Introduction

I (first author) am working as a physiatrist and professor at a university hospital in South Korea and spent a sabbatical/research year in Montreal since January 2023. I was exposed to the healthcare system in Quebec, particularly in the field of pain medicine. The systems in South Korea and Quebec differ significantly, prompting consideration of the inefficiencies resulting from each system. Healthcare system functioning is complicated and influenced by social, economic, and political factors. This article is written based on personal perspectives. It aims to present the differences between the systems in South Korea and Quebec, highlight the issues arising from each system, and provide ideas for potential solutions. Institutional Review Board consent was not required owing to the topic of the article.

South Korean healthcare system

South Korea has a national health insurance system [1,2]. The National Health Insurance Service (NHIS) is funded through national funds and insurance fees from companies and citizens [1,2]. Insurance fees are set differentially depending on income and ability; however, health insurance benefits are identical for the entire population. When South Korean citizens use healthcare services, part of the total cost is borne by the individual. After the individual has paid the healthcare institution (if the individual has private insurance, this may be paid by the private insurance company), the remainder is paid by the NHIS following a review by the Health Insurance Review and Assessment Service (HIRA). The co-payment is 20% for inpatients and differs for outpatients depending on the type of healthcare institution: 30% for clinics, 40% for hospitals, 50% for general hospitals, and 60% for advanced general hospitals. The NHIS provides support for “covered” medical costs, while the patient must bear 100% of “non-covered” medical costs [3]. In summary, after a healthcare visit, the patient directly pays the healthcare institution copayments for covered costs (30%–60% of covered medical costs) and fees for non-covered costs (100%). The remaining covered costs after copayments are paid to the healthcare institution by the NHIS after the HIRA has reviewed the validity of the treatment actions.

Covered costs are fixed, whereas prices are set freely by the hospital for non-covered costs, meaning that prices can differ between institutions. For example, if a patient receives a transforaminal epidural steroid injection (TFESI) for lumbosacral radiculopathy at a clinic, the patient must pay 53,000 South Korean won (KRW, approximately 53 Canadian dollars [CAD]) out of the total cost of 182,000 KRW (182 CAD). The remaining 129,000 KRW (129 CAD) is paid to the clinic by the NHIS following a review. Covered costs include various nerve blocks, intra-articular steroid injections, epidural injections, and trigger point injections, while extracorporeal shockwave therapy, prolotherapy, ultrasound diagnosis, manual therapy, neuroplasty, and nucleoplasty are non-covered costs.

One characteristic of South Korean healthcare is that there are no general practitioners or family doctor roles [4]. In many cases overseas, patients will visit a general practitioner or family doctor before seeing a pain medicine specialist, and the general practitioner or family doctor will then refer the patient to a pain medicine specialist if necessary. In South Korea, patients can visit pain medicine specialists immediately without first visiting a general practitioner or family doctor. In most cases, patients can receive treatment at any healthcare institution in South Korea without restrictions. To receive treatment at a tertiary medical institution, a medical treatment request from a primary or secondary medical institution is required. However, this is only a formality and does not act as a significant barrier. Furthermore, the financial burden is less to visit a healthcare institution because the fees are low (e.g., the out-of-pocket cost for a single-level TFESI in South Korea is approximately 53 CAD, compared to 600–700 CAD in private clinics in Quebec), and 40% to 70% of the covered costs are paid by the NHIS. Therefore, in 2020, the average number of annual outpatient visits in South Korea was 14.7 per person, which is 2.5 times higher than the Organisation for Economic Co-operation and Development (OECD) average of 5.9 annual visits per person [5]. It is economically and institutionally easy for patients to see a pain physician, and because of the relatively low healthcare fees, pain physicians need to see many patients to make what they consider a reasonable profit. Precise charting of medical records is not usually feasible; therefore, medical charts are often poorly completed, and HIRA reviews tend to be lenient towards charting. As a result, patients can reserve and have consultations with a pain physician on the same day. Even for patients who must undergo computed tomography or magnetic resonance imaging scans before treatment, completing the initial consultation, examinations, and treatment is often possible in a single day. Thus, the South Korean healthcare system is effective because of the synergistic nature of physician needs and patient healthcare usage patterns [6]. Another unique aspect of the South Korean healthcare system is that even a general practitioner or physician who is not a pain-related specialist can treat patients with pain if they are confident. Furthermore, physicians can perform fluoroscopic- and ultrasound-guided injections (e.g., TFESI and ultrasound-guided intra-articular or peritendinous steroid injections) without official training. Although such cases are uncommon, this system allows pediatricians to be confident in their ability to treat pain and provide pain treatment to adults.

