Changes in the Utilization of Korean Medicine Clinical Services on Clinic Level Before and After COVID-19
Article information
Abstract
Objectives
The coronavirus disease 2019(COVID-19) impacted the utilization of medical services in Republic of Korea, leading to decreased utilization due to social distancing and diverted healthcare priorities. Post-pandemic, anxiety about infection remained high, further affecting medical service utilization, however, there was no study between infection disease and the utilization of Korean Medicine clinical services. Therefore, this aimed to find the changes in the utilization of Korean Medicine clinical services on the level of clinics by reflecting the environmental factors of the COVID-19.
Methods
This study examined data from 2016 to 2022, focusing on clinic-level statistics derived from census, national health insurance(NHI), and the data of medical care assistance. It described changes in the number of clinics and doctors, patient’s visits, and medical expense and compared pre- and post-COVID-19 especially.
Results
In the utilization of Korean Medicine clinical services before and after COVID-19, the number of Korean Medicine clinics and doctors per 10,000 people nationwide increased, but in Gwangju, Jeonnam, and Chungnam, both decreased. The number of visits in Korean Medicine clinics for NHI and medical care assistance decreased, but that of visits in Western Medicine clinics recovered. The medical expense increased in both Western Medicine clinics and Korean Medicine clinics, and the rate of increase in Western Medicine clinics was higher than that of Korean Medicine clinics.
Conclusion
These changes were the result of COVID-19 affecting medical services including Korean Medicine, and further research is needed on Korean Medicine clinical services due to external effects including infectious diseases.
Introduction
Factors affecting the utilization of medical services vary widely and can be typically divided into environmental, demographic, and health factors1). In particular, the situation of the infectious disease pandemic represented by Coronavirus disease 2019 (COVID-19) acted as one of the strong environmental factors for the utilization of Korean Medicine clinical services. Due to COVID-19, the World Health Organization declared an international public health emergency in January 2020, and social distancing, as one of quarantine guidelines, was implemented in Republic of Korea(Korea) in March of the same year2). In addition, existing medical services were relatively reduced as priorities across the components that make up the health care system were concentrated on infectious diseases3). In this situation, research results have been reported that equity in medical services has deteriorated as a result of measures to mitigate infectious diseases such as social distancing as well as the effect of the infectious disease itself4). From the past, infectious diseases have deepened inequality and the results have been amplified in an unequal society5,6).
Since then, social distancing has been completely finished in Korea on April 18, 20222). However, according to the medical service experience survey by Ministry of Health and Welfare, the percentage of people who felt anxious about infection while using medical institutions increased sharply from 3% in 2018 and 6% in 2019 to 14.7% in 2020 and 31.2% in 2021, and still continued to be 24.3% in 2022. The experience of using medical services in Korea has been lower since 2020 for both outpatient and inpatient compared to 2017–20197). The decline in medical utilization continued, negatively affecting health equity5), with the damage concentrated on the vulnerable8).
In Korea, the social security system allows the vulnerable to receive medical services through medical care assistance. However, due to the dual roles of medical care assistance in conjunction with public assistance and health insurance, it was challenging to evaluate the adequacy of medical care assistance based on the survey of the subjects’ actual conditions and to develop a long-term plan9). Therefore, studies on the utilization of Korean Medicine clinical services related to medical care assistance are insufficient, but the analysis of the utilization of Korean Medicine clinical services itself has been conducted several times. They generally found the utilization of Korean Medicine clinical services was higher in groups of women and the elderly, and some studies reported that the lower the income and education level, the more inclined they were10–12). Most existing studies have primarily focused on understanding the actual situation, with no studies examining the various factors affecting the utilization of Korean Medicine clinical services, particularly the prevalence of infectious diseases. Therefore, this study aims to identify changes in the utilization of Korean Medicine clinical services on the level of clinics by reflecting the environmental factors of the COVID-19 pandemic.
Methods
This study analyzed data from 2016 to 2022, before the start of the study, when data could be commonly secured using the census from Statistics Korea, national health insurance (NHI) statistics from and Health Insurance Review & Assessment Service, and medical care assistance data from NHI Services. In addition, in order to compare changes in medical resources in an environment under the same conditions, the subjects were limited to the level of clinics, that is, clinics by type of Western Medicine clinics and Korean Medicine clinics. From the results, the total population, the number of Korean Medicine clinics, the number of Korean Medicine doctors, the number of visits for clinics, and medical expense were extracted, and the number of Korean Medicine clinics and Korean Medicine doctors per 10,000 people, medical expense per visit for clinics, and the rate of increase or decrease compared to the previous year were calculated. In addition, as of 2019, before the outbreak of COVID-19, the changed rate of medical expense from 2022 when social distancing was completely ended, and the changed rate from the previous year were computed.
