Abstract
The purpose of this study is to analyze the publicness of medical services in public and private medical institutions, with a focus on treatment performance using National Health Insurance data. Data from the National Health Insurance Service were used to compare the publicness of medical services in public and private medical institutions. Beta regression analysis was conducted after adjusting for the relevant characteristics to identify the impact on the public treatment performance of medical institutions. The public case rate of public health institutions was higher than that of private medical institutions. According to the type of medical care institution, the public case rate was higher in general hospitals and tertiary hospitals than in hospitals. Recently, it has often highlighted that increasing emphasis of profitability in the evaluation of public health institutions is damaging the publicness of medical services. Even in this study, it can be evaluated that the public case rate of public health institutions is not higher than that of private medical institutions.
Keywords: medical services, private hospitals, public health and medical services, public hospitals, publicness
1. Introduction
The goals of Korea health and medical policies are to enhance the quality of health and medical services by making improvements to health and medical policies, to reduce the citizens’ financial burden of medical expenditures and enhance sustainability, to fortify the national health safety net by enhancing the disease management system and expanding essential medical services, to reinforce preventive health management, and so on. In particular, following the outbreak of Middle East respiratory syndrome in 2015 and coronavirus disease-2019 (COVID-19) in 2019, there has been an increase in discussions on the necessity for and expansion of public healthcare services. Public health based on publicness is a concept that includes the specific scope of coverage and preparation needed to guarantee medical care to anyone, without any restrictions. This specific scope of coverage is set to provide medical services to all citizens regardless of their ability to pay, such as through basic benefit packages or guaranteed health care packages.[1] In addition, this policy-making process is conducted transparently and openly as a means of building public trust.[2,3]
At the core of the concept of publicness lies public interest. It can be said that publicness is greater when the motive of a given action is based on the public interest of the majority, rather than the pursuit of individual or group profit. In this regard, an act performed by a public organization cannot be said to align with publicness if it does not set the public interest as its main purpose. Also, the act of securing publicness is not something that can be accomplished by supplying goods and services from the government.[4] The publicness of health care means that the beneficiaries of relevant services must be universal. That is, in principle, public health services must target a large number of people as opposed to providing individual services. Health care services for the general public can be divided into personal health care services and community health services.[5] Personal health care services targeting individuals comprise a relatively large portion of the private sector, while the scale of community health services targeting the general population are relatively large in the public sector. The World Bank defined health care policy development, disease prevention and control, and public health human resource development and capacity building as components of the public sector of health care.[6] Meanwhile, the World Health Organization emphasized public health status inspection and analysis, disease control, participation in health promotion, and public health care quality management as components of the public sector of health care.[7]
In Korea, public health and medical services are defined as all activities by the state, local governments, and health and medical institutions to ensure universal access to medical care and to protect and promote health, regardless of region, class, or sector.[8] In addition, in Korea, the term public health institution is used to refer to health and medical institutions established and operated by the state, local governments, or public organizations and specified by Presidential Decree for the main purpose of providing public health care.[8,9] In the United States, hospitals are classified into private for-profit hospitals, private nonprofit hospitals, and public hospitals according to the type of ownership.[10] Private for-profit hospitals are owned by nonprofit institutions, such as nonprofit organizations, churches or religious organizations, and charities, with some of them being managed and supported by the government. Private for-profit hospitals are owned by individuals or corporations and are capable of generating profits. Public hospitals are hospitals established by the federal government or state. The 4 roles and functions of public hospitals in the US can be summarized as the following[11]: first, they are in charge of medical care for medically vulnerable populations, such as the uninsured and low-income individuals. Second, they lead education and research on early measures for emergency patients and emergency medical care. Third, they provide preventive programs such as vaccination, early cancer screening, accident prevention, and crisis management, while maintaining close relationships with local health institutions. Fourth, they provide education for medical personnel. Private nonprofit hospitals also provide education, research, and charity medical care, so the role and function of hospitals seem to be similar to that of public hospitals. In Japan, public hospitals and private hospitals can be distinguished based on the agent of their establishment. Public hospitals are established by the state and public organizations, while private hospitals are established by organizations such as individuals and medical corporations. In Japan, public hospitals perform roles such as providing emergency medical care, psychiatric treatment, and medical treatment in areas such as cancer and cardiovascular disease, as designated by national policy.[12]
