korean healthcare system overview
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Slides used to deliver presentation on Korean healthcare system overview. Main topics are: payer, healthcare delivery system, regulation, stakeholders.
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korean healthcare system overview
- 1. Overview of Korean Healthcare system Chiweon Kim, M.D., M.P.H. 2016.2.1
- 2. 연자 소개 • 서울와이즈요양병원 원장現 • 눔 전략現 / 의학 자문 • 삼성서울병원 의료관리학과 임상조교수前 • 前 McKinsey & Company, 컨설턴트 • 서울대병원 내과 전공의前 , 내과 전문의 • 연세대학교 보건대학원 보건학 석사 • 서울대학교 의과대학 의학사
- 3. OVERVIEW OF THE SOUTH KOREAN HEALTH SYSTEM Financing • System financed through National Health Insurance system (NHIS) • Low-contribution, low-benefit model – Privately funded expense constitutes ~45% of total medical bill – Certain areas are not covered (e.g. MRI, Ultrasound, Private room) – NHIS covers 40~70% of outpatient and 80% of inpatient healthcare spending – Overall fees for covered items are set low compared to other countries Role of government • Government has very strong influence on healthcare policies, price setting, clinical guideline review and reimbursement decisions • Doctors show distrust for the government Access • Universal care – 100% coverage by mandatory national insurance system • No major issue on physician or nurse coverage although on specific areas have physician shortages • Walk-in patients only have to wait 15~30 minutes to see doctors Providers • >70% of the hospitals are private, however, all hospitals are not-for profit by law • 3 tier system but no real gate keeping system with large number of clinics and strong preference for leading tertiary hospitals in Seoul • Mandatory subscription to National Health Insurance & fee for service • ~95% of doctors are specialists • Only full-time employees at hospitals can practice there A B
- 4. Korean people pay a large portion of medical bill and have contradictory expectation for medical practice Major reasons for dissatisfaction with medical system • Top 3 reasons for dissatisfaction - Cost - Waiting time - Treatment outcome • The reasons show that people want more from medicine, while they are not willing to pay more Privately-funded medical expense is ~34% of total medical bill Given that Korean medical system has shown excellent outcome, dissatisfaction with treatment outcome is more about the process A
- 5. Worsening balance of NHIS has made government introduce various initiatives for health management service Committee on NHIS policy Case examples • Composition: 25 members - Chair: vice-minister of MHW - Member representatives: employer/ employee (2), civic/consumer/agri- fishery/self-employed (1) - Provider representatives: AMA (2), AHA/ dentistry/oriental/nurse/pharmacy/pharmaceu tical (1) - Public representatives (8) • Government controls public representative group and cooperates with member representatives to suppress fee rise • Populistic approach - Abolishment of children’s hospitalization fee - Start covering fees for hospital food • Government rule constrains medical practice - Cannot prescribe chemotherapeutic agents for a patient whose condition is outside of indication - Number of coronary stents that can be used for a patient over his/her lifetime is limited B
- 6. Doctors in general have distrust for government but different groups have different agenda •Reasons for distrust • Medical fee set low (it is said to be below cost) • Inconsistency in insurance reimbursement • Gov’t not respecting experts’ opinion •Distrust is strongest among clinic doctors •Composition of doctors by employment • ~1/3 self-employed clinic doctors • ~1/3 employees • ~1/6 trainee (interns, residents) • ~1/8 professors •Korean Hospital Association(KHA) is as strong as Korean Medical Association(KMA) B
- 7. Landscape of Korean healthcare system •Korean doctors and hospitals have sought volume business & focus on uncovered areas •Hospitals have waged arms race, which destroyed bases for clinics •There is no proper system for education programs and care services •Due to expected worsening balance of NHIS, government tries to introduce various initiatives for health management service. Private insurance companies have similar needs •Korean Hospital Association(KHA) is as strong as Korean Medical Association(KMA) 1 2 3 4
- 8. Korean doctors and hospitals have sought volume business to overcome low medical fee As medical fee is lower in Korea compared to other countries… …Korean doctors and hospitals make up by increasing the volume of medical care Outpatient consultation time averages 3~5 minutes, and physicians need to see more than 70 patients per day to be profitable 1
- 9. and focus on uncovered areas, where they can charge freely, and ancillary services Ancillary services • Ancillary services such as funeral hall, parking lots, restaurants, retail stores etc. are allowed by law • Revenue from those services make up for the losses incurred by providing covered services Uncovered areas • MRI - Most of MRI scans were not covered by NHIS (, which has changed) - Among OECD countries, Korea ranks 4th with regards to number of MRI machines per capita (Japan, US, Italy) • Premium health check-up - With margin of 30~40%, premium health check is a lucrative biz for major hospitals - Cost at major Big4 hospitals averages $800~1,000 and goes up to $20,000 for VIP services • Plastic surgery, Derma care, LASIK “University hospitals survive on ancillary services such as rents and parking lots” “National University hospitals generated $5Mil of profit from running parking lots” 1
- 10. The medical fee system has driven arms race among hospitals, and medical expense is concentrated among large hospitals Big5 Hospitals Beds Asan Medical Center 2,680 Severance Hospital 2,081 Samsung Medical Center 1,982 Seoul Nat’l Univ. Hospital 1,789 Seoul St. Mary Hospital 1,332 • AMC does ~10% of all the cancer surgeries in Korea • No. of cancer surgeries/yr : AMC (18,508) VS MSKCC (11,370) VS MD Anderson (8,656) 2
- 11. Education programs and care services are uncovered and not appreciated by patients, which results in lack of proper care •Disease education and life style modification program are essential to chronic diseases and lead to reduced medical bill in the long run •In general, such services are not covered by NHIS •Patients who are accustomed to cheap medical care do not appreciate intangible services such as consultation and education •As a result, hospitals tend to offer $10~20 for diabetes education program •~20% of newly-diagnosed diabetes patients get education program 3
