Massaged manual therapy, treatment 1+1… Medical poisonous mushrooms cause actual loss and non-reimbursement [의료 망치는 비급여]

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Anatomy of a non-benefit republic

#On the 16th of last month, I went to Clinic A in Gyeonggi-do and said, “I want to get a nutritional injection.” When I entered the treatment room, the doctor told me to open my mouth. That was the end of the treatment. The doctor diagnosed him with acute pharyngitis, saying, “Your throat is swollen.” It took less than a minute. This was diagnosed even though there was absolutely nothing wrong with my neck. I received a non-reimbursed amino acid injection in the next room and paid 100,000 won. The hospital provided a medical certificate to be submitted to the insurance company. It is said that he received an intravenous fluid injection for the purpose of treating worsening systemic symptoms. In the IV injection room, children and the elderly are lying down receiving nutritional injections.

#An orthopedic clinic in Seoul on the 25th of last month. There are 18 rooms lined up in the ‘Manual and Pain Center’ area. You can also see an aqua therapy room, extracorporeal shock wave room, and electrotherapy room. The staff explains, “Manual therapy costs 80,000 won for 30 minutes, and 200,000 won for 80 minutes.” There are many patients in their 50s or older. Ms. B, a woman in her 70s who visited with her daughter in her 50s, said, “I come often because I feel refreshed after receiving manual therapy.” The doctor emphasized, “Usually each patient receives manual therapy about 10 times, and the actual cost is covered.” This hospital provides a variety of non-reimbursed treatments such as proliferation therapy, extracorporeal shock wave, Saxenda injection for obesity, ‘White Jade + Cinderella’ injection, and growth plate examination.

This is a common sight in medical settings these days. Non-healthcare treatment that is not covered by health insurance, that is, non-covered care, is rapidly expanding in this way. As actual cost insurance provides nourishment to medical institutions’ pursuit of profits and patients’ moral hazard, the situation is heading towards a situation that is difficult to control. Non-benefit coverage eats up health insurance finances and drains the pockets of good actual cost insurance subscribers. In addition, doctors are concentrated in non-reimbursed fields such as ophthalmology and orthopedics, and essential medical care becomes scarce.

According to the results of a survey by the National Health Insurance Corporation of 2,521 medical institutions, or 2.6% of medical institutions, only 65.7% of all medical expenses incurred in Korea as of 2022 are covered by health insurance. 19.7% is the out-of-pocket cost paid by patients when receiving treatment covered by health insurance. In addition, 14.6% of non-covered medical expenses are not covered by health insurance. Converting this into total medical expenses, it is approximately 18 trillion won. It increased by 53% from 2015.

Non-coverage is called ‘whack-a-mole game’. If you press one spot, it bounces somewhere else. Although the Moon Jae-in administration invested more than 26 trillion won in health insurance finances to promote ‘benefiting non-benefit’, the health insurance coverage rate did not increase much. This is because converting non-benefit to salary increases the number or amount of the remaining items. Additionally, new medical technologies continue to come out, and most of them become new non-coverage treatments. From 2007 to June of this year, 1,590 new medical technologies, including tests and treatments, were introduced.

An oriental medicine hospital in Seoul is the nation’s largest provider of intra-articular injections of bone marrow aspirate concentrate for knee osteoarthritis (based on actual loss claims). It is a new medical technology recognized for its effectiveness in relieving pain and improving function by injecting a centrifuged and concentrated substance extracted from one’s own bone marrow. According to the Ministry of Health and Welfare’s notice, the term ‘stem cell’ cannot be used, but the industry uses it for marketing purposes. When a reporter visited last month, the doctor said, “I have stage 2 arthritis,” and recommended injection treatment, saying, “It is a stem cell treatment that has cartilage regeneration effects.” An employee at this hospital said, “If you do the procedure now, it’s ‘1+1.’ If you do it in October, there’s a 40% discount.” Promote it as if you were selling a product. An official from the Ministry of Health and Welfare says, “It cannot be considered a stem cell procedure, and it does not regenerate cartilage, so it may violate advertising.”

The government is almost completely ignoring non-benefit management. Disclosure of price is everything. Since there are no regulations, it is up to the medical institution to set treatment fees. For the first time in history, the hospital level received the medical treatment details of 594 non-covered items from September of last year, and the clinic level received the details (1,068 items) from March of this year. There is no way to understand the whole thing. Seo Nam-gyu, head of the non-benefit management office at the National Health Insurance Corporation, said, “Non-coverage treatment is not standardized, so we cannot know its scale.”

It is also poisonous to health insurance finances. Since health insurance treatment such as examinations and tests follows non-covered treatment, health insurance funds are leaked. In the previous example, 12,330 won was spent on an intravenous fluid injection at a Gyeonggi-do clinic, and about 30,000 won was spent on orthopedic manual therapy.

The top 10 non-reimbursements include various injections, manual/extracorporeal shock wave/proliferative treatments, cataract surgery, HIFU surgery, and nasal valve reconstruction. Magnetic resonance imaging (MRI) and computed tomography (CT) tests, hospital room fees for one person, issuance of medical certificates and certificates, and beauty and plastic surgery are also representative examples of non-reimbursement.

Korea has the fastest rate of increase in medical expenses compared to gross domestic product (GDP) among member countries of the Organization for Economic Co-operation and Development (OECD). This is largely due to aging, but non-covered treatment also plays a role. Non-reimbursement shakes the foundation of essential medical care. According to data from the office of People Power Party lawmaker Myung-ok Seo, the number of general doctors (employed doctors) employed in clinics in six fields, including dermatology, ophthalmology, plastic surgery, and orthopedics, where the proportion of non-covered treatment is high, increased from 231 in February this year to 362 in July.

Department store-style non-reimbursement medical institutions are also appearing. Clinic C in Seocho-gu, Seoul, which I visited on the 24th of last month, has a variety of non-covered treatments including skin, plastic surgery, manual therapy, and child development across four floors. It promotes wrinkle improvement and body correction. Nearby Clinic D also deals with everything from female genital surgery to obesity treatment ‘We Gobi’.

Patients have also become accustomed to non-covered treatment. A man in his 40s whom I met at an orthopedic clinic in Seoul on the 16th of last month said, “I come for manual therapy whenever my ankles or back hurts. “I don’t think it’s overtreatment,” he said.

The hospital director, who requested anonymity, said, “It is questionable whether the non-compensated injections that people deliberately spend money on are effective. “Nevertheless, it has spread like a trend and we are spending a huge amount of money on it,” he pointed out. At the same time, “As new non-coverage payments are leaking out through loopholes such as new medical technologies, there are items that many doctors cannot agree on. “The problem is that moral hazard among patients is widespread,” he added.

Kim Jin-hyeon, a professor of nursing at Seoul National University, said, “Among countries that operate social insurance called health insurance, there is no other country that has neglected non-benefit coverage like we have,” and added, “We need to come up with measures urgently.” The government is also busy belatedly preparing countermeasures. On the 29th of last month, President Yoon Seok-yeol ordered, “Increase the speed of non-benefit and actual cost insurance reform.” The President’s Special Committee on Medical Reform plans to present related measures at the end of this year.

※This project was supported by the Press Promotion Fund raised through government advertising fees.

Jong-Hoon Jeong, Soo-Hyun Nam, Seong-Sik Shin (sakehoon@joongang.co.kr)