Studies analyzing the performance of medical services provided by public and private medical institutions do not provide consistent results. In a study that analyzed the contents of medical services provided by private and public hospitals for various disease and illness classifications, corrected for the severity of disease and illness, the cost in public hospitals was about 20% lower than that in private hospitals.[13,14] In addition, the efficiency of public hospitals was higher than that of private hospitals. There was also a study that found that private hospitals had fewer prescription drugs and fewer testing categories than public hospitals but demanded more revisits.[15] In a study that compared the status of treatment by type of hospital ownership for patients hospitalized for acute myocardial infarction among Medicaid subscribers, results showed that for-profit hospitals provided more expensive treatment than public hospitals and private nonprofit hospitals.[16] In yet another study that analyzed the effect of hospital ownership on hospital efficiency, efficiency was found to be highest in private nonprofit hospitals, followed by public hospitals and then private for-profit hospitals. Also, nonprofit hospitals showed the highest degree of efficiency improvement.[17] There was also a study whose results demonstrated that public and private medical institutions did not produce consistent results due to large differences in their service provision, performance, and efficiency.[18]
Following the outbreaks of Middle East respiratory syndrome and COVID-19, there have been ongoing discussions regarding the expansion of public health services to strengthen the publicness of health and medical services, as was done in Korea. However, the analysis of the role of public health performed by public and private medical institutions remains insufficient. As such, there is a need to analyze the contents of public health services and treatment results between public and private medical institutions. The results of such analyses can then be used as the basis for establishing the roles and functions of public and private medical institutions for the ultimate goal of strengthening the publicness of such medical services. The purpose of this study is to provide policy alternatives for the appropriate roles and functions of public and private medical institutions by comparatively analyzing the publicness of medical services in public and private medical institutions, with a focus on treatment performance using National Health Insurance data.
2. Methods and materials
Data from the National Health Insurance Service were used to compare the publicness of medical services in public and private medical institutions. The analysis targets were randomly selected and used 10% of the total number of patients treated in public and private medical institutions classified as hospital level or higher in 2017. The variables included in the analysis were variables available in the National Health Insurance Service data.
As for ensuring social equity, such as medical treatment for medically vulnerable populations, treatment results for patients receiving medical aid, near-poverty groups, foreign workers, disabled patients, and patients aged 65 or older were utilized. Along with these, regarding the inevitability of government intervention, such as services that are likely to be in short supply due to low profitability, the results of treatment in intensive care units, emergency rooms, isolation units, and treatment of special patients (tuberculosis, leprosy, pneumoconiosis) were utilized. These variables were defined as public cases (episodes). Using this public case rate, the publicness of public and private medical institutions was compared.
Public case rate = [case rate of medical aid + case rate of the near-poverty groups + case rate of foreign works + case rate of disabled patients + case rate of patients aged 65 years or older + case rate of intensive care units + case rate of emergency rooms + case rate of isolation units + case rate of special patients (tuberculosis, leprosy, pneumoconiosis)]/ 9
Medical, oriental medicine, and dentist offices were included among health care institutions higher than hospital level. After establishing patient-by-patient cases (episodes) for treatment performance, the rate of cases among all patients in each medical institution was used for the treatment performance. Primary and secondary diagnoses were used for diagnosis names. When conducting the statistical analysis, beta regression analysis and SAS Enterprise Guide were used.
This study is a study using open data and does not collect or record personally identifiable information. Therefore, ethical approval is not necessary.
3. Results
Table 1 shows the number of medical institutions and the number of cases. A total of 4109 medical institutions of hospital level or higher were analyzed for the purpose of this study. There were 224 public health institutions (5.5%) and 3885 private medical institutions (94.5%). The total number of cases was 146,863,818. The number of cases in public health institutions was 20,246,437 (13.8%), and the number of cases in private medical institutions was 126,617,381 (86.2%).
Table 1.
