Examining the factors associated with inpatients’ perception of overtreatment in Korea: a cross-sectional study

This study was the first to examine factors associated with inpatient’s perception of overtreatment using Korean representative secondary healthcare data. Analyzing patients’ perception of having experienced overtreatment while being hospitalized is worthwhile, because such information contributes to the evaluation the quality of medical services and faithful implementation of a patient-centered treatment paradigm [1, 2, 19]. In addition, the estimated prevalence of overtreatment from patients’ perceptions can be used as basis for reasonably estimating the objective amount of overtreatment. Interestingly, this study found that 19.9% of inpatients perceived overtreatment in Korea (under the definition of any overtreatment), which is consistent with 20.6% reported by Lyu et al. [13] in their sample of American physicians. This is a remarkable coincidence in that the prevalence of overtreatment was perceived at a similar level despite these studies being conducted in different countries with different sample populations.

The determinants of patients’ perception of overtreatment identified in this study are as follows. First, in the results of predisposing factors, females and individuals with a single-marital status were more likely to perceive both any and strict overtreatment. Although not about overtreatment, this result is somewhat inconsistent with the findings of a meta-analysis that concluded there were no gender differences in satisfaction with regard to health care [21]. Similarly, Weisman et al. [22] did not find a pattern of gender differences in satisfaction; however, men benefited from the care more quickly, had better doctor-patient communication, and found the office staff courteous and helpful; whereas women were only more satisfied with customer service. In other words, the researchers concluded that gender differences in patient satisfaction depended on the type of medical service. Given our study showed that women were more likely to feel they are receiving overtreatment, medical personnel should actively focus on enhancing communication with female patients to lessen the perception of overtreatment.

Meanwhile, single individuals are more likely to perceive overtreatment than those who are married. This finding is interesting because the marital status can affect the communication between patients and doctors. Commnunication is regared as a major factor in reducing unnecessary examinations and treatements, positively affecting the overall medical process and treatment results [19, 23‐25]. Patients may find it difficult to understand medical terminology and may not pay careful attention during a conversation with a doctor due to pain and symptoms. Thus, single patients may feel that communication has not been done properly. However, in the case of a married couple, communication can be facilitated because both the patient and spouse communicate with the physician. In fact, these interpretations seem to rely on the caregiver role rather than marital status.

The valuable findings of this study are that all enabling factors were statistically significant. The higher income group, employers enrolled in NHI, and people with PHI were more likely to experience overtreatment. The fact that higher income groups are more likely to report overtreatment could be due to the fact that they concern about the high opportunity cost of spending time on treatment, compared with lower income groups. It should be noted that the highest income group was significant only for strict overtreatment. We carefully infer that the wealthiest people do not suspect excessive treatment when they perceive the “normal” level of overtreatment because they have less concerns about the cost.

Additionally, it is worth noting that in the typical medical service setting, providers cannot officially obtain a patient’s financial information, only the type of health coverage. The Korean NHI system separates subscription qualification into three groups: employees, employers, and medical aid recipients [26]. Among them, there is no difference in NHI benefits for employees and employers, except in calculating premiums. Medical aid is a co-payment system funded by a national tax, which allows the economically poor or patients with high medical needs to use medical services at meager prices [26]. It is remarkable that people with PHI reported overtreatment, because patients who are privately insured are entitled to (partial) reimbursement of their medical bills. This might be due to a small trace of the provider’s moral hazard induced by PHI, which is thoroughly discussed in Korea [27, 28]. Lyu et al. [13] found that 70.8% of all physicians were more likely to perform unnecessary procedures when they expected more profits. Therefore, we raise suspicions that medical providers may be performing excessive treatment after inferring payment ability with regard to having PHI.

Meanwhile, all the need factors included in the model were significantly associated with the perception of overtreatment. Patients with chronic diseases and disabilities were more likely to report experiencing overtreatment. This may be due to the persistent and incurable nature of their condition, which can influence their thoughts and feelings about their treatment. In particular, an interesting finding is that disability was a significant factor for any overtreatment, but it was not significant for strict overtreatment. Rather, the disabled were less likely to perceive strict overtreatment. This may be because most individuals with disabilities receive overtreatment at a normal level rather than a positive or very positive level. Thus, determining if they are receiving excessive medical treatment would be difficult to differentiate because the amount of medical treatment they receive is inherently high.

