Improving Efficiency Through Explicit Rationing Criteria and Utilization Review: The Case of Regulating Brain MRI in South Korea

Y. SHIN 1 and Y. K. DO 1 2
1 Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Republic of Korea
2 Institute of Health Policy and Management, Seoul National University Medical Research Center, Seoul, Republic of Korea

 

BACKGROUND

• Healthcare quality issue: Improving efficiency while increasing access to healthcare
• Expansion of National Health Insurance (NHI) coverage for brain magnetic resonance imaging (MRI) in 2018
• Policy response to overuse concerns: Specifying the explicit rationing criteria & rigorous utilization review

 

OBJECTIVE

Understand how the regulation based on explicit rationing criteria & utilization review changed physicians’ decisions to make brain MRI reimbursement claims

 

METHODS

• Theory: Herbert Simon’s bounded rationality
• Mixed-methods (exploratory sequential design)
- Semi-structured interview with physicians (n=29)
- Multilevel analysis & Time series analysis of NHI claims data

 

Explicit rationing criteria often became tools for physician discretion, due to the uncertainty and conflict prevalent in the medical decision-making process.