Health Insurance Policy Committee Analyzes Medical Costs to Strengthen Compensation for Critical, Emergency, and Basic Care
Expanded Coverage for Immunotherapy Drug "Keytruda" Reduces Patient Burden
"Korean-Style Primary Care Physician" Model to Launch Next Year... Integrated Health Management for Those in Their 50s and Older
The government will restructure the unbalanced medical fee system to focus on essential medical services. Compensation for so-called "profitable" areas such as specimen and imaging tests will be reduced, and the funds saved will be redirected to essential medical services and basic care, such as surgeries, procedures, and consultations. The scope of health insurance coverage for the high-cost immuno-oncology drug Keytruda has also been significantly expanded.
On the 23rd, Lee Hyun, Second Vice Minister of Health and Welfare and Chairperson, is speaking at the 24th Health Insurance Policy Deliberation Committee meeting for 2025. Ministry of Health and Welfare
The Ministry of Health and Welfare convened the "24th Health Insurance Policy Deliberation Committee Meeting" on the 23rd to discuss these measures.
Based on the analysis of medical expenses for the 2023 fiscal year, the government will begin regular adjustments to the relative value scale starting in 2026. Until now, revisions to the relative value scale have occurred every five to seven years, making it difficult to quickly reflect changes in medical technology and perpetuating distortions and imbalances in fees across different fields.
According to the results from the Medical Cost Analysis Committee, specimen testing (192%) and imaging diagnostics (169%) at tertiary general hospitals are highly profitable compared to their costs, whereas basic care (63%) and physical therapy (33%) fall far short of covering their costs.
Accordingly, the government will review approximately 6,000 out of a total of about 9,800 medical service fees, adjust the fees for overcompensated test areas, and use the resources secured to strengthen compensation for essential medical services such as critical and emergency surgeries, pediatric care, and childbirth, as well as undercompensated basic services like consultations and inpatient care.
The previously opaque specimen test consignment and subcontracting market will also be reorganized. The existing "consignment test management fee (10%)" will be abolished, and a new fee system reflecting the roles of each consignment and subcontracting institution will be introduced. In particular, to curb the widespread practice of discounting test fees, the billing and payment process will be improved, mandatory reporting of patient safety incidents will be instituted, and new regulations will be established to restrict repeated subcontracting, thereby improving the quality of testing.
The approximately 240 billion won previously allocated to the abolished management fee will be used to increase fees in undercompensated areas such as consultations. In addition, to ensure patient safety, the government will improve certification standards for subcontracted institutions and implement mandatory incident reporting as part of its quality management measures. This reorganization of the consignment and subcontracting compensation system is scheduled for announcement revision in the first half of next year and will be implemented in line with the timing of the regular relative value scale adjustments.
For tertiary general hospitals and comprehensive secondary hospitals, following the lifting of the emergency care system in October, the additional emergency room specialist consultation fee will be incorporated into the base fee, and the corresponding fee and statutory copayment will be applied. For emergency and critical surgery add-ons that have been incorporated into the base fee at regional, specialized emergency, and regional trauma centers, the 150% add-on will be maintained and the statutory copayment will apply. Regional emergency medical centers and regional emergency medical institutions will also be subject to a 150% add-on and the statutory copayment for the relevant fees.
Significant Reduction in Patient Burden for Keytruda and Dupixent
At the committee meeting, an agenda item to expand health insurance coverage for "Keytruda (ingredient: pembrolizumab)" and "Dupixent (ingredient: dupilumab)" was also approved.
Previously, Keytruda was covered only for four types of cancer, including non-small cell lung cancer. Starting January 1 of next year, coverage will be expanded to nine types of cancer (17 treatment regimens), including head and neck cancer and gastric cancer. As a result, the annual per-patient drug cost will drop significantly from approximately 73.02 million won to 3.65 million won (for monotherapy, with a 5% copayment). Coverage for Dupixent, a treatment for atopic dermatitis, will also be expanded to include severe type 2 inflammatory asthma, reducing the annual patient burden from about 15.88 million won to around 4.76 million won.
Additionally, through a drug benefit adequacy reassessment in 2025, the government will maintain coverage for four ingredients-olopatadine hydrochloride, Wearyongseon-Gwallugeun-Hagocho, bepotastine, and L-aspartate-L-ornithine injection (0.5g/ml)-for which clinical usefulness has been confirmed, while the remaining drugs will be reconsidered at a later date.
Meanwhile, in preparation for a super-aged society, a "community-based primary care innovation pilot project" centered on local clinics will be launched. Starting in July 2026, this project will target citizens aged 50 and older. When a patient registers with a specific clinic, a "primary care team" composed of doctors, nurses, and nutritionists will provide integrated services ranging from prevention and disease management to home visits. The core of this initiative is the introduction of an "integrated fee" system that moves away from the traditional fee-for-service model, which pays per visit, to a compensation model based on the outcomes of continuous patient management.
A Ministry of Health and Welfare official stated, "Amid demographic and disease structure changes such as super-aging and the rise of chronic diseases, it is crucial to establish a sustainable health management system centered around community-based primary care teams." He added, "We will build a primary care system in which patients and medical institutions can trust and actively participate."
© The Asia Business Daily(www.asiae.co.kr). All rights reserved.