Results
The total number of Korean Medicine clinics per 10,000 population continued to increase by 0.67% per year on average. However, the trend of change compared to the previous year has been on the decline since 1.45% in 2017, fell to 0.29% in 2020, slightly rose to 0.61% in 2021, and then decreased again to 0.25% in 2022. Compared to 2019, it was found to have increased by 1.15% in 2022. By region, the rate change from 2019 to 2022 increased in 12 out of 17 metropolitan local governments and decreased in 5 of them. Among them, Ulsan increased the most by 5.61%, and Chungnam decreased the most by 2.14%. The trend of change compared to the previous year continued to increase in metropolitan cities except Incheon and Gwangju. The decline compared to the previous year was confirmed before 2019, and the change was repeated in local governments other than metropolitan areas except Gangwon and Jeonbuk (Table 1).
The Number of Korean Medicine Clinics per 10 Thousands Residents
The total number of Korean Medicine doctors per 10,000 population also continued to increase by an annual average of 2.30%, increasing by 5.62% in 2022 compared to 2019. By region, the rate change from 2019 to 2022 increased in fourteen out of seventeen metropolitan local governments and decreased in three of them. Among them, Daegu increased by 11.53%, Incheon 11.25%, and Sejong 10.69%, and Gwangju decreased the most by 3.64%. Compared to the previous year, the trend of change in Sejong went up to 9.28% in 2017 and 10.38% in 2020, while Gwangju showed −3.60% in 2018 and 4.31% in 2021 (Table 2).
The Number of Korean Medicine Doctors per 10 Thousands Residents
On the contrary, the total number of visits for Korean Medicine clinics had gone sideways and fall down after 2019. The annual average change rate declined in all areas except Sejong. After 2020, there was a positive change rate in 2021 in four areas: Daegu, Daejeon, Sejong, and Gyeonggi, and in 2022 in two areas: Incheon and Sejong. The rate change of 2022 compared with 2019 only increased in Sejong, decreased in Incheon and Gyeonggi by less than 10%, and by more than 10% in others (Table 3).
The Number of Visits to Korean Medicine Clinics under National Health Insurance
The total medical expense for Korean Medicine clinics decreased only in 2020 compared to previous years, and it recovered in 2022 to a level similar to 2019. Separated from metropolitan areas, the annual average increases ranged from 1.20% in Gwangju to a maximum of 11.45% in Sejong from 2016 to 2022. Compared to 2019, Sejong experienced a rate change of 15.65% in 2022. In others, it has gone down and up from 2019, with increase in Incheon and Gyeonggi compared from 2019 to 2022. The trend from 2019 to 2022 slid down only in Jeonnam and Gyeongnam (Table 4).
The Medical Expense of Korean Medicine Clinics under National Health Insurance (Korean Thousand Won)
The number of visits in Korean Medicine clinics for NHI was about 100 million until 2019, and then decreased to about 86.8 million in 2022. The number of visits for medical care assistance rose slightly to about 54.8 million in 2019 and then decreased from 2020 to 49.6 million in 2022. The trend of change for all compared to the previous year showed −2.14% in 2018 and 2.95% in 2019, but decreased by 10.30% in 2020 and then continued to decrease. In the case of medical care assistance, the rate of change did not differ significantly from 2017 to 2018, increased by 3.50% in 2019, and then decreased by 6.37% in 2020 and continued to decline. The ratio of visits covered by NHI and medical care assistance remained consistent, ranging from 0.05 to 0.06 (Figure 1).
The number of visits to Korean Medicine clinics
* In the Republic of Korea, the Coronavirus disease 2019 began spreading on January 20, 2020. The government ceased social distancing measures as a form of quarantine on April 18, 2022.
The medical expenses of Korean Medicine clinics covered by the NHI increased until 2019, reaching 2.58 trillion won, before decreasing by 5.13% compared to the previous year in 2020, to approximately 2.45 trillion won. In 2022, it rose again to 2.55 trillion won. Meanwhile, the medical expenses for medical care assistance also saw a slight reduction in 2020 but subsequently rose above the 2019 levels. The ratio of medical expenses covered by NHI and medical care assistance remained consistent at 0.07 (Figure 2).
The medical expense of Korean Medicine clinics
* In the Republic of Korea, the Coronavirus disease 2019 began spreading on January 20, 2020. The government ceased social distancing measures as a form of quarantine on April 18, 2022.
The total number of visits for clinics increased slightly from 626.49 million in 2016, fell −12.73% compared to the previous year in 2021, and then recovered to 638.84 million in 2022. In the case of medical care assistance, it also increased slightly from 35.69 million in 2016, decreased by 4.47% compared to the previous year in 2021, and then recovered to 36.89 million in 2022 (Figure 3).
The number of visits for out-patients in clinics
* In the Republic of Korea, the Coronavirus disease 2019 began spreading on January 20, 2020. The government ceased social distancing measures as a form of quarantine on April 18, 2022.
