The number of actual loss insurance payments paid for non-coverage treatment such as manual therapy and extracorporeal shock wave therapy is increasing. According to the non-life insurance industry on the 5th, actual loss insurance payments in the first half of this year amounted to 4.9439 trillion won, an 8.3% increase compared to the same period last year. Among these, the departments with the highest ratio of non-covered medical expenses were orthopedics and family medicine. The photo shows an orthopedic clinic in downtown Seoul on this day. News 1
The government is considering a plan to manage and manage manual therapy and extracorporeal shock wave therapy, which have been pointed out as the main culprits for non-severe and excessive treatment and the increase in actual cost insurance premiums, and to limit the coverage of patient expenses under actual cost insurance.
According to the government and medical community on the 27th, the Special Committee on Medical Reform is discussing these plans with the medical community and insurance industry ahead of the announcement of the second implementation plan for medical reform next month, which includes measures to strengthen non-benefit management and reform the actual loss insurance structure.
Thanks to actual loss insurance coverage, some non-covered treatments have expanded excessively. It has been pointed out that this increases overall medical expenses and drains the pockets of good actual loss insurance subscribers. The government believes that this distortion of the medical field is causing doctors to flock to non-reimbursed fields such as ophthalmology and orthopedics, and desolating the essential medical field.
Accordingly, we believe that non-severe and excessive non-coverage management is necessary and are considering a plan to cover some non-coverage treatment. It is highly likely that the top 10 non-covered treatments with high actual loss insurance claims, including manual therapy, extracorporeal shock wave therapy, proliferative therapy, cataract surgery, HIFU surgery, and nasal valve reconstruction, will be targeted. Medical institutions can set prices for non-covered treatment at will, but as a result, treatment costs vary widely depending on the medical institution, and there is no way to control them. If this is covered, health insurance will cover a certain portion of medical expenses and the government will be able to control medical expenses and health insurance application standards. The government plans to classify these non-serious and excessive non-coverage items as a type of selective benefit (a system that applies health insurance by increasing the out-of-pocket rate for treatment with uncertain cost-effectiveness) and plans to minimize the burden of health insurance by raising the patient burden rate to 90-95%. . Regarding manual therapy, the number of treatments is expected to be limited for each disease. In the case of extracorporeal shock waves, kidney stone lithotripsy, etc. will remain as before, and management of only orthopedic pain treatment items will be strengthened.
A government official explained, “Even if you make it a benefit and increase the out-of-pocket expenses, if actual loss insurance covers it, the management effect will disappear. An opinion was presented that a plan to reduce or limit coverage for out-of-pocket expenses for benefit items is needed.” Previously, the government announced that it would limit reimbursement for mixed treatment that combines non-covered manual therapy and covered physical therapy. The government plans to finalize the second implementation plan at the end of next month after holding a public hearing.
Reporter Esther [email protected]
