Changes in the volume of cataract surgeries and associated factors in Korea

Abstract

Despite the continuous implementation of the government’s policy to strengthen NHI coverage, the health insurance coverage rate is still relatively low compared to other OECD countries. The increase in the use of non-essential non-covered medical services is known to be the main cause, and cataract surgery is receiving attention recently as a representative example.</br>A DRG payment system has covered cataract surgery, and NHI has recently covered non-covered ophthalmic examinations. PHI has covered costs for premium lenses and non-covered ophthalmic examinations of cataract surgery. As such, if both NHI and PHI pay for the same medical service, there is a high possibility that the use of non-essential medical services and the cost will increase. Specifically, PHI pays for out-of-pocket costs and expensive multifocal lenses, lowering the patient’s price barrier and increasing the provider’s gross income. In other words, the terms and conditions of PHI that reimbursement for non-covered services without any management mechanism increase the number of surgery using expensive non-covered services according to the rational choice of each stakeholder, thereby affecting the finances of NHI.</br>In order to effectively manage the use of non-essential non-covered medical services, it is necessary to review and manage the structural abnormalities caused by the wrong design of the initial PHI’s terms and conditions.