Factors affecting healthcare utilization among foreign beneficiaries of national health insurance in Korea

doi:10.21203/rs.3.rs-4705771/v1

Download PDF

Research Article

Factors affecting healthcare utilization among foreign beneficiaries of national health insurance in Korea

https://doi.org/10.21203/rs.3.rs-4705771/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

To explore the factors affecting healthcare utilization (both inpatient and outpatient services) among foreign beneficiaries of the National Health Insurance (NHI) in Korea.

Methods

We conducted a two-part model analysis employing Andersen's behavioral framework, using health insurance claims data from 2022.

Results

The results indicated that individual need characteristics, such as disability, CCI, and chronic diseases, had the most significant impact on total healthcare utilization and its associated costs. The next significant characteristic was the residence period; the longer the period, the higher the likelihood of healthcare utilization, but the lower the associated costs. Among the predisposing characteristics, individuals aged 65 years and older had the most significant impact on healthcare costs. Additionally, among the enabling characteristics, residency period, residency status, and beneficiary type were most significant.

Conclusion

Foreigners residing in Korea are eligible to use the Korean healthcare system by enrolling in NHI. As the foreign population is projected to grow even faster due to Korea's aging society and low birth rate, this study can assist public health administrators in formulating evidence-based policies.

foreigners

national health insurance

health care utilization

ambulatory care

hospitalization

Korea achieved universal health coverage in 1989 [1]. However, the public healthcare system hasn’t fully covered foreign residents who do not hold Korean nationality, leading to unequal access to healthcare. Although legislation to extend healthcare coverage to foreigners was prepared in 1981, discussions in the 1980s due to labor shortages.

The National Health Insurance (NHI) in Korea covers employees, self-employed individuals, and their families. The employee category includes government employees, school teachers, business employers and employees. Since the self-employed category encompasses households not covered by the employee category, the Korean NHI effectively covers the entire population. Foreign employees could voluntarily enroll in the NHI since 1998 but were mandated to do so in 2006, and self-employed foreigners since 1999, with mandatory enrollment in 2019. Consequently, every foreigner could access Korean healthcare securely by 2019 [2, 3].

Foreigners in Korea [4] utilize healthcare services less frequently, attributed to various factors such as language barriers, limited social networks, cultural differences, health-related beliefs, lack of information, economic constraints, geographical limitations, and other similar reasons [2, 5–7]. However, these findings have limitations in generalizing to the entire foreigner population in Korea, as they are derived from qualitative studies or population surveys. Additionally, one study [2] that utilized administrative data was confined to voluntary enrollees as its study population. Therefore, it is essential to investigate the healthcare utilization patterns of foreigners in Korea following the implementation of the mandatory enrollment policy in 2019. We aimed to investigate healthcare utilization patterns among the entire foreign population in Korea, employing Andersen's behavioral model framework.

Data

For this study, health insurance claims data were utilized. It's worth noting that Korea offers universal healthcare coverage through its national health insurance system [8]. Not only are foreign employees required to enroll in the NHI, but self-employed foreigners who reside in Korea for at least six months are also obligated to do so. The National Health Insurance Service (NHIS) in Korea operates on a third-party payment system, where medical institutions submit medical bills to the NHIS, which manages various databases, including enrollees' socioeconomic information and patients' medical records. Data from foreign beneficiaries enrolled in 2022 were analyzed, resulting in a sample of 1,386,329 individuals after excluding those with missing values or outliers.

Measurement

The dependent variable was represented by separate dummy variables for healthcare utilization, distinguishing between inpatient and outpatient services. A value of 1 indicated the use of the respective service, while a value of 0 indicated non-utilization. The hospitalization period and the duration of doctors' visits were represented by continuous variables, measured in days. Similarly, the total payment for hospitalization and outpatient services was represented by continuous variables, measured in Korean won.

The selection of variables was guided by Andersen's behavioral framework. Firstly, the predisposing characteristics considered were sex, age, and nationality. The nationality category included China, Vietnam, Uzbekistan, USA, Japan, Canada, and Taiwan, with each nationality selected based on its ranking in at least one of the following factors: the number of enrollees, total amount of medical payment, and medical bill per person.

