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[Column] Give choice to opt-out Oriental medicine from health insurance coverage  
  • By Park Jae-young Executive editor
  • Published 2020.07.21 11:46
  • Updated 2020.07.21 12:05
  • comments 0

The writer is the executive editor of The Korea Doctors Weekly, the sister paper of Korea Biomedical Review.—Ed.

About four years ago, I wrote two columns to assert that the government should allow car insurance subscribers to exclude Oriental medicine treatment from insurance coverage, and adopt a similar system for the national health insurance program.

To put it simply, I suggested cutting insurance premiums for subscribers who never want Oriental medicine treatment.

Executive Editor Park Jae-young

Many readers agreed with me, but my assertion was just an individual’s voice. No scholar has ever researched this, and no government officials or politicians seem to have considered it. None of the various associations or organizations formally raised this issue.

Four years have passed. We now have a new issue – the government plans to allow herbal medicine to receive the national health insurance benefit.

So, here I make my point again. Whatever it may be, I can accept the government’s plan on one condition – let people choose whether to exclude Oriental medicine treatment from the national health insurance.

Many people don’t want Oriental medicine treatment

Let those who want reimbursement in Oriental medicine treatment pay more insurance premiums. For people who would never want such treatment, cut insurance premiums.

If the national health insurance should cover a particular medical practice or a drug, it means that the entire population has to share the cost. There must be rational reasons for everyone to agree upon. Such reasons generally comprise three things -- safety, efficacy, and economic feasibility.

Someone undergoes a dangerous procedure, and the whole Korean people support it? Another person takes clinically unverified medicines, but the public provides the money? A person purchases a product worth 10,000 won ($8.35) for 200,000 won, and the entire population helps out? All of these examples are nonsense.

This is why the authorities have set up a strict procedure for medical practices and drugs to pass all the three obstacles to receiving health insurance benefits.

The burden of proof rests with physicians or pharmaceutical companies as they are medical practice performers or drug sellers. Many services fail to meet one of the three conditions and do not get the reimbursement benefit, even though service providers invest a lot of time and money to support evidence.

Many drugs proved safety, efficacy, and a certain level of economic efficiency but are facing uncertain delays in reimbursement review due to the government’s prudent management of the national health insurance budget.

Herbal medicines have neither proved any of the three nor attempted to do so. Health and Welfare Minister Park Neung-hoo said the government would allow “herbal medicine’s reimbursement after securing safety, efficacy, and economic feasibility” at a parliamentary audit in the fall last year. Why did he reverse his words himself? Did he get aggressive lobbying? If not, did he secure a considerable amount of study results during the past several months in secret?

If he has any data, he should disclose it. If not, please let me out of it, at least. I don’t have time to stop innocent people from taking unauthorized medicines without data for safety, efficacy, and economic feasibility. But it would be absurd if the government forces me -- a doctor and a civilized citizen -- to share the cost for unwanted herbal medicine.

Giving reimbursement to herbal medicine is a serious challenge to the fundamental principles of social insurance. Social insurance is implemented in two suppositions -- one is that everyone has the same risk (even if they are not the same). The other is that everyone can get the same benefit for the same risk.

However, the second supposition does not work in oriental medicine. According to a survey published in 2012 by the state-run Korea Institute for Health and Social Affairs, only 6 percent of Korean adults use Oriental medical institutions. It’s 6 percent, not 60 percent. Why do the remaining 94 percent of the people have to pay for additional services that they do not use?

Some critics may say the KIHSA’s data was based on a small-scale survey, and the actual number might be over 6 percent. To make such an assertion, we need evidence. The government must have accurate data, but it has never unveiled the proportion of the population who uses Oriental medicine. Except that about 4 percent of the total national health insurance budget is spent on Oriental medicine, the government is completely hiding the percentage of people using that 4 percent.

It’s not a confidential matter, but why can’t the government open the data? Before the government pushes to allow herbal medicine reimbursement, it should disclose how many Korean people received insurance benefits when using Oriental medicine in the past year or the past five years, or since 2009 when the nation first allowed insurance benefits for Oriental medicine.

There should be a significant number of Koreans who won’t get Oriental medicine treatment, regardless of the government’s disclosure of accurate data. It is illogical to force them to pay extra premiums on health insurance. The aging population and the sliding fertility rate will lead to a steady rise in health insurance premiums. Selling an unwanted product in a bundle will stimulate resistance to health insurance premium hikes.

Examples of car insurance show how dangerous it is to give Oriental medicine the insurance benefit. The proportion of Oriental medicine treatment out of the car insurance medical coverage has rapidly gone up from 16.5 percent in 2013 to 43 percent in 2019. At this pace, Oriental medicine will soon take up more than half of the car insurance medical coverage. Does this look normal? No matter how significant the other factors may be -- such as the establishment of a safe driving culture or the reduction of traffic accidents --, this is an inexplicable phenomenon if we do not consider the moral hazards of some patients and some (or a significant number) of Oriental medicine practitioners.