Strengths and weaknesses of the South Korean healthcare system

An advantage of the South Korean healthcare system is that patients with pain can easily see pain medicine specialists on the same day. In addition, because healthcare fees are low, patients can see a specialist without financial burdens. Patients who have private insurance frequently pay no treatment fees. However, the disadvantage of this system is that low fees make it necessary for pain medicine specialists to treat a large number of patients. In clinics, a single physician must treat 60 to 150 patients per day. Although this has not been proven, it is expected to result in a higher risk of misdiagnosis. Moreover, there may be many instances in which physicians fail to check a patient’s underlying diseases or medications. In addition, because of the low healthcare fees for covered costs, physicians may recommend more expensive injections to patients, which could lead to patients receiving unnecessary injections. Because patients can easily see pain physicians and the medical costs are low, there is a higher chance of “doctor shopping,” where patients freely visit multiple healthcare institutions. This, in turn, can lead to repeated treatments at different institutions. This has also led to an increase in the number of hospital visits by people who do not require a doctor. Physicians may try to supplement the low fees for covered costs by overprescribing non-covered treatments for which they can freely set prices without oversight from the HIRA.

Quebec healthcare system

In the Canadian province of Quebec, medical institutions are divided into public institutions (hospitals and clinics) and private clinics. In public institutions, patients do not have to pay any fees for visits and treatment, as they are covered by the universal healthcare system for citizens [7]. In private clinics, which are increasing in number yet still represent a very small minority of health institutions in the province, patients have to pay out-of-pocket for all the treatments and medical services they receive, and insurance companies rarely reimburse them. However, patients often wait for several months to see a physician at a public institution [8]. Patients who do not want to wait that long can decide to pay fully for care in private clinics, but the services provided are limited in the few private clinics that exist. Physicians in Canada are capable of earning three to four times as much money as physicians in South Korea for the same treatment. For lumbar TFESI, although not three to four times the cost in South Korea, doctors at public clinics receive approximately 300 CAD from the government per treatment, whereas private clinics typically receive 600 to 700 CAD per treatment directly from patients, although this cost varies among clinics.

Strengths and weaknesses of the Quebec healthcare system

One advantage of the Canadian healthcare system is that patients visiting public healthcare institutions do not have any out-of-pocket costs. However, although patients who experience pain can receive treatment on the same day in South Korea, they often have to wait for several months in Canada. Those who are unwilling to wait several months can pay a high cost for treatment at a private clinic. In addition, to perform pain-control procedures in Canada, physicians must undergo resident training in a related discipline to obtain a license for that treatment. This guarantees that physicians can perform pain treatment procedures, ensuring that patients can safely receive high-quality treatment. To the best of our knowledge, no reports have compared the number of physicians practicing pain management in South Korea and Canada. However, according to the 2018 OECD Health Statistics, there were fewer physicians relative to the population size in South Korea (2.4 physicians per 1,000 population) than in Canada (2.7 physicians per 1,000 population). Many hypotheses have been formulated to explain why the waiting time for patients is much longer in Canada than in South Korea despite similar numbers of physicians, such as differences in work culture, patient and doctor expectations, patient evaluations, and charting methods.

Proposed solutions for improving healthcare systems

Thus far, we have explained some of the characteristics of the South Korean and Quebec (Canadian) healthcare systems. We have described some of the advantages and disadvantages of each system. As healthcare systems can differ, it is difficult to directly apply the strengths of one system to that of another country. Nevertheless, if the strengths of each system could be applied to the other, we believe that this would help supplement the shortcomings of both systems. Thus, South Korea must consider the possibility of increasing healthcare costs. By raising prices, patients would need to bear higher costs, reducing the ease of access to healthcare and encouraging only those who need care to visit hospitals or clinics. This would, in turn, reduce the number of patients who need to be seen by pain physicians and allow those physicians to treat their patients with more care and attention. This could also reduce the number of unnecessary treatments performed by pain physicians, supplementing low healthcare fees. In addition, stricter criteria are required for the selection of non-covered costs. It is necessary to improve the overall quality of care for patients with pain by restricting the treatment of these patients to physicians with pain-related licensing and training.

However, some solutions have been proposed to decrease the waiting times for patients in Quebec. Reducing the charting burden for physicians with more efficient electronic medical records may be helpful. Creating a chart format that can be completed for each musculoskeletal disease could help reduce the time required for charting. These formats would need to prioritize items that are essential for patient care and reduce or eliminate items that are less important. There is also a need for institutional changes to ensure that physicians are not disadvantaged in medical lawsuits due to the lack of charting. Moreover, creating chart formats to simplify charting could reduce the administrative staffing required, which would also help reduce overall healthcare costs.

Conclusion

We examined various characteristics of the healthcare systems in South Korea and Quebec and analyzed their strengths and weaknesses. We also suggested measures to overcome these weaknesses. However, the healthcare systems in each country are related to a combination of several variables; therefore, it may be difficult to compensate for these limitations. It is important for each country to clearly understand the advantages and disadvantages of the other’s healthcare system. Efforts must be made to clearly recognize these advantages and disadvantages, build upon their strengths, and gradually improve their weaknesses.

Article information

Conflicts of interest

Min Cheol Chang has been an associate editor of Journal of Yeungnam Medical Science (JYMS) since 2021. Mathieu Boudier-Revéret has been an editorial board member of JYMS since 2021. They were not involved in the review process of this manuscript. There are no other conflicts of interest to declare.

Funding

None.

Author contributions

Conceptualization: MCC, MBR; Writing-original draft: MCC, MBR; Writing-review & editing: MCC, MBR.

References

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