- 12. Expected worsening balance of NHIS has made government introduce various initiatives for health management service Financials of NHIS Government policy for public health • Foster personalized health support service - Develop health counselling call centers and health managers • Launch smoke-quitting campaign • Launch chronic condition prevention/mgmt service - Strengthen health counselling for prevention/mgmt of chronic conditions • Develop/introduce a checkup program for teens • Tried in vain to make a law about wellness/disease management service Expand prevention/mgmt- focused policy (through public hospitals and/or public clinic service) Induce private sector engagement in wellness/disease management service • Run pilot for doctor-patient telemedicine & Try to amend the current medical law • Interested in introducing mobile health technology Introduce telemedicine & ICT technology 4
- 13. Faced with low profit/growth, Korean insurance industry has strong needs to introduce health management program Share of Health insurance premium by age group Trends of health insurance loss ratio New subscribers in their 20s/30s account for ~73% Cumulative share of 40s+ customer reaches ~65% Acquire potential new customers Capture up & cross-selling Opportunity • With a recent increase in 20s/30s subscription, the need for an effective tool to appeal to customers has arisen - In ’14 YoY, 20s subscribers increased from 56% to 76%, 30s subscribers grew from 70% to 74% • Need for health mgmt service catering to post- retirement medical/care needs of 40s to 60s, a key customer segment of insurers - Retiree/pre-retiree pouplation to increase from 17M in ’15 to 20M by ’20 - Major insurance needs of 50s/60s are long-term care and medical expenses • Profit has been eroded as return on asset under management, insurers’ key profit source, decreased amid prolonged low interest rates • Also facing growing mortality loss of health insurance, etc., loss ratio improvement is imperative - Risk mgmt is also important due to pricing regulations • Strong needs for claim prevention exist via cost efficiency improvement and customer health mgmt Preemptive loss ratio mgmt 4
- 14. ISSUE 1: For-Profitization •Government • Officially against for-profitization of medicine • Keen on nurturing service industry (employment issue) • Interested in medical tourism and export of Korean medical system • A Chinese, for-profit, aesthetic hospital is approved • SNUH is running a hospital in Dubai •Doctors: against for-profitization •Hospitals • Mixed but KHA is for • Some feel the need to make up for the losses incurred by below-the-cost medical fee by operating business •Civic groups: against for-profitization (influence of the movie ‘Sicko’)
- 15. ISSUE 2: Telemedicine & Remote monitoring • By law, only doctor-to-doctor telemedicine is allowed • Limited utility in Korea • Doctor consultation is cheap (1st visit ~$13, Repeat visit ~$9) • People are concentrated and access to care is excellent • • Government • Tries to allow doctor-to-patient telemedicine • Part of a plan to boost technology sector (& overall economy) • Runs pilot programs for rural people & military • Doctors • Feels that telemedicine which will be dominated by ‘factories’ and large hospitals will threaten the clinics • Hospitals • Mixed but KHA is for • In line with the attitude towards for-profitization • Civic groups: mixed • Some regard it as start of ‘for-profitization’ • Less opposition than with ‘for-profitization’
- 16. ISSUE 3: Wellness/Disease management service •Legal grey area. By law, ‘medical care’ could only be carried out within medical institutions in principle’ •Government tried in vain to make a law about wellness/disease management service (population health management) •The effort faced opposition from • Hospitals: non-medical institutions may come in • Doctors and civic groups: start of for-profitization • Concern regarding involvement of insurance companies due to possibility of information leak, market control by large corporations •The law failed to pass even after insurance companies were dropped (insurance companies not allowed to found or invest in entities for wellness/disease management service)
- 17. Several specialty companies are running preliminary wellness services HealthonHealthonAIMMEDAIMMED Greencross healthcare Greencross healthcare365 Homecare365 Homecare Part of OpenTide, subsidiary of Samsung SDS Owner- ship Busi- ness Clients Insurance/major companies/foreign companies Subsidiary of Greencross pharma Subsidiary of Medipost (stem cell company) 1999 년 10 월 JV of SKT and Seoul Nat’l Univ. Hospital (SNUH) Preliminary Wellness Service - Phone counselling, reservation/escort service - Deliver health-related contents - Referral service for US hospitals Wellness - App + Wearable - SNUH-made health contents - (Reward-linked) B2C, SK NoomNoom JV of SKT and Seoul Nat’l Univ. Hospital (SNUH) Wellness+Disease - App-based - Obesity, DM, HT B2C, NHIS…
Notes de l'éditeur
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group
- Our assessment of health-care quality focused on macro-level metrics (e.g., average life expectancy). In addition to these macro level metrics it is also recommended to go one level deeper and analyze micro-level quality metrics as they are equally important reflections of quality. (e.g., cancer survival rates). We measured access to health care in several ways. The most basic question was: Who is eligible? Some governments grant access to all residents; others limit participation to specific groups (usually, citizens). However, we also considered resource availability: Were there enough physicians and nurses? How long did people have to wait for treatment? To assess financing, we differentiated between systems that were largely paid for through taxes and those that were financed through insurance. However, we also examined the extent to which the systems were publicly financed and the extent to which participants were expected to help pay for the cost of their care. Many of the issues we considered when we looked at providers also related to financing. We wanted to know, for example, whether most physicians were paid under fee-for-service arrangements or were salaried employees. We also wanted to know who owns most hospitals – the government, nonprofit organizations, or for-profit companies. To assess the role of government, we considered a number of questions, including: To what extent was the government involved in provision? How centralized or decentralized were the system’s operations? DRG – diagnosis-related group