Allowing reimbursement to herbal medicine will make it difficult for other medical services to get insurance benefits despite their proof of safety, efficacy, and economic feasibility. The issue does not affect herbal medicine only.

Recently, the entire medical and pharmaceutical industries are raising their voices to oppose herbal medicine reimbursement. They even threatened to go on a strike. The medical community, suffering a double whammy of falling revenues and rising costs amid Covid-19, started to express fury over the government’s push. The government-led online campaign to thank healthcare workers for their Covid-19 fight isn’t helping. Instead, the government wants to spend an already-tight national health insurance budget in the wrong place. This must have made the medical community hit the ceiling.

Despite such anger and opposition, the government seems to go ahead with its plan. The government will say it will start only with a pilot project. It will be okay to see the result of the pilot project and decide whether to proceed further.

The problem is that there is no way to evaluate the result of the pilot project. There is no tool to measure safety, efficacy, and economic feasibility. The government is expected to conduct a brief survey, saying a certain percent of the Korean people were satisfied with the project. It keeps pushing to allow insurance benefits for herbal medicine. If the government takes a poll on people who took herbal medicine for low prices, they will surely say they are satisfied.

There is no tool to verify herbal medicine scientifically

So, I suggest to the medical community that we change how we fight. If the medical and pharmaceutical industries keep the focus on whether to allow herbal medicine reimbursement or not, they have no advantage in this fight. The government will embellish the move as “enhancing overall health insurance coverage” and elevate the issue as “an effort for supporting Oriental medicine with scientific evidence and globalizing it.” The medical and pharmaceutical industries’ opposition to the plan would be denounced as “a turf war to benefit doctors and pharmacists only.” People who have a good feeling or a fantasy about Oriental medicine will interpret the government’s plan to broaden health insurance coverage. Those who don’t will complain about the health insurance premiums will go up. Still, they will blame the medical community, not the government.

Thus, it will be better for the medical community to push for a separation of Oriental medicine from the national health insurance program, rather than oppose herbal medicine reimbursement. Honestly, saying, “We should allow reimbursement after verifying herbal medicine’s safety, efficacy, and economic feasibility” is equal to saying that we should not allow reimbursement. There is no tool to verify them.

There is a saying that attack is the best form of defense. So, let’s not ask the verification of herbal medicine, which is almost impossible. Instead, we should ask the government to separate complementary health insurance from the existing health insurance.

Such an argument is much more appealing to the general public. People who don’t want to receive Oriental medicine treatment will have no reason to disagree because their health insurance premiums will go down. If 4 percent of the total medical cost is spent on Oriental medicine, the government can give them a 4 percent discount on the health insurance premiums. Those who prefer Oriental medicine and support reimbursement for herbal medicine can pay extra insurance premiums and receive the health insurance benefit. This is a reasonable method because it fits the user-pays principle.

Either it is opt-in or opt-out, I don’t mind details. I think an opt-in method is reasonable because it is right to accept those willing to pay extra insurance premiums to use Oriental medicine under insurance coverage. However, given the Oriental medicine community's stance, an opt-out method – cutting premiums only for those who promise not to receive Oriental medicine insurance coverage- is also acceptable. This should also be applied to car insurance policies.

If we do so, we can eliminate the irrational payment for unused supplementary service fees or innocent citizens’ absurd spending money on treatment fees and recovery of lost income for fake patients who lie on the bed of an Oriental medicine hospital after a minor car accident.

It’s unfair to apply different criteria for reimbursement of Western and Oriental medicine

In terms of policy consistency, this approach is much more justified. It makes no sense to run a universal health insurance system and apply completely different criteria for allowing reimbursement to medical practice and Oriental medicine practice.

On one side, the government strictly demands a thorough verification of safety, efficacy, and economic feasibility. On the other, the government never demands any of them. At the same time, the government treats the two the same in terms of reimbursement. This is ridiculous. The government should separate the two in funding and allowing reimbursement. If you want to take out money from the same bank account, you should apply the same rule for the two. If you're going to use different criteria, you should open two different accounts.

According to a global standard, Oriental medicine is a complementary alternative medicine (CAM). As I mentioned above, separating Oriental medicine from the national health insurance system is equal to introducing a supplementary health insurance system. It is rational to apply complementary insurance to complementary medicine. If the government tries to weaken the national health insurance's fundamental function to support complementary medicine, it is like putting the cart before the horse.

I demand the government establish an “Oriental medicine-excluded health insurance policy” to give the public a choice. This will be reasonable in all aspects and help boost the competitiveness of Oriental medicine.

I also ask all healthcare experts to speak in one voice.

We cannot tolerate the situation where science and non-science, or the core and the periphery, are treated the same. Instead of shouting slogans like “We oppose herbal medicine reimbursement,” we should demand the government separate Oriental medicine from the national health insurance and operate it in a separate insurance policy.

editor@docdocdoc.co.kr

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