The enabling characteristics considered included insurance premium ranking, residency status, resident period, place of residence, and insurance beneficiary type. The insurance premium ranking serves as an indicator of one's economic status, ranging from 1 for the lowest to 4 for the highest level, determined based on factors such as income and wealth. Residency status was classified into six groups based on ranking: overseas Korean, low-skilled employment, permanent residency, student, marriage, and other categories. Overseas Korean refers to individuals who acquired Korean nationality at birth but later acquired foreign nationality, as well as their offspring. Permanent residency refers to individuals who have resided in Korea for a certain period and whose income level is at least equal to the Gross National Income (GNI) per person. Student refers to foreign students enrolled in educational institutions in Korea. Marriage refers to either foreigners married to Korean nationals or individuals raising children born from a marriage to Korean nationals. Low-skilled employment refers to foreign blue-collar workers employed in industries such as manufacturing, construction, agricultural, livestock and fisheries, food and accommodation, and housekeeping services.

The period of residency was determined by calculating the duration between the starting and ending dates based on one’s last residence status in 2022. However, the resident period was limited to a maximum of five years because we tracked data from 2022 back to 2018. Then, the resident period was divided into four groups: less than one year, from one year to less than three years, from three years to less than five years, and more than five years.

The place of residence was divided into two groups due to the concentration of foreigners in Seoul, Incheon, and Gyeonggi Province: Metropolitan area and other areas. The insurance beneficiary type was categorized into four groups: employees, family members of employees, self-employed individuals, and household members of the self-employed.

The need characteristics considered included disability status, the Charlson Comorbidity Index (CCI), and the presence of chronic diseases. CCI was originally developed to predict one-year mortality risk by summing weighted scores (ranging from 1 to 6) assigned to comorbidities present in a patient [9]. For this study, after calculating the score using the Quan algorithm method with data from the past two years, the study sample was divided into two groups: 0 and more than 1 [10].

The presence of chronic diseases was defined if an individual had a medical record of any of the twelve specific diseases within the past two years. These diseases, selected based on the Statistical Year Book on NHIS, include hypertension (I10-I13, I15), diabetes mellitus (E10-E14), heart disease (I05-I09, I20-I27, I30-I52), cerebrovascular disease (I60-I69), malignant neoplasm (C00-C97, D00-D09, D32-D33, D37-D48), liver disease (B18-B19, K70-K77), mental and behavioral disorders (F00-F99, G40-G41), tuberculosis (A15-A16, A19), diseases of the nervous system (G00-G37, G43-G83), disorders of the thyroid gland (E00-E07), chronic kidney disease (N18), and musculoskeletal diseases and arthropathies (M00-M09, M11-M19, M45) [11].

Statistical modeling

For the descriptive statistics of continuous variables, we utilized mean ± standard deviation (SD) and median with interquartile range (IQR) because the median is less sensitive to outliers in skewed distributions, such as medical bills. For categorical variables, we presented the percent distribution of the enrollees. We applied a two-part model to analyze the factors influencing healthcare utilization and the number of foreign enrollees, assuming that the factors affecting utilization and the number differ.

A two-part model is useful when most medical bill values are zero (0) with heterogeneous variance [12]. Therefore, we conducted the analysis in two steps. Firstly, logistic regression was applied to identify the factors affecting healthcare utilization. Then, a generalized linear model with a log link function was applied to individuals who utilized healthcare services, assuming a gamma distribution.

A summary of characteristics from the study population can be found in Table 1. In 2022, male foreigners (52.1%) were enrolled in NHIS more than females (47.9%), and the largest age group among foreigners was 20–34 years old (36.2%). The socially active age group of 20–64 years old comprised the majority of the sample population at 85.1%, with an average age of 39.7 years old. The majority nationality was Chinese, comprising 50.9%, while the most frequent residency status was overseas Korean, comprising 29.9%. The majority duration of residency was more than five years, comprising 42.8%, and 65.8% of the sample population resided in the Metropolitan area. The largest beneficiary type was self-employed individuals, comprising 41.2%, followed by employees, comprising 33.5%. Disabled individuals comprised only 0.4% of the sample population, so the majority of foreign enrollees were non-disabled. Individuals with a CCI score higher than 1 comprised 38.2% of the population, while 32.1% of the study population had at least one chronic disease out of the 12 diseases considered.

