Korea Institute for Health and Social Affairs 'Study on the Current Status and Improvement Measures of Real-World Insurance'
"Real-World Insurance is a Private Contract... Government Intervention is Inappropriate"
As the second phase of medical reform measures, including improvements to non-reimbursable services and indemnity insurance, originally scheduled to be announced within the year, will inevitably be delayed beyond the year-end, the medical community has called for recognizing doctors' autonomy in non-reimbursable treatments and establishing measures to prevent infringement on their medical practice rights.
According to the report titled "Current Status and Improvement Measures of Indemnity Medical Insurance" released on the 20th by the Medical Policy Research Institute under the Korean Medical Association, a survey of 813 doctors regarding the status, issues, and improvement measures of indemnity insurance found that more than half of the respondents (59.3%) answered that "indemnity insurance is necessary." When asked whether indemnity insurance affects the deterioration of health insurance finances, 55.8% responded negatively, saying "yes," while 36.0% said "no," and 7.7% answered "don't know."
Doctors reported that they find it most difficult to respond when patients with indemnity insurance request diagnosis certificates eligible for indemnity insurance claims (36.3%) or when patients demand treatments that can be claimed under indemnity insurance (21.5%). Additionally, 62.7% of doctors experienced receiving official letters requesting explanations or settlement proposals from indemnity insurance companies regarding diagnosis certificates. Among them, 68.0% said they wrote more detailed medical records and sent them to the insurance companies.
As improvement measures for the indemnity insurance system, doctors cited "improving the treatment environment by prohibiting complaints about infringement on doctors' medical practice rights (30.4%)," "clarifying standards for non-reimbursable items related to indemnity insurance (23.0%)," and "improving the design structure of indemnity insurance products (22.8%)." Furthermore, 54.1% said that appropriate guidelines for non-reimbursable items should be created by the relevant specialty academic societies.
Based on these findings, the research team proposed, from the perspective of healthcare providers, recognizing doctors' autonomy in non-reimbursable treatments, prohibiting insurance companies from requesting explanations for legally issued attending physician diagnosis certificates, banning requests for diagnosis certificates that guarantee insurance coverage from subscribers, establishing appropriate guidelines for non-reimbursable items, supporting research to establish medical evidence for non-reimbursable items, and forming and operating medical advisory groups by specialty.
Institutionally and policy-wise, they suggested resetting policy directions to establish the roles and relationships between public and private insurance, sharing roles of the Ministry of Health and Welfare regarding indemnity insurance, strengthening the role of medical associations, mandating disclosure of indemnity insurance operation status, and legislating these requirements. Furthermore, from the perspective of medical service users, improvement measures included excluding statutory copayments from indemnity insurance coverage when developing new products, preparing measures to adjust copayment ratios, strengthening product explanation obligations with legal sanctions for non-compliance, and establishing sanctions against inducement of excessive subscriptions.
The research team diagnosed, "Until now, the policies implemented by the government to improve indemnity insurance have been relatively insufficient for healthcare providers and users," adding, "especially, long-term improvement measures that should be pursued from a big-picture institutional and policy perspective have not been properly implemented."
They continued, "Since indemnity insurance is a private contract between individual insurance subscribers and private insurance companies, it is fundamentally wrong to directly control or manage insurance subscribers and doctors?that is, medical service users and providers?or to control and manage non-reimbursable services." This is because forcibly managing and controlling parts determined by private contracts by the state ignores free market economic principles and directly infringes on individual property rights, health rights, and freedom of occupation.
The research team emphasized, "Close discussion and consultation with healthcare providers are essential in the decision-making process of indemnity insurance-related policies," and added, "Furthermore, the roles of public and private insurance should be separated, and the issue of low medical fees should be resolved so that non-reimbursable indemnity insurance no longer infringes on the role of public insurance."
© The Asia Business Daily(www.asiae.co.kr). All rights reserved.