Type of institution subject to study and number of patients cases.
| Type of medical care institution | Public health institution | Private medical institution | Total | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Number of institutions | Number of patients cases | Number of institutions | Number of patients cases | Number of institutions | Number of patients cases | |||||||
| N | (%) | N | (%) | N | (%) | N | (%) | N | (%) | N | (%) | |
| Tertiary Hospital | 11 | (4.9) | 8150,053 | (40.3) | 32 | (0.8) | 20,323,101 | (16.1) | 43 | (1.0) | 28,473,154 | (19.4) |
| General Hospital | 56 | (25.0) | 9980,207 | (49.3) | 248 | (6.4) | 45,793,223 | (36.2) | 304 | (7.4) | 55,773,430 | (38.0) |
| Hospital | 157 | (70.1) | 2116,177 | (10.5) | 3605 | (92.8) | 60,501,057 | (47.8) | 3762 | (91.6) | 62,617,234 | (42.6) |
| Total | 224 | (100.0) | 20,246,437 | (100.0) | 3885 | (100.0) | 126,617,381 | (100.0) | 4109 | (100.0) | 146,863,818 | (100.0) |
Table 2 shows the treatment results of publicness, such as intensive care unit case rate, emergency room case rate, isolation bed case rate, and special patient (tuberculosis, leprosy, pneumoconiosis) case rate, analyzed by type of institution (public, private), type of medical care institution (hospital, general hospital, tertiary hospital), region, urbanization level, number of beds, and number of doctors. Based on the type of medical care institution, the proportion of cases of publicness was highest in the hospital class. In hospital-level medical institutions, the number of cases of publicness was about 28% higher in public health institutions than in private ones. In general hospital-level medical institutions, the number of cases of publicness was about 32% higher in public health institutions than in private ones.
Table 2.
Public cases rate by type of institution.
| Categorization | Type of institution | Total (N = 4109) | A/B | P value | |
|---|---|---|---|---|---|
| Public health institution (A) (N = 224) | Private medical institution (B) (N = 3885) | ||||
| Total | 11.87 ± 5.62 | 9.58 ± 5.99 | 9.70 ± 5.99 | 1.24 | <.0001 |
| Type of Medical Care Institution | <.0001 | ||||
| Tertiary Hospital | 8.96 ± 0.89 | 8.34 ± 1.24 | 8.50 ± 1.18 | 1.07 | |
| General Hospital | 11.09 ± 2.64 | 8.41 ± 2.28 | 8.90 ± 2.57 | 1.32 | |
| Hospital | 12.38 ± 6.50 | 9.68 ± 6.18 | 9.78 ± 6.22 | 1.28 | |
| Region | <.0001 | ||||
| Seoul | 10.98 ± 4.36 | 7.79 ± 5.36 | 7.94 ± 5.36 | 1.41 | |
| Gyeonggi-Incheon | 10.65 ± 6.30 | 9.73 ± 5.92 | 9.76 ± 5.93 | 1.09 | |
| Chungcheong | 12.01 ± 5.83 | 10.98 ± 6.03 | 11.05 ± 6.01 | 1.09 | |
| Jeolla | 13.86 ± 5.11 | 8.55 ± 6.13 | 8.82 ± 6.19 | 1.62 | |
| Gyeongsan | 12.12 ± 5.83 | 10.24 ± 6.01 | 10.33 ± 6.01 | 1.18 | |
| Gangwon | 9.64 ± 5.17 | 10.86 ± 4.81 | 10.64 ± 4.88 | 0.89 | |
| Jeju | 13.52 ± 3.98 | 13.10 ± 5.98 | 13.2 ± 5.50 | 1.03 | |
| Level of Urbanization | <.0001 | ||||
| District | 11.26 ± 4.75 | 8.74 ± 5.95 | 8.83 ± 5.93 | 1.29 | |
| County | 13.21 ± 5.83 | 12.22 ± 4.93 | 12.34 ± 5.04 | 1.08 | |
| City | 11.67 ± 5.94 | 9.91 ± 6.05 | 10.01 ± 6.05 | 1.18 | |
| Number of Beds | <.0001 | ||||
| 0 | 5.45 ± 7.29 | 4.87 ± 4.39 | 4.88 ± 4.47 | 1.12 | |
| 1–29 | 10.31 ± 7.82 | 10.63 ± 5.08 | 10.62 ± 5.21 | 0.97 | |
| 30–99 | 12.06 ± 6.71 | 6.49 ± 5.35 | 6.61 ± 5.44 | 1.86 | |
| 100–299 | 13.07 ± 4.97 | 12.89 ± 4.89 | 12.91 ± 4.89 | 1.01 | |
| Over 300 | 9.92 ± 4.63 | 12.47 ± 4.19 | 12.05 ± 4.36 | 0.80 | |
| Number of Doctors | <.0001 | ||||
| 1 | 11.54 ± 9.07 | 7.69 ± 5.38 | 7.75 ± 5.45 | 1.50 | |
| 2–10 | 15.59 ± 3.97 | 10.24 ± 6.21 | 10.4 ± 6.22 | 1.52 | |
| 11–50 | 9.07 ± 5.29 | 6.83 ± 4.28 | 7.14 ± 4.49 | 1.33 | |
| 51–100 | 8.80 ± 5.37 | 7.72 ± 2.59 | 7.92 ± 3.25 | 1.14 | |
| Over 101 | 8.28 ± 2.80 | 8.32 ± 1.68 | 8.31 ± 2.02 | 1.00 | |
Beta regression analysis was conducted after adjusting for the relevant characteristics to identify the impact on the public treatment performance of medical institutions. Table 3 shows the results of beta regression analysis. As a result of the analysis, the public case rate of public health institutions (OR 1.24, 95% CI 1.15~1.33) was higher than that of private medical institutions. According to the type of medical care institution, the public case rate was higher in general hospitals (OR 1.33, 95% CI 1.26~1.39) and tertiary hospitals (OR 1.33, 95% CI 1.21~1.45) than in hospitals. Based on the level of urbanization, the public case rate was higher in counties (OR 1.55, 95% CI 1.41~1.69) than in districts.