Table 1

Descriptive statistics for the study population
Variables			N
Total			1,386,329	(100%)
Predisposing characteristics	Sex	Male	722,845	(52.1%)
	Sex	Female	663,484	(47.9%)
	Age, years	Under 20	97,503	(7.0%)
		20–34	501,559	(36.2%)
		35–49	367,141	(26.5%)
		50–64	311,274	(22.5%)
		65 or older	108,852	(7.9%)
		Mean age	39.7(± 16.7)
	Nationality	China	705,247	(50.9%)
		Vietnam	143,781	(10.4%)
		Uzbekistan	59,157	(4.3%)
		USA	52,226	(3.8%)
		Japan	23,457	(1.7%)
		Canada	16,178	(1.2%)
		Taiwan	14,971	(1.1%)
		ETC.	371,312	(26.8%)
Enabling characteristics	Insurance premium ranking	1Q(low)	221,789	(16.0%)
		2Q	404,062	(29.2%)
		3Q	645,134	(46.5%)
		4Q(high)	115,344	(8.3%)
	Residency status	Overseas Korean	415,040	(29.9%)
		Low-skilled employees	284,394	(20.5%)
		Permanent residency	157,699	(11.4%)
		Foreign students	148,169	(10.7%)
		Marriage	129,526	(9.3%)
		Etc.	251,501	(18.1%)
	Residency period, years	Under 1	148,367	(10.7%)
		1–3	249,042	(18.0%)
		3–5	396,089	(28.6%)
		5 or more	592,831	(42.8%)
	Place of residency	Outside of metropolitan area	474,815	(34.3%)
	Place of residency	Metropolitan area(Seoul, Gyeonggi, Incheon)	911,514	(65.8%)
	Beneficiary type	Employees	464,631	(33.5%)
		Family members of employees	212,514	(15.3%)
		Self-employed	571,011	(41.2%)
		Household members of self-employed	138,173	(10.0%)
Need characteristics	Disability	Non-disabled	1,381,040	(99.6%)
	Disability	Disabled	5,289	(0.4%)
	CCI	0	856,376	(61.8%)
	CCI	1 or more	529,953	(38.2%)
	Chronic disease	None	941,009	(67.9%)
	Chronic disease	Present	445,320	(32.1%)

The average amount of health care utilization of the study population can be found in Table 2. Only 9.2% of the study population used inpatient services during the year, while 77.5% used outpatient services. Among those who used inpatient services, the average duration of hospitalization was 11.7 days, with a median of 4.0 days, and the average total medical bill amounted to $3,206, with a median of $1,409. Among those who used outpatient services, the average duration of an outpatient visit was 13.5 days, with a median of 8.0 days, and the average total medical bill amounted to $565, with a median of $281.

Table 2

Utilization status of medical services of the study sample
Dependent variable			N	(%)
Inpatient services	Utilization	No	1,258,677	(90.8%)
	Utilization	Yes	127,652	(9.2%)
	Hospital stays¹⁾	Mean ± SD	11.7 ± 35.6
	Hospital stays¹⁾	Median (IQR)	4.0 (6.0)
	Costs¹⁾³⁾	Mean ± SD	3,206 ± 7515
	Costs¹⁾³⁾	Median (IQR)	1,409 (2,229)
Outpatient services	Utilization	No	312,639	(22.6%)
	Utilization	Yes	1,073,690	(77.5%)
	Count of visits²⁾	Mean ± SD	13.5 ± 16.3
	Count of visits²⁾	Median (IQR)	8.0 (15.0)
	Costs²⁾³⁾	Mean ± SD	565 ± 1327
	Costs²⁾³⁾	Median (IQR)	281 (560)
¹⁾ only for the hospitalized patients(n = 127,652)
²⁾ only for those utilized outpatient services(n = 1,073,690)
³⁾ 1 USD = 1291.95 KRW (in 2022)

Factors affecting inpatient services

The results of the two-part model analysis for inpatient services can be found in Table 3. The need characteristics, such as disability, CCI, and the presence of chronic disease, significantly influenced the probability of hospitalization, duration of inpatient service, and the total amount of services provided.

