half of this year, followed by otolaryngology (15.5%), pediatrics (10.1%), urology (11.3%), oriental medicine hospital (7.1%), and obstetrics and gynecology ( Insurance payments also increased by 5.1%). The non-reimbursement rate for these subjects is in the high 50-60% range.

On the other hand, ophthalmology, where the non-coverage ratio was as high as 76.9% in 2022, plummeted to 28.2% last year and 28.9% in the first half of this year. Non-reimbursement insurance benefits for ophthalmology decreased from 456.4 billion won in 2022 to 54.7 billion won last year and 31.4 billion won in the first half of this year.

Before the Supreme Court ruling in 2022, excessive cataract surgery and inflated non-reimbursed prices were serious, but after the Supreme Court ruling that ‘hospitalization treatment is not necessary,’ the actual loss insurance compensation standards were strengthened, which has the effect of calming down the excess cataract surgery.

However, as the pattern of new non-coverage trends is repeated, it is pointed out that price regulation related to non-coverage medical expenses and the use of standard names and codes related to non-coverage are ultimately necessary.

According to the non-coverage report data for the second half of last year that Kim Yoon, a member of the Democratic Party of Korea, received from the National Health Insurance Corporation, the gap in non-coverage medical expenses between medical institutions was found to be widening by up to 300 times. The median price for manual therapy was 90,000 won and the maximum was 1.5 million won, and the median price for extracorporeal shock wave therapy was 70,000 won and the maximum was 500,000 won.

An insurance industry official said, “If regulation of non-coverage is not implemented, the supply of non-coverage will expand even if there is similar covered treatment. This ultimately directly leads to the burden of national medical expenses due to an increase in actual loss insurance premiums, so price control is necessary to prevent abuse of non-coverage and actual loss insurance.” “he said.

President Yoon Seok-yeol previously ordered at the Cabinet meeting on the 29th of last month to prepare a plan to improve actual cost insurance within the year, and also announced on the 4th that he would speed up the restructuring of tertiary general hospitals and the reform of non-reimbursement and actual cost insurance.

srchae@yna.co.kr

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2024/11/05 06:11 Sent