Medical expense per visit have continued to increase since 2016, regardless of NHI/medical care assistance or Western/Korean Medicine clinics. Looking at the trend of change for NHI compared to the previous year, the expense of Western Medicine clinics increased by 10.25% on average, showing a 15.70% increase in 2020 and a 12.64% increase in 2021. The expense for medical care assistance at Western Medicine clinics increased by 8.47%, and also showed a high rate of increase of 12.59% in 2020 and 9.33% in 2021. In contrast, the expense of NHI for Korean Medicine clinics increased by 5.63% on average, and the increase decreased since 2018 to 4.16% in 2022. The expense of medical care assistance for Korean Medicine clinics increased by 5.23% on average and was relatively equal, around 5% every year (Figure 4).
The change of medical expense per visit for out-patients
* In the Republic of Korea, the Coronavirus disease 2019 began spreading on January 20, 2020. The government ceased social distancing measures as a form of quarantine on April 18, 2022.
Discussion
From 2016 to 2022, the number of Korean Medicine clinics and doctors per 10,000 people has steadily increased. Compared to 2019, the number of Korean Medicine doctors per 10,000 people in 2022 increased by 5.62%, but the number of Korean Medicine doctors increased by 1.15%, which was relatively low. In addition, there was a big difference by region, and it was confirmed that the number of Korean Medicine clinics and doctors both decreased in Gwangju, Chungnam, and Jeonnam among the metropolitan local governments. In Gyeongbuk and Jeju, the number of Korean Medicine clinics per 10,000 decreased, but the number of Korean Medicine doctors increased, and in the rest of the region except Chungbuk and Jeonbuk, the number of Korean Medicine doctors increased more than the increase rate of the number of Korean Medicine doctors per 10,000 people, which would be the result to be due to the newly opening or expansion of Korean Medicine hospitals.
Although the total number of Korean Medicine clinics and doctors is increasing, it has been confirmed that Korean Medicine clinics or doctors, or both have decreased in some metropolitan local governments since COVID-19. In particular, a study that analyzed the relationship between demand elasticity of transportation time in the past and the utilization of Korean Medicine clinical services in that the area where doctors and medical institutions fell at the same time was far from the metropolitan area, pointed out that Korean Medicine institutions are more vulnerable than other medical institutions13). This reduction in medical utilization was also expected to affect equity, that was, as access to medical utilization decreases, it was expected to have a negative impact on the utilization of Korean Medicine clinical services by socio-economically vulnerable groups. According to a study that analyzed patients’ utilization of oriental medical institutions from 2017 to 2020, even in Taiwan, which closed its borders due to COVID-19, the average number of visits monthly decreased by more than 15%, especially when the epidemic was serious. In addition, it was found that telemedicine in rural areas, which are vulnerable to medical care, decreased significantly. The suggestion that the appropriate allocation of medical resources should be considered in order to resolve inequality in medical utilization by region, as well as the decline rate of visits and utilization of local medical care, is very consistent with the results of this study14).
Between NHI and medical care assistance in Korean Medicine, the ratio of visits and medical expenses was slight and showed a consistent trend, regardless of COVID-19. Before COVID-19, medical expense for medical care assistance increased sharply due to the rising number of beneficiaries, expanded coverage, an aging population, and other factors15). To control this growth, changes were made to the medical care assistance system, including the implementation of copayments and the selection of medical centers. Factors influencing the utilization of medical services by beneficiaries of medical care assistance included medical appropriateness, accessibility, and the effectiveness of healthcare16). This study found that the total number of visits and medical expenses for medical care assistance increased compared to the reduction of these metrics for NHI, despite COVID-19. This indicates that COVID-19 did not affect the medical needs of beneficiaries of medical care assistance and led them to visit Western Medicine clinics instead of Korean Medicine clinics during and after COVID-19 due to those factors. This shift could be attributed to external factors, as people were exposed to the infectious disease for over two years during the pandemic17).
The number of visits for Korean Medicine clinics has decreased since 2020 for both those covered with NHI and those who received medical care assistance. On the other hand, the number of visits for Western Medicine clinics decreased in 2020 and increased in 2022 to recover to pre-COVID-19 levels. As a result of summing up the number of visits at Western/Korean Medicine clinics, despite the pandemic of COVID-19, it was found to be consistent with the previous research that Korean Medicine clinics and Western Medicine clinics played a complementary role18). In addition, the continued increase in the number of visits for medical care assistance in despite of the external effect of infectious disease was able to reaffirm previous studies that showed inequality in the high-income class in medical utilization, but rather the degree of advantage in the low-income class in terms of the number of medical utilization increased19).