Table 3.
Results of Beta regression analysis on the effect of types and characteristics of institutions on public case rate.
| Categorization | Odds ratio | 95% CI | |
|---|---|---|---|
| Type of Institution | Private Medical Institution | 1.00 | Reference |
| Public Health Institution | 1.24 | (1.15 ~ 1.33) | |
| Type of Medical care Institution | Tertiary Hospital | 1.33 | (1.21 ~ 1.45) |
| General Hospital | 1.33 | (1.26 ~ 1.39) | |
| Hospital | 1.00 | Reference | |
| Region | Seoul | 1.00 | Reference |
| Gyeonggi-Incheon | 0.95 | (0.88 ~ 1.03) | |
| Chungcheong | 1.05 | (0.96 ~ 1.16) | |
| Jeolla | 0.99 | (0.91 ~ 1.09) | |
| Gyeongsan | 0.99 | (0.92 ~ 1.07) | |
| Gangwon | 1.13 | (1.01 ~ 1.26) | |
| Jeju | 1.10 | (0.94 ~ 1.29) | |
| Level of Urbanization | District | 1.00 | Reference |
| County | 1.55 | (1.41 ~ 1.69) | |
| City | 1.06 | (1.00 ~ 1.12) | |
| Number of Doctors | 1.00 | (1.00 ~ 1.00) |
The results of beta regression analysis conducted to analyze the effect of the type and characteristics of medical institutions on each variable constituting public cases were presented in Supplemental Digital Content. The results of beta regression analysis on the effect of types and characteristics of institutions on the case rate of medical aid (see Appendix 1, Supplemental Content, http://links.lww.com/MD/K649), the case rate of the near-poverty groups (see Appendix 2, Supplemental Content, http://links.lww.com/MD/K650), the case rate of foreign works (see Appendix 3, Supplemental Content, http://links.lww.com/MD/K651), the case rate of disabled patients (see Appendix 4, Supplemental Content, http://links.lww.com/MD/K652), the case rate of patients aged 65 years or older (see Appendix 5, Supplemental Content, http://links.lww.com/MD/K653), the case rate of intensive care units (see Appendix 6, Supplemental Content, http://links.lww.com/MD/K654), the case rate of emergency rooms (see Appendix 7, Supplemental Content, http://links.lww.com/MD/K655), the case rate of isolation units (see Appendix 8, Supplemental Content, http://links.lww.com/MD/K656), the case rate of special patients (tuberculosis, leprosy, pneumoconiosis) (see Appendix 9, Supplemental Content, http://links.lww.com/MD/K657) were presented in Supplemental Content.
