Table of Contents
- 1 ‘Differential application of insurance premiums’ 4th generation actual loss insurance, is it effective in suppressing overtreatment? “Achieve limited non-benefit management”
- 2 What are the limitations of focusing solely on non-covered treatment when evaluating the effectiveness of South Korea’s 4th generation actual loss insurance in curbing overtreatment?
Digital Daily Publication Date 2024-11-24 12:00:00
Decrease in the proportion of non-covered treatment for ‘sprains and strains’… However, there are still cases of worsening loss ratios and suspected cases of excessive treatment.
ⓒPixabay
[디지털데일리 권유승 기자] The ‘4th generation actual loss insurance’, which applies differential insurance premiums according to the amount of medical use, was found to be partially effective in reducing the proportion of non-covered medical treatment such as sprains.
However, as loss ratio (ratio of insurance premiums paid to insurance premiums received) deterioration and overtreatment still occur, it is analyzed that there is a need to continuously seek mid- to long-term non-benefit management measures.
According to the Insurance Research Institute on the 24th, the 4th generation actual loss insurance is characterized by differential application of premiums according to the non-benefit insurance premiums paid for the previous year. The self-payment ratio was raised for both benefits and non-benefit, and coverage for some non-benefit items with a high risk of overtreatment, such as manual therapy and nutritional injections, was also reduced.
Depending on the subscription period, actual loss insurance is divided into ▲1st generation actual loss insurance (sold until September 2009) ▲2nd generation actual loss insurance (sold from October 2009 to March 2017) ▲3rd generation actual loss insurance (sold from April 2017 to 2021) (sold until June 2021) ▲4th generation actual loss insurance (sold after July 2021), etc. Divided into branches.
The 4th generation actual cost insurance is effective in reducing the proportion of non-covered medical treatment such as sprains.
According to the results of analysis of the statement of medical expenses compensated by a large domestic non-life insurance company to subscribers of its actual cost medical insurance from 2021 to 2023, converted to a patient level, the ratio of non-reimbursement to medical expenses of the 4th generation actual cost insurance for sprain and strain treatment is It was lower on average compared to group actual loss (accident) insurance and actual loss medical insurance of other generations.
On average, the ratio of non-coverage to medical expenses was highest in the 2nd generation, and based on the mean and median, the 4th generation recorded the lowest figures at 48.9% and 50.2%, respectively.
In the case of the first generation, which has the highest average age, the number of treatment days was the longest at 3.7 days, and the medical cost was 619,000 won, which was higher than the 4th generation actual loss insurance of 606,000 won and the number of treatment days was 3.0 days.
Jeon Yong-sik, a senior research fellow at the Korea Insurance Research Institute, said, “The 4th generation actual cost insurance appears to have the effect of suppressing non-coverage treatment, as intended,” adding, “For the 4th generation, a differential insurance premium system based on annual non-coverage payment performance has been implemented since last July. “, Excessive non-reimbursement use will be able to be controlled additionally in the future,” he analyzed.
However, it is pointed out that it is too early to be reassured as an analysis of hospital and regional standards shows that overtreatment of patients with 4th generation actual loss insurance is suspected.
Among patients treated at the hospital, the proportion of patients with non-covered medical expenses in the top 25% reached 38% for 4th generation actual cost insurance patients.
In particular, in Seoul and Gyeonggi regions, the median medical expenses and non-coverage medical expenses of 4th generation actual cost insurance patients were higher than those in non-metropolitan areas.
Accordingly, it is evaluated that the non-benefit management purpose of the 4th generation actual loss insurance has been achieved to a limited extent, and it is suggested that continuous non-benefit management methods be sought in the future.
Senior Research Fellow Jeon said, “There is a need to find ways to curb the incentive to over-treat medical care that arises from non-covered physical therapy and injection drugs,” and added, “We need to spread the increase in insurance premiums felt by actual cost insurance subscribers over multiple periods and manage the loss ratio stably.” “For this reason, it is necessary to consider a plan to allow rate adjustment within 5 years, provided that certain statistical requirements are met,” he suggested.
What are the limitations of focusing solely on non-covered treatment when evaluating the effectiveness of South Korea’s 4th generation actual loss insurance in curbing overtreatment?
## World Today News Interview: Is 4th Generation Actual Loss Insurance Effective at Curbing Overtreatment?
**Introduction**
Welcome to World Today News. Today we’re discussing the effectiveness of South Korea’s 4th generation actual loss insurance in addressing the problem of overtreatment. Joining us are two distinguished experts: [Guest 1 Name & Title] and [Guest 2 Name & Title].
**Section 1: Understanding the Goals & Design of 4th Generation Actual Loss Insurance**
* **Moderator:** Could you both explain the specific goals behind the implementation of 4th generation actual loss insurance?
* **Moderator:** [Guest 1], you mentioned the differential premium system implemented in July. Could you elaborate on how this works and what its intended impact is?
* **Moderator:** [Guest 2], what are your thoughts on the strategies employed by the 4th generation insurance compared to previous versions? Do they address the root causes of overtreatment effectively?
**Section 2: Effectiveness in Reducing Non-Covered Treatment**
* **Moderator:** The article mentions a decrease in non-covered treatment for conditions like sprains. [Guest 1], does this data suggest the 4th generation insurance is successfully achieving its aims?
* **Moderator:** However, the article also highlights regional disparities in treatment costs. [Guest 2], how might these variations impact the overall effectiveness of the 4th generation insurance?
* **Moderator:** Do you think focusing solely on non-covered treatment is the right approach, or should other factors be considered in gauging the success of the program?
**Section 3: The Challenge of Overtreatment**
* **Moderator:** The article raises concerns about potential overtreatment still occurring despite the new insurance model. [Guest 1], how does the incentive structure of the 4th generation insurance potentially contribute to this issue?
* **Moderator:** [Guest 2], what additional measures could be implemented to further mitigate the risk of overtreatment? Are there any successful international examples we could learn from?
**Section 4: Long-Term Sustainability and Future Directions**
* **Moderator:** Critics argue that the current system might not be financially sustainable in the long term. [Guest 1], what are your thoughts on the potential for rising loss ratios and how can that be addressed?
* **Moderator:** [Guest 2], the article suggests allowing rate adjustments within a defined period. Could you expand on this idea and discuss its potential benefits and drawbacks?
* **Moderator:** Looking forward, what are your biggest concerns and hopes for the future of actual loss insurance in South Korea?
**Conclusion**
Thank you both for sharing your valuable insights.
This discussion highlights the complexity of addressing overtreatment within the healthcare system.
It underscores the need for continuous evaluation, adaptation, and collaboration between insurers, policymakers, and healthcare professionals to ensure a sustainable and patient-centered approach.
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