The purpose of this study was twofold. First, it aimed to identify the present status of non-benefit medical expenses, using the procedure- or service-specific non-benefit medical expense data of tertiary hospitals as released by the Health Insurance Review & Assessment Service (HIRA) and compare the data with the mean non-benefit medical expenses to find cost variations, if any. Second, it aimed to compare, by year, the top three high-cost procedures/services (both minimum and maximum means) as well as the non-benefit procedures/services with the largest cost variations, and present the findings as the basic information for developing policies on proper management of non-benefit medical expenses.
The target of analysis was the present status of the non-benefit medical expenses reported by 41 tertiary hospitals among the 44 previously designated (three excluded due to designation revocation or new designation), based on the relevant data for 2015, 2016, 2017, and 2018 (until April). Frequency analysis, including the computation of the mean, standard deviation (S.D.), and coefficient of variation (C.V.), was conducted, resulting in the findings as follows: First, the present status of the sub-items of procedures/services subject to non-benefit coverage was examined and compared. The findings revealed a total of 51 non-benefit items for 2015. Then the number showed a gradual upward trend from 53 (2016) to 98 (2017), followed by a dramatic increase to 193 (2018).
Second, regarding the year-specific status of the non-benefit medical procedures/services, the year 2015 had 19 (out of 51) items that were eligible for a 100% out-of-pocket coverage (37%). The figure showed a gradual downward trend, with 25% for 2016 (13 out of 53), 14% for 2017 (14 out of 98), and 8% for 2018 (15 out of 193). The proportion of the items subject to a 75.0-99.9% out-of-pocket coverage was 20% for 2015 (10 out of 51), 38% for 2016 (20 out of 53), 37% for 2017 (36 out of 98), and 44% for 2018 (85 out of 193), respectively, showing an upward trend. Between 2015 and 2018, the non-benefit items with large plus cost variations include MRI fees, procedure/surgery fees, testing fees (e.g., ultrasonography), and varicose vein surgery fees (treatment materials).
Third, the study compared and analyzed the means and the C.V. for the non-benefit items over the four-year period. The da Vinci Surgical System laparoscopic radical prostatectomy (LRP) (prostatecancer) was found to have charged between KRW 7,370,853 (min. mean) and KRW 10,747,879 (max. mean), hence the highest-ranking non-benefit item (both min. and max.) during the period analyzed. The C.V. for the daVinci robotics-assisted LRP (prostate cancer) were: 0.24 for 2015 (min. mean), 0.57 for a single training visit for 2015 (min. mean), and 0.22 for 2018 (max. mean); and 0.13 for 2015 (max. mean) and 0.09 for 2018 (max. mean). Both the minimum and maximum cost variations showed a gradual downward trend. Regarding the C.V. for training and consulting fees, diabetes scored 0.55, which was the highest-ranking C.V. in both the minimum and maximum non-benefit medical expense categories over the four-year period.
Fourth, the study performed year-specific analysis of the top three high-cost procedures/services, as well as the non-benefit items with the largest C.V.. According to the findings, (a) in the min. mean cost category, the top three non-benefit high-cost items were the da Vinci Surgical System-assisted LRP (prostatecancer) and the same robotics-assisted radical surgery for thyroid cancer (thyroid cancer),and eye correction surgery (LASIK); and (b) in the max. mean cost category, the top three non-benefit high-cost items were the aforementioned two robotics-assisted surgeries, and dental implant.
According to the above results, to standardize non-benefit medical expense items across tertiary hospitals due to their variations in the expenses, the government should expand standardized non-benefit medical expenses and make it mandatory for medical institutions to use the items or names of such standardized expenses. Furthermore, the legal basis should be established to identify and control non-benefit medical services, and it is necessary to put in place monitoring methods such as the review system to evaluate the level of non-benefit medical expenses and services. Moreover, by implementing a practical non-benefit medical expense disclosure system, it would be needed to reduce non-benefit medical expense deviations and provide related information so that people can better predict their medical expenses.