Health Insurance Reimbursement Reform Aimed at Reducing Antibiotic Overuse and Misuse

The spread of antibiotic resistance, often referred to as 'superbugs,' is a grave public health issue threatening human survival. South Korea is also grappling with high antibiotic usage rates and resistance levels, making a government-wide response urgent. This article examines the current status of government policies designed to effectively reduce antibiotic overuse and misuse, and delves into how health insurance reimbursement reform can drive tangible change.

The Threat of Antibiotic Resistance and Korea's Current Situation

As the rampant spread of superbugs looms as a warning of treatment's end, antibiotic resistance is a global crisis that shakes the very foundation of modern medicine – beyond merely increasing medical costs – affecting surgery, cancer treatment, and organ transplantation. The phenomenon where bacteria no longer respond to antibiotics, making infections difficult to treat and mortality rates climb, poses a critical obstacle to humanity's efforts to extend life. The World Health Organization (WHO) has designated antibiotic resistance as one of the 'greatest threats facing humanity in the 21st century,' calling for a concerted international response. If current trends continue, it is predicted that over 10 million people will die annually from antibiotic-resistant infections by 2050.

Korea's current situation shows antibiotic usage rates among the highest in the OECD, with national antibiotic consumption directly linked to community infection management levels. South Korea ranks high among member countries of the Organisation for Economic Co-operation and Development (OECD) in antibiotic use, which in turn increases the risk of developing antibiotic-resistant bacteria. Historically, Korea has had a tendency to prescribe antibiotics frequently even for viral infections. The prescription rate for antibiotics in acute respiratory infections (colds, sore throats, acute bronchitis, etc.) is high, leading to unnecessary antibiotic use when considering that antibiotics are ineffective against viral infections. Surveillance results from the Korea Disease Control and Prevention Agency (KDCA) indicate that antibiotic resistance rates for major pathogens remain high globally, necessitating comprehensive management strategies.

Amidst the international community's response and Korea's mounting challenges, global efforts are underway to combat antibiotic resistance. The WHO recommends the establishment and implementation of national action plans for antibiotic resistance, and entities like the European Union (EU) are already enforcing robust antibiotic management policies. The South Korean government has also established a 'National Action Plan for Antimicrobial Resistance Management' and has been promoting efforts to reduce antibiotic use, strengthen resistance surveillance, and conduct education and public awareness campaigns at the inter-agency level. It encourages the operation of Antimicrobial Stewardship Programs (ASPs), primarily in major tertiary hospitals, and utilizes the Health Insurance Service to analyze healthcare institutions' antibiotic prescription data and provide feedback on appropriateness evaluation results. However, a thorough review of how effectively these policies are functioning in practice and what drives actual change, along with the urgent need to devise practical incentives to encourage active participation from healthcare institutions and professionals, remains a critical task.

Current Government Policies on Antibiotic Overuse and Misuse and Their Limitations

The government has focused on strengthening surveillance systems and establishing antibiotic use guidelines by enhancing systems to monitor the occurrence and trends of antibiotic-resistant bacteria, and by developing appropriateness evaluation and guidelines for antibiotic use for specific diseases. The KDCA continuously monitors the antibiotic resistance status of major pathogens and collects and manages information on resistant bacteria isolated from healthcare institutions. Furthermore, the Health Insurance Service analyzes healthcare institutions' antibiotic prescription data to evaluate prescription rates for specific conditions and the use of broad-spectrum antibiotics, guiding usage reduction by notifying institutions of the results. TF teams composed of infectious disease specialists and others develop antibiotic use guidelines reflecting the latest findings, distribute them to healthcare institutions, and encourage compliance.

While questions remain about the effectiveness of healthcare institution accreditation assessments and public awareness campaigns, the government has attempted a multi-faceted approach, including incorporating the importance of antibiotic management into healthcare institution accreditation criteria and conducting public campaigns to prevent antibiotic overuse and misuse. This has contributed to some extent in making healthcare institutions recognize the importance of antibiotic management and improving patient awareness. However, these administrative and promotional approaches alone clearly have limitations in fundamentally altering actual prescribing practices in clinical settings. Criticisms suggest that healthcare institution accreditation assessments often focus on compliance with documented guidelines, limiting their direct impact on correcting antibiotic usage patterns in real-world clinical practice.

As the need for institutional support to guide changes in prescription patterns arises, current policies primarily focus on administrative guidance and promotion, leading to a prevailing assessment that they are insufficient in providing healthcare institutions or professionals with practical incentives to transition to 'appropriate antibiotic use.' Under the current health insurance reimbursement system, where antibiotic use can be directly linked to increased patient visits, healthcare institutions have relatively limited economic motivation to voluntarily reduce antibiotic prescriptions. For effective change, economic and institutional support must be accompanied, which can be achieved through health insurance reimbursement reform. A structure must be created where healthcare professionals receive tangible rewards for practicing appropriate antibiotic use.

Methods to Reduce Misuse Through Health Insurance Reimbursement Reform

Examining the structure that incentivizes overtreatment, a weakness of the 'fee-for-service' system, the current Korean health insurance reimbursement system is fundamentally based on 'fee-for-service.' This system pays for each medical service performed by healthcare institutions. Consequently, the more patient visits, tests, and prescriptions there are, the higher the healthcare institution's revenue. This system acts as a major factor encouraging overtreatment and unnecessary antibiotic prescriptions for conditions like 'upper respiratory infections,' which frequently involve antibiotic prescriptions. From a healthcare institution's perspective, prescribing antibiotics based on 'just in case' scenarios, without clear evidence of treatment necessity, can be advantageous for revenue enhancement.

To guide appropriate antibiotic use through incentive-based reimbursement design, reducing antibiotic overuse and misuse requires actively considering reforms to the reimbursement system itself, directly linking 'appropriate antibiotic use' to healthcare institution revenue. First, there is a premium for non-antibiotic prescription. For conditions where antibiotic prescription is clearly unnecessary, such as the common cold, acute sinusitis, and acute pharyngitis, healthcare institutions that provide evidence-based appropriate care without prescribing antibiotics could receive additional points in their reimbursement rates or be granted separate performance rewards. Second, there is reimbursement linked to antibiotic appropriateness evaluation. Institutions with excellent results in antibiotic appropriateness evaluations conducted by the Health Insurance Service or KDCA could receive reimbursement bonuses, or reimbursement rates could be partially adjusted for institutions with insufficient evaluation results. Third, expanding the application of prospective payment systems (PPS) could be considered. For certain conditions or procedures, a PPS, where a fixed total amount is paid rather than per service, could be expanded to areas prone to antibiotic overuse and misuse. Furthermore, by providing reimbursement bonuses or separate performance-based payments to institutions practicing appropriate antibiotic use in community primary care, they can be encouraged to contribute to reducing misuse in the community.

Regarding pilot projects for reimbursement reform and the presentation of a long-term roadmap, these reimbursement reform proposals require the formation of a task force (TF) team involving the Ministry of Health and Welfare, the Health Insurance Service, relevant academic societies, and medical experts. This TF team should conduct pilot projects to design specific plans and verify their effectiveness. The feasibility of each proposal must be closely evaluated through pilot projects, and measures to minimize potential side effects should be sought. In the long term, it is crucial to redefine the role of health insurance in solving the antibiotic resistance problem and present a clear roadmap for establishing a health insurance reimbursement system that can sustainably encourage appropriate antibiotic use. Adjusting patient co-payments could also be considered. For medically clear unnecessary antibiotic prescriptions, a policy of slightly increasing patient co-payments could be implemented to encourage patients to recognize the risks of antibiotic overuse and demand appropriate treatment from their doctors.