[Exclusive] MRI and Ultrasound, Previously Leaking Health Insurance Funds, Reduced Spending by Narrowing Coverage Criteria

Sharp Increase in Ultrasound and MRI Expenses Due to 'Moon Jae-in Care'
Stricter Coverage Criteria Since July Last Year... 3 Billion KRW Decrease in September
Government Focuses on Sustainability of Health Insurance Management

Last year, the government narrowed the health insurance coverage criteria for ultrasound and magnetic resonance imaging (MRI), which had been expanded by the previous administration, resulting in a slowdown in the increase of the number of tests and insurance expenditure. Amid recent criticisms regarding the burden of health insurance spending following the government's decision to increase medical school admissions, the government plans to manage health insurance expenditures with a focus on the 'sustainability' of medical services to minimize financial leakage.

According to the National Health Insurance Service on the 8th, since the strengthening of the coverage criteria for upper abdominal ultrasound tests in July last year, the actual health insurance expenditure related to these tests has decreased by more than 10%.

The number of ultrasound tests in June last year, just before the coverage criteria were tightened, was 1,456,000, with actual expenditure of 87.1 billion KRW. However, by September, the third month after the criteria were strengthened, the number of tests dropped to 1,296,000 and expenditure to 76.3 billion KRW, decreases of 11.0% and 12.4%, respectively.

Compared to the same period the previous year, the decline in September was also clear. Ultrasound expenditure in September 2022 was 79.2 billion KRW, but in September last year, when the strengthened criteria were applied, it decreased by about 3 billion KRW (3.7%↓). The number of medical visits also decreased by 3.9%.

However, changes were minimal in the initial months of July and August last year. July 2022 expenditure was 85.3 billion KRW compared to 85.9 billion KRW in July 2023, and August 2022 was 86.3 billion KRW versus 86.8 billion KRW in August 2023. Considering the time lag before the revised criteria took effect, the National Health Insurance Service analyzed that the impact of the strengthened coverage criteria appeared from September, the third month.

A Ministry of Health and Welfare official said, "In the two months immediately following the strengthening of the ultrasound coverage criteria, the increase stagnated, and from the third month, September, about 3 billion KRW was saved," adding, "This is a significantly reduced figure." The official also said, "We will be able to accurately assess the effects of the strengthened coverage criteria once data from October to December last year are available, but it is expected that insurance expenditure also decreased during this period."

The government strengthened the health insurance coverage criteria to ensure the 'sustainability' of health insurance finances by curbing excessive medical treatment.

According to the Ministry of Health and Welfare, the health insurance finances are expected to shift to a current account deficit starting in 2026. The deficit is projected to be 307.2 billion KRW in 2026, 789.5 billion KRW in 2027, and 1.5836 trillion KRW in 2028, with the deficit widening. Therefore, the government's goal is to normalize medical supply by reducing unnecessary medical shopping and medical overuse.

In particular, since the announcement of the 2017 health insurance coverage expansion policy known as 'Moon Jae-in Care,' the costs for ultrasound and MRI increased tenfold from 189.1 billion KRW in 2018 to 1.8476 trillion KRW in 2021. Ultrasound coverage expanded to upper abdomen in 2018, lower abdomen and urology, emergency critical patients in 2019, eye and orbit in 2020, and chest and heart in 2021. MRI coverage expanded to brain and cerebrovascular in 2018 and spine in 2022.

However, concerns about financial leakage due to excessive testing and insufficient actual coverage criteria led the government to announce the 'Improvement Plan for Appropriate Ultrasound Testing' at the 7th Health Insurance Policy Deliberation Committee in April last year and strengthen the coverage criteria starting with upper abdominal ultrasound tests in July. Upper abdominal ultrasound tests are applied only when upper abdominal disease is suspected and medically necessary. From October, simple headaches or dizziness were excluded from brain and cerebrovascular MRI coverage. These strengthened coverage criteria appear to have slowed the increase in actual expenditure for ultrasound and MRI last year.

Comparing the increase in actual expenditure for ultrasound and MRI over the past three years (2021?2023, cumulative from January to September each year), expenditure increased by 35.6% in 2022 compared to the previous year but only rose by 4.7% in 2023. Actual expenditure for brain, cerebrovascular, and spine MRI also increased by 25.8% in 2022 but decreased by 4.3% in 2023.

The government plans to strengthen the criteria for lower abdominal and urological ultrasound tests in the first half of this year, applying coverage only when disease is suspected. A Ministry of Health and Welfare official said, "Due to aging, health insurance expenditure is expected to continue increasing," adding, "We will strengthen criteria for unnecessary coverage to suppress spending and maintain fiscal soundness."