If You Receive Cold Treatment at a Large Hospital, National Health Insurance Coverage Is Not Applicable

Samsung Seoul Hospital, Gangnam-gu, Seoul. Photo by Mun Honam munonam@

[Asia Economy Reporter Choi Dae-yeol] From now on, large hospitals will incur losses in fees if they provide outpatient treatment for mild illnesses such as colds, indigestion, or constipation. However, even if medical fees decrease as a result, the patient's out-of-pocket rate will be raised so that the patient's expenses do not decrease. The fee system has been revised to encourage large hospitals to focus on treating severe patients.

The 'Medical Fee Improvement Plan to Establish the Function of the Medical Delivery System,' approved by the Health Insurance Policy Deliberation Committee on the 5th, contains these details. The basic direction aligns with the government's ongoing efforts to reform the medical delivery system. It includes measures to prevent patients from flocking to tertiary general hospitals, also known as large hospitals, and to ensure treatment is focused on severe patients. This improvement plan will be implemented starting in October.

Once the plan is applied, tertiary general hospitals will see reduced revenue when treating mild patients. Outpatient medical quality evaluation support payments will no longer be available for outpatient treatment of mild patients. Additionally, the 30% classification surcharge rate, calculated based on the fee-for-service, will not be applied. The government has designated 100 mild diseases, including gastroenteritis and conjunctivitis.

Lowering fees in this way will discourage tertiary general hospitals from treating mild patients, but conversely, the reduction in medical fees could lead to more patients visiting these hospitals. Therefore, the out-of-pocket rate for mild patients will be raised from 60% to 100%, meaning health insurance will not be applied.

For example, if a patient with a mild disease such as a corn or callus receives outpatient follow-up treatment at a tertiary general hospital, including dermatological procedures and dermatological ultraviolet therapy, the current basic consultation fee is 24,060 KRW (15,110 KRW for follow-up consultation + 8,950 KRW for first-grade medical quality evaluation support), with a procedure fee of 24,330 KRW, plus a classification surcharge of 7,299 KRW, totaling 55,680 KRW. Of this, the patient pays 60% of the procedure fee, which is 39,400 KRW.

A simulation of medical expenses for 100 patients with mild conditions of "corns and calluses" receiving follow-up outpatient treatment at a tertiary hospital, who underwent ① dermatological procedures and ② dermatological ultraviolet therapy. Although the total medical expenses decrease, the amount borne by the patients remains the same.

Under the improvement plan, the basic consultation fee will exclude the evaluation support payment, amounting to 15,110 KRW. The procedure fee remains the same, but the classification surcharge will not be added. The total medical fee will decrease by more than 16,000 KRW to 39,440 KRW. If the out-of-pocket rate is not adjusted, health insurance will apply, increasing the likelihood that patients will visit tertiary general hospitals more frequently. To address this, in such cases, the entire medical fee will be borne by the patient, keeping the patient’s burden at 39,400 KRW, the same as before. The Ministry of Health and Welfare plans to gather more opinions and prepare detailed improvement measures regarding exceptions for cases where it is unavoidable to treat mild patients.

Furthermore, to enable tertiary general hospitals to focus on severe patients, the inpatient fee for intensive care units (ICUs) in tertiary general hospitals will be increased by 10%, and the staffing reporting system will be improved to allow more flexible use of ICU nurses. The current ICU inpatient fee for a first-grade nursing tertiary general hospital is 383,000 KRW, which will be raised by 10% to 422,000 KRW. Fees will also increase to promote multidisciplinary integrated care, where experts from various fields simultaneously treat severe patients such as those with rare and intractable diseases.

To help patients find appropriate medical institutions according to their condition, the referral and patient return system will be strengthened. If a patient who has been visiting local clinics or hospitals experiences worsening symptoms requiring treatment at a tertiary general hospital, the physician can refer the patient through the government-established 'Referral and Return System.' Health insurance will pay a basic fee of 10,000 KRW for such referrals, and up to 18,000 KRW if the patient's imaging medical information is attached. Conversely, tertiary general hospitals that actively return patients whose conditions have improved or mild patients to local clinics or hospitals will receive higher return fees if they have a well-established return system.

Starting next month, the payment for inpatient safety management fees will also increase. This measure aims to protect both patients and medical staff from incidents such as assaults within medical institutions. The inpatient safety management fee applies to hospitals with 100 or more beds, including psychiatric and general hospitals, which are required to secure relevant equipment and personnel. Kim Kang-lip, Vice Minister of Health and Welfare (Chairman of the Health Insurance Policy Deliberation Committee), stated, "This system improvement will reduce unnecessary visits by mild patients to large hospitals and encourage tertiary general hospitals to focus on severe and inpatient cases, thereby strengthening medical capabilities."

This content was produced with the assistance of AI translation services.