We found that subjective health status was another factor that affected inpatients’ perception of overtreatment. Patients suffering mild or bad conditions were more likely to perceive overtreatment. However, since subjective health status was the state of health at the time of the investigation, there could be a time lag from the experience of hospitalization. In other words, the participant’s health condition at the time of the survey could be different than their health condition in the past when they experienced overtreatment. A variable to correct this is health recovery. This study confirmed that the inpatients who indicated that their health had recovered directly after being hospitalized perceived less overtreatment. In summary, the subjective health status variable should be regarded as a control variable in determining the factors of overtreatment. Alternatively, it can be argued that persistent care and monitoring services are crucial because the health status at the time of the survey affects the response of their past experience of overtreatment.

Other results showed that the patients hospitalized in the general tertiary and general hospitals are considerably more likely to report overtreatment. On the medical provider’s side, general (tertiary) hospitals would be motivated to expand revenue through overtreatment. Lyu et al. [13] showed that 20% of physicians exercised overtreatment due to pressure from the medical institution or management. On the contrary, patients may expect general hospitals to have a more outstanding quality of medical services than other medical institutions, such as clinics or health centers. Indeed, most patients with severe diseases are admitted to general tertiary hospitals [29]. Therefore, patients in tertiary hospitals may be more likely to report overtreatment because their severe condition calls for more reexamination, retreatment, and costs.

Another concern related to the type of hospital is the compensation model of hospitals. Lyu et al. [13] criticized the fee-for-service and flat salary physician compensation model driving overtreatment from physicians. According to fee-for-service, the more medical service provided, the higher the profit; thus, this encourages the medical provider’s overtreatment motivation [30]. In contrast, the flat salary model has no incentive for doctors to reduce unnecessary treatment and only makes them focus on avoiding malpractice claims [13]. The Korean national health system has employed fee-for-service mechanisms [31], constituting the main revenue source of hospitals. Moreover, hospitals have been adopting a salary compensation model for physicians. In other words, it can be inferred that Korea’s healthcare system has a compensation system that promotes overtreatment. Therefore, Korean health policymakers need to refer to other countries’ systems that provide financial incentives to hospitals to reduce the waste of medical resources, such as Maryland’s new global payment system [32].

Lastly, the patients who had received surgery were more likely to report strict overtreatment. Because surgery is mostly invasive, causes pain, and prolongs the length of hospital stay, it can come at a opportunity cost to patients, such as a loss of working income. Therefore, inpatients who received surgery reported more overtreatment. These findings suggest that a significant proportion of patients who underwent surgery perceive overtreatment to be beyond a positive level, while relatively few patients perceive it as a normal level. At the same time, it means that people who have not undergone surgery recognize the normal level of overtreatment considerably.

Patients who had not undergone surgery reported the “normal” level of overtreatment. In this regard, the advantage of sensitivity analysis is that it can assign different policy implications based on the interpretation of the normal level of overtreatment. The normal level has a low level of certainty; therefore, it is difficult to accept that overtreatment has actually occurred. However, because the number of patients experiencing normal overtreatment was higher than the number of patients experiencing excessive (positive) and exceptionally excessive (very positive) overtreatment, it can increase consumer power and cause collective complaints. Therefore, it is necessary to reinforce communication, emotional care, and monitoring activities after discharge from the hospital based on “any overtreatment.” In contrast, reports or perceptions of strict overtreatment can be used as a criterion to check whether there actually was overtreatment in medical services and what form it took. Korea has been operating the Health Insurance Review and Assessment Service (HIRA), which is a public corporation with jurisdiction and responsibilities for the quality of medical care services. HIRA reviews and evaluates medical providers’ bills, keeping an eye on appropriate patient treatment, overtreatment and overbilling, and the standard of medical care [33‐35]. If HIRA uses this indicator, it will be able to narrow down the scope of overtreatment and overcharge investigations. Thus, HIRA could reduce the burden of extensive overtreatment investigations of hospitals and clinics across the country and effectively monitor overtreatment.

Based on the results of this study, we suggest empowering HIRA to intervene in the miscommunication between inpatients and medical providers. Furthermore, the authority of HIRA to monitor overtreatment and intervene where indicated at general tertiary hospitals should be strengthened.