[Broken Pediatric Care] ④ How Did Pediatrics Become the Most Avoided Specialty?

Cost Recovery Rate Only 79% with No Non-Insured Services
Ongoing Legal Risks, Including 1.6 Billion Won Compensation for Neonatal Brain Injury

Editor's NoteAlthough there are expectations that residents who left hospitals in protest against the increase in medical school quotas in February last year will resume their training after a year and a half, the situation in essential departments that handle critical and emergency patients remains precarious. In particular, the field of pediatrics is facing a shortage of applicants due to the low birth rate, an unreasonable fee system, and increasing legal risks, causing residents to avoid the specialty and existing specialists to leave. As regional disparities in medical services widen, the care system for sudden pediatric emergencies and severe pediatric diseases requiring specialized intensive treatment is also faltering. With fewer children being born and even fewer doctors to care for them, Asia Economy will examine the current state of the pediatric medical system and directions for improvement in a six-part series.

"Three out of the six doctors at our hospital are residents who resigned due to the conflict between the medical community and the government. Now that they are returning to their original training hospitals, I am not sure if we will be able to find replacements. Recruiting pediatricians in a non-metropolitan area is as difficult as picking stars from the sky."

This is what the director of a pediatric hospital in Daejeon said. The collapse of pediatric emergency and critical care stems from the severe shortage of pediatricians, which in turn is caused by the persistent avoidance of the specialty. Due to legal risks and low reimbursement rates, new doctors are reluctant to pursue pediatric training, and board-certified specialists are avoiding pediatric practice.

According to the medical community on August 27, the main reasons for the avoidance of pediatrics include low reimbursement rates, legal risks, and the declining birth rate. In a survey conducted last year by the Korean Pediatric Society, 90% of respondents cited "low reimbursement rates" as the reason for the decrease in applications to pediatric residency programs. This was followed by "risk of medical accidents (legal risk)" at 80% and "low birth rate" at 70%.

Pediatrics is one of the specialties where the reimbursement from the National Health Insurance does not even cover the cost of care. According to the National Health Insurance Service, the cost coverage rate for pediatric care is only about 79%.

In particular, the nature of pediatric care means that there are almost no non-insurance (out-of-pocket) services, which further exacerbates the problem. Previously, in 2002, the Constitutional Court ruled in a lawsuit filed by the medical community that reimbursement rates below cost were unconstitutional, but justified some degree of fee control under the mandatory designation system because profits could be made through non-insurance services. However, in pediatrics, it is virtually impossible to offset losses from below-cost reimbursement with non-insurance services.

As a result, many pediatric hospitals are relying on additional government support measures to continue operations. Jung Sungkwan, chairman of the Woori Children’s Medical Foundation, which operates a pediatric specialty hospital, said, "We are making up for losses through support from projects such as the Pilot Project for Establishing Regional Pediatric Care Cooperation Systems, the Essential Specialty Function Enhancement Support Project, and the Moonlight Children's Hospital Project."

This situation is the same at tertiary general hospitals that treat severe pediatric cases. For example, when administering chemotherapy to pediatric cancer patients, four to five medical staff members must hold the child's limbs to ensure precise injection into blood vessels, muscles, or the spinal canal, but there is no additional payment based on the patient's age, resulting in losses for the hospital.

The fact that the age-based additional payment only applies up to age 15 is also problematic. Kim Hyeri, a professor in the Department of Pediatric Oncology and Hematology at Asan Medical Center, pointed out, "In cases of pediatric cancer, especially leukemia, it often develops during middle or high school years and requires two to three years of treatment, but under the current reimbursement system, once treatment begins and the patient turns 15, there is no longer any age-based additional payment."

The increased legal risk after the "Ewha Mokdong Hospital Neonatal Group Deaths" incident in 2017 has also had a negative impact. Although all seven medical staff members were acquitted, the sight of professors and residents being detained was a major shock to the medical community, and since then, the rate of applications to pediatric residency programs has plummeted.

This legal risk for pediatricians continues to this day. On July 25, the Ulsan District Court Civil Division 12 (Presiding Judge Lee Yeonjin) ordered a hospital to pay 1.6 billion won in damages in connection with an accident in which a newborn suffered brain damage resulting in disability.

However, the medical community argues that most of these unavoidable medical accidents were the result of the best possible medical judgment at the time, and that imposing excessive legal liability on doctors for the outcomes only leads to avoidance of care, care gaps, and the collapse of essential medical services.

Lee Jooyoung, a pediatric emergency medicine specialist and National Assembly member from the Reform Party, said, "Regardless of respecting the judiciary's decisions, if a doctor is found to have violated the duty of explanation even when there was no negligence, no pediatric specialist will be willing to accept such risks. If these rulings continue, no intern will apply for a pediatric residency program."