Moreover, the fact that the number of visits for Korean Medicine clinics has decreased and the number of visits for Western Medicine clinics has increased indicated the need for Korean Medicine shifted to that for Western Medicine during COVID-19. This could be explained under the medical service system, first of all, medical services can be systematized into “individual and family-community-basic health care-request for each stage”20).
The importance of the ‘individual and family’ stage has increased as the current major diseases have shifted from acute infectious diseases to chronic diseases and interest in health has increased. This can be used to strengthen primary care if the patients by themselves can understand their disease and make appropriate decisions to visit experts21). In the era of chronic diseases, however, the COVID-19 pandemic, where asymptomatic infections account for the majority22), health problems cannot be solved by ‘individuals and families’ themselves, and expert help and professional referrals have become essential. In addition, the health of local residents should be promoted through the activities of the ‘community.’20). However, quarantine based on social distancing made the function of the ‘community’ within the medical service system stop. In the ‘primary health care’ stage, the patient contacts the medical personnel for the first time and basic medical services are provided20). ‘Primary health care’ operates in a small area and is generally handled by general medical or clinic-level medical institutions. During the COVID-19 pandemic, however, the government did not include Korean Medicine clinics to assign the responsibility of deploying facilities and providing medical services to the area, but only Korean medical institutions, mostly Korean Medicine hospitals which Western Medicine doctors work in, were employed. Therefore, in a situation where the psychological concerns of local residents increase due to COVID-19 and affect health behavior, mental health, and the degree of practice of quarantine rules22), it is induced that it acted as a factor that facilitated patients to visit the hospital due to the negative results of the quarantine policy emphasizing preemptive diagnosis.
The medical expense per visit was found to increase for all in Korean/Western Medicine clinics. The medical expense per visit to Korean Medicine clinics showed an annual increase rate close to the average, and were relatively even, but the rate of increase to Western Medicine clinics from 2020 to 2021 was about three times that of Korean Medicine clinics. This increase in medical expense increased not only the burden of disease and the socioeconomic impact, but also the indirect costs for medical utilization according to the region, aggravatinging the regional variation23). In general, the ‘Say’s rule’ that supply creates demand is in line with the supplier-induced demand in health economics. In particular, the supply of domestic medical services is leading to excessive competition in the free market economic system that seeks operating profits led by the private sector24). It has been regarded as a major cause of the increase in medical expenses. In addition, along with the supply of medical personnel, the availability of medical personnel based on regional distribution is one of the important indicators that can confirm access to medical utilization. Yeo JY, et al reported an increase in proportion to clinic density and medical capacity25). In this study, noticeable differences in visits and medical expenses between regions were observed between 2019 and 2022; those in Incheon, Sejong, and Gyeonggi showed increases or relatively smaller decreases compared to other regions, whereas those in Gwangju, Jeonnam, and Gyeongbuk showed significant decreases. The number of Korean Medicine doctors in Incheon, Sejong, and Gyeonggi exhibited higher increases, while that in Gwangju and Jeonnam experienced decreases compared to other regions in the rate of change between 2019 and 2022. Consequently, the variation in the number of Korean Medicine doctors by region was more pronounced than that in the number of Korean Medicine clinics. Therefore, it is necessary to continuously monitor the number of Korean Medicine clinics and doctors by region so that plans should be established to supplement regional variations in the utilization of Korean Medicine clinical services.
The strengths of this study were findings to analyze national statistics for figuring out the change of medical utilization by impact of COVID-19 as infectious disease, especially focused on clinic-level. There were also some limitations. First, there might be other factors to attribute the change of medical utilization without COVID-19. Second, this study was not based on personal data so it was hard to distinguish the results on individual.
Until now, no studies have been published on the effect of infectious diseases on patients’ visits to Korean Medicine clinics in Korea. It is necessary to consider these findings in advanced researches and policy establishment because it was not just how medical utilization has changed, but also the impact on equity of medical utilization could be confirmed.
Conclusion
As a result of using health insurance statistics and medical care assistance statistics from 2016 to 2022 to analyze the change in the utilization of Korean Medicine clinical services before and after the outbreak of COVID-19, the number of Korean Medicine clinics and doctors per 10,000 people nationwide increased, but in Gwangju, Jeonnam, and Chungnam, both decreased compared to before COVID-19. After COVID-19, the total number of visits in Korean Medicine clinics for NHI and medical care assistance decreased, but the that of Western Medicine clinics recovered similarly to before. The rate change in the number of visits and medical expense between 2019 and 2022 more closely linked with that of Korean Medicine doctors than to Korean Medicine clinics. The medical expense per visit for NHI and medical care assistance increased in both Western and Korean Medicine clinics, and the rate of increase in Western Medicine clinics was higher than that of Korean Medicine clinics. These changes were the result of COVID-19 affecting medical services, and further research is needed on Korean Medicine clinical services due to external effects including infectious diseases.