The outline of the 5th generation actual expense insurance has become clear. The out-of-pocket rate for mild illnesses will increase compared to the 4th generation actual expense insurance, while the out-of-pocket rate for severe illnesses such as cancer, cerebrovascular disease, heart disease, and rare difficult-to-treat diseases will be maintained or can be adjusted through special contracts. The government expects that the introduction of the 5th generation actual expense insurance will reduce insurance premium burdens by 30 to 50%.
On the afternoon of the 19th, the government held the 8th Medical Reform Special Committee meeting at the Government Seoul Office and noted that it approved the '2nd Implementation Plan for Medical Reform' containing these contents. This comes about seven months after the 1st Implementation Plan was announced last year.
The Medical Reform Special Committee is a discussion body established in April last year to improve regional and essential medical care through structural reform. The government is pursuing a goal of a structural transition in the overall medical system through the Medical Reform Special Committee. While the 1st Implementation Plan focused on expanding the medical workforce and improving the training environment and fees for residents, the 2nd Implementation Plan includes content such as the introduction of the 5th generation actual expense insurance, nurturing local hospitals, strengthening primary care, and establishing a medical accident safety net.
According to the 2nd Implementation Plan disclosed that day, the government will begin overhauling the actual expense insurance and payment system. The actual expense insurance will be restructured focusing on appropriate coverage for out-of-pocket expenses and the rationalization of non-covered services centered on severe cases. Adjustments to the out-of-pocket rate will be made considering the increase in medical utilization through actual expense insurance.
The out-of-pocket rate for inpatient care, primarily used by severe patients, will be maintained, while the out-of-pocket rate for outpatient care, which involves many mild patients, will increase. In particular, the out-of-pocket rate for non-emergency patients using outpatient services in emergency rooms will increase significantly from 18% to 81%. New special contracts for severe and non-severe cases will be established, allowing insurance subscribers to choose their premium burdens based on health status.
Items that are essential for severe patients or patients with rare diseases will be transitioned from non-covered to covered status, setting expense and treatment standards. These non-covered treatments will include medical procedures and drugs in the fields of severe and essential healthcare, as well as new medical technologies for severe, rare, and emergency patients.
Among the non-covered items that impose a significant expense burden on patients, medically important items will be newly created and managed as 'managed benefits.' Managed benefits will be established within the selective benefit system, with prices and treatment standards set by the government. However, unlike general benefit items, the out-of-pocket rate has been set at 95%. The items to be included in managed benefits will be determined by a separate decision-making body involving the medical community and patient groups.
Alongside the structural transition of general hospitals to focus on severe and essential medical care, the government will also promote support for regional comprehensive secondary hospitals and the specialization of essential specialized functions. Secondary hospitals will strengthen their comprehensive and key functions and specialized capabilities through the 'Support Project for Regional Comprehensive Secondary Hospitals' and the 'Support Project for Essential Specialized Functions.' First-level clinics will implement a model focused on outpatient care to manage diseases continuously from prevention to treatment through the 'Medical Innovation Pilot Project,' with specific plans to be discussed further.
The Ministry of Health and Welfare stated, 'Secondary hospitals will also transition their structures to specialize capabilities by function,' adding, 'As general hospitals transition to focus on severe cases, we will support the development of secondary hospitals' capabilities to prevent a concentration phenomenon in large hospitals.'
Finally, to protect patients from harm due to medical accidents and to safeguard medical staff, the medical accident safety net will also be strengthened. A 'Patient Spokesperson' will be established to support patients within the medical dispute mediation system, and a 'Conference Appraisal System' and 'National Ombudsman' involving experts from various fields will be introduced to participate in dispute resolution. Hospitals will be required to enroll in liability insurance to prepare for medical accident compensation, and new insurance products that strengthen special compensation functions for essential medical services will also be developed.
Minister of Health and Welfare Cho Gyuhong said, 'There are some concerns from the initial healthcare sector regarding this implementation plan, but we will gather opinions from the medical community during the execution process to enhance acceptability and effectiveness,' and added, 'We will move toward a better future healthcare where future medical leaders can thrive through the swift implementation of medical reform.'