[Asia Exclusive] "Without Reforming the Medical Delivery System, 'Moon Care' Cannot Be Effective"

If MRI treatments have increased excessively, there is some over-treatment,
but there is also a part where previously unaffordable costs have been resolved.
A thorough analysis and adjustment of these pros and cons are necessary.

[Asia Economy Reporter Choi Dae-yeol] "A country where people cannot receive treatment due to lack of money is not a country. Whether poor or wealthy, healthy or unhealthy, elderly or children, living in Seoul or provinces, all citizens must be guaranteed the right to health and the right to receive good treatment when sick." (September 2012, from 'That Man Moon Jae-in')

"The treatment-centered characteristic of Korean healthcare causes various problems. Because preventive activities that reduce medical demand itself are lacking, focus is only on treatment, relying on machines and using expensive medical equipment, leading to much waste. Waste is not only a financial problem but also very harmful to patients." (March 2015, from 'Directions and Tasks for Reforming Korea's Health Care Supply System')

This year marks the 20th anniversary of the National Health Insurance Service (NHIS). Korea's health insurance system, which began in the 1970s with some workplaces and union-based schemes, steadily expanded its coverage, and in the 1990s, moves toward unification accelerated, culminating in full integration in 2000 and the birth of the current single insurer, the NHIS. Kim Yong-ik, chairman of the NHIS, has led and closely observed these turning points in health insurance.

He was formerly a medical school professor, an activist leading various civic groups related to medical movements, and has held various administrative and legislative roles between the Blue House and the National Assembly, but the consistent keyword throughout is the assertion that everyone has the right to health. Among the current administration's presidential campaign pledges, the health insurance coverage expansion policy (Moon Jae-in Care), which explicitly includes the president's name, encapsulates Kim's decades-long emphasis. Although it claims the plausible justification of universal health rights for the people, there are many opponents during the actual policy promotion and implementation process. Recently, when meeting with reporters, Chairman Kim acknowledged criticisms that the coverage expansion policy is progressing more slowly than expected. However, he also believes there are sufficient ways to accelerate it going forward.

- In 2018, the health insurance coverage rate rose by 1.1 percentage points to 63.8%. It seems somewhat sluggish; how do you view the cause?

▲ President Moon announced the coverage expansion policy in August 2017. Preparations were made that year, and benefit expansion began the following year. It was a period of system change, and the duration is too short to measure the effect with indicators. The coverage rate indicator for 2018 reflects both the efforts made during the Park Geun-hye administration in 2017 and the measures implemented in the first half of 2018. To accurately evaluate Moon Care's results, it would be appropriate to wait until the middle of the next administration.

- The initial target coverage rate was 70%. What areas will be focused on this year to achieve that?

▲ While working to increase the coverage rate, some negative phenomena occurred. Moon Care and benefit expansion are internal reforms of the health insurance system. However, the NHIS does not directly provide medical services to the public. When the medical community provides services, the NHIS pays them. Rational changes in the medical delivery system must occur simultaneously with the benefit expansion under Moon Care. Without this, the effects cannot be fully realized. For example, if MRI usage rapidly increases, there are parts of overuse and parts that increased because it was previously too expensive to perform. Good and bad aspects are mixed, so a detailed analysis and rational adjustment are necessary.

Balloon effect expected during coverage expansion transition
Cosmetic and nutritional-related elective non-covered services like nutritional injections and manual therapy are the worst offenders
All should be identified, classified, and itemized

- Non-covered services have increased mainly at local clinics, lowering the coverage rate. What measures are there to resolve this?

▲ The concentration of demand in large hospitals or metropolitan medical institutions indicates problems in the medical delivery system. When insurance increases benefits, that side should accept and resolve it simultaneously, but this has not been easy. Coverage expansion involves converting all medically necessary non-covered services into covered services under a management system, so a balloon effect during the transition is natural. That is why we intend to accelerate the management of non-covered services.

Managing non-covered services means converting existing non-covered items to covered ones on one hand, and excluding others on the other. Items judged difficult to include in medical coverage are removed, but this process is slow. Elective non-covered services related to cosmetics and nutrition, such as nutritional injections and manual therapy, are considered to cause the largest balloon effect. We plan to identify all non-covered services, classify them, and set item categories. Accurately understanding when and how they are used is the priority.

- There are criticisms that doctors increase non-covered treatments as their income decreases. Is it possible for doctors to earn sufficient income solely from covered treatments?

▲ That is why medical delivery system reform must proceed together. Medical institutions must also strive to reduce medical costs. In the short term, this may be seen as a loss, but ultimately, all NHIS funds are used for benefits. If wasteful spending is reduced, more resources can be allocated to better areas. For example, rehabilitation services are insufficient domestically due to low fees, resulting in lack of supply.

Unless profit margins for all medical acts are equalized, over-treatment and under-treatment cannot be prevented. Over-treatment is usually seen as problematic, but under-treatment is also clearly an issue. Misalignment between diagnosis and treatment reduces efficiency for both patients and the NHIS. Inadequate treatment can lead to higher costs. An invisible goal of Moon Care is to eliminate over- and under-treatment and move toward appropriate treatment. It is not just about increasing coverage rates but raising fee levels so that the medical care received by the public is the most normal and appropriate treatment. The key is how normalized the system becomes, which is of significant importance to public interests.

Medical institutions must also strive to reduce medical costs
Though it may be seen as a short-term loss, all NHIS funds are used for benefits
Under-treatment issues like rehabilitation ignored due to low fees must also be addressed

- Community care and regional health management are emphasized. Is this part of preparing for aging?

▲ Moon Care indeed has a character of preparing for aging. Along with the system, changing the physical environment around the elderly, such as roads and housing, is also important. By 2050, the population aged 65 and over will exceed 40%. Efforts to keep the elderly healthy are crucial. The goal is to keep them functioning like middle-aged adults until about 75, promote lifelong learning to maintain productivity, and find ways to employ them. This is the core of aging preparation strategy.

Moreover, health is the foundation for implementing these strategies. Strengthening health insurance coverage is essential to control elderly medical expenses. Non-covered services are rapidly increasing; if Moon Care is not implemented and the status quo remains, their proportion will only grow. Although Moon Care increases the NHIS burden, leaving non-covered services as is will cause continuous expansion and higher out-of-pocket costs. Conversely, if they are covered, expansion is controlled and growth is much smaller. Controlling excessive elderly medical expenses and redirecting as many resources as possible to prevention and community care is necessary.