4. Discussions
In previous studies, the publicness of medical services has continuously changed according to the environment at the time of each study and the researchers. In addition, there were differences according to the designated variables for each study, which made it difficult to analyze the publicness of medical services because they were not standardized. For these reasons, there is a lack of objective indicators for the publicness of medical services. Taking this into consideration, this study focuses on the treatment performance of public and private medical institutions by using the National Health Insurance data, which includes the current status of medical service use of citizens who have maintained their qualifications as health insurance subscribers and beneficiaries of medical benefits in Korea. In particular, this study compared the publicness of medical services in private medical institutions. The results demonstrated that the public hospitalization rate of public health institutions was 1.24 times higher than that of private medical institutions. In addition, the public case rate was higher in tertiary general hospitals and general hospitals than in hospital-level medical institutions. These results are similar to those of previous studies that found that public health institutions such as tertiary general hospitals and general hospitals had a high proportion of public cases, such as medical benefit patients.[19] However, the scale of the case rate, such as the number of patients, was different from that of previous studies.
In preparation for future epidemics of new infectious diseases such as COVID-19, Korea is promoting a policy to strengthen public health through the expansion and installation of public health institutions. However, there are many who criticize plans to increase the number of public health institutions in a situation where private medical institutions are already excessive, especially when considering that the publicness of medical services is more influenced by the direction of the government health care policies than by the internal circumstances of medical institutions. Rather than the quantitative expansion of public health institutions, it is more important to focus on the roles and functions that such institutions will perform. Public health institutions emphasize publicness in the purpose of their establishment and their operational goals. For the benefit of society as a whole, the operational goals of public health institutions are to prevent and manage major health problems that affect the majority of people in terms of public health or that private medical institutions avoid taking responsibility for in the medical service delivery system. Furthermore, they should aim to achieve equity in the supply of medical services by providing them to medically vulnerable populations. In addition, public health institutions receive human resources and financial support from the government. However, there are those who criticize the fact that medical services provided by public health institutions are not substantially different from those provided by private medical institutions.
Some public health institutions are specialized and play a major role in managing severe diseases such as mental illnesses, infectious diseases, cancer, and rare intractable diseases. Furthermore, the role of public health institutions has been strengthened for specialized diseases such as cancer, rare incurable diseases, and tuberculosis, which are supported by the government. As such, the medical services that a health institution can provide are influenced by various factors based on the given disease, its severity, and difficulty of treatment. There are also differences in medical service provisions and capacities depending on the agent that established a given medical institution, along with its intended purpose. Recently, it is often highlighted that increasing emphasis of profitability in the evaluation of public health institutions is damaging the publicness of medical services. Even in this study, it can be evaluated that the public case rate of public health institutions is not higher than that of private medical institutions. If public health institutions provide medical services with a focus on profitability, it will be difficult for them to fulfill their roles and functions. Therefore, it is necessary to develop and evaluate objective evaluation indicators for the public sector of healthcare. Furthermore, it is necessary to provide differentiated financial and administrative support to each medical institution based on their evaluation results.
This study has the following limitations. First, since the evaluation of the publicness of public and private medical institutions was analyzed using the National Health Insurance data, the subject of the analysis was the use of medical services by patients. Second, the use of medical services that were evaluated was not adjusted for severity of the illness or treatment. In future studies, it is necessary to conduct a comparative study after correcting for such differences in severity, paying closer attention to specific diseases and specific subjects for analysis. Third, clinic-level medical institutions were excluded from the analysis. This is because health institutions such as community health centers and health branch offices fall under the category of public health institutions.
5. Conclusions
This study conducted an empirical analysis on the provision of medical services by public and private medical institutions using National Health Insurance data. Therefore, the results of this study can be used as basic data necessary for establishing rational roles of public and private health institutions and establishing policies to strengthen the publicness of healthcare services.
Author contributions
Conceptualization: Euichul Shin, Changwoo Lee.
Data curation: Euichul Shin, Changwoo Lee.
Formal analysis: Euichul Shin.
Methodology: Euichul Shin, Changwoo Lee.
Supervision: Euichul Shin.
Writing – original draft: Euichul Shin, Ji Man Kim.
Writing – review & editing: Ji Man Kim.
Supplementary Material
Abbreviation:
- COVID-19
- coronavirus disease-2019
The datasets generated during and/or analyzed during the current study are publicly available.
The National Health Insurance Service data are available on the National Health Insurance Sharing Service website.
Supplemental Digital Content is available for this article.
The authors have no funding and conflicts of interest to disclose.
How to cite this article: Kim JM, Lee C, Shin E. A comparative analysis on the publicness of medical services in public health institutions: With an empirical analysis of the national health insurance database. Medicine 2023;102:46(e35994).
Contributor Information
Ji Man Kim, Email: mann25@gmail.com.
Changwoo Lee, Email: mannis@nate.com.
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