Among the predisposing characteristics, females exhibited a higher likelihood of hospitalization compared to males (OR = 1.09), while also experiencing shorter periods (-18%) and paying smaller medical bills (-13%). Compared to the age group younger than 20 years old, individuals aged 20 years and older exhibited a lower likelihood of hospitalization. Additionally, as age increased, medical bills also increased, with this trend being more significant in the age group of 65 years and older.

Compared to individuals of other nationalities, Vietnamese enrollees exhibited a lower likelihood of hospitalization (OR = 0.9), while also experiencing longer periods of hospitalization (+ 7%) and paying larger medical bills (+ 8%). While Taiwanese enrollees did not show a significant likelihood of hospitalization, once hospitalized, they experienced longer periods of hospitalization (+ 58%) and incurred larger medical bills (+ 32%).

Among the enabling characteristics, individuals with a residency status of marriage exhibited a higher likelihood of hospitalization (OR = 1.59), as well as longer hospital stays (+ 7%) and larger medical bills (+ 5%) compared to other residency statuses. Conversely, individuals with a type of low-skilled employees did not show a significant likelihood of hospitalization; however, once hospitalized, they experienced longer hospital stays (+ 26%) and incurred larger medical bills (+ 6%). Overseas Koreans exhibited a higher likelihood of hospitalization (OR = 1.18), as well as longer hospital stays (+ 7%) and larger medical bills (+ 5%).

However, foreign students exhibited a lower likelihood of hospitalization (OR = 0.53), as well as shorter hospital stays (-14%) and smaller medical bills (-19%). When compared to those with less than one year of residency, individuals who resided one year or more but less than three years showed the highest likelihood of hospitalization (OR = 1.9). Furthermore, the odds ratios tend to decrease as the duration of residency increases. As the duration of residency increases, both the length of hospital stays and the amount of medical bills decrease as well.

Compared to employee beneficiaries, family members of employees showed a higher likelihood of hospitalization (OR = 1.33), with longer hospital stays (+ 45%) and larger medical bills (+ 28%). Similarly, household members of self-employed individuals showed a higher likelihood of hospitalization (OR = 1.29), with longer hospital stays (+ 46%) and larger medical bills (+ 32%). While self-employed individuals did not show a significant likelihood of hospitalization, once hospitalized, they experienced longer periods of hospitalization (+ 42%) and incurred larger medical bills (+ 24%).

Table 3. Result of two-part model analysis of inpatient services

Variable		1^stpart		2^nd part
		Utilization		Hospital stays		Costs
		β	odds	β	exp(β)	β	exp(β)
		β	ratio	β	exp(β)	β	exp(β)
Sex (ref.=male)	Female	0.087*	1.09	-0.197*	0.82	-0.144*	0.87
Age (ref.=under 20)	20-34	-0.387*	0.68	-0.035	0.97	0.161*	1.17
	35-49	-0.586*	0.56	0.006	1.01	0.242*	1.27
	50-64	-0.525*	0.59	0.163*	1.18	0.419*	1.52
	65 or older	-0.201*	0.82	0.790*	2.2	0.723*	2.06
Nationality (ref.=etc.)	China	0.031	1.03	-0.004	1	0.012	1.01
	Vietnam	-0.110*	0.9	0.067*	1.07	0.080*	1.08
	Uzbekistan	0.179*	1.2	-0.025	0.98	0.066	1.07
	USA	-0.141*	0.87	-0.088*	0.92	0.001	1
	Japan	-0.179*	0.84	0.046	1.05	0.110*	1.12
	Canada	-0.163*	0.85	-0.089	0.92	0.054	1.06
	Taiwan	-0.112	0.89	0.457*	1.58	0.277*	1.32
Insurance premium rank (ref.=1Q)	2Q	0.028	1.03	-0.031	0.97	-0.014	0.99
	3Q	0.031	1.03	-0.082*	0.92	-0.025	0.98
	4Q	0.024	1.02	-0.192*	0.83	-0.079*	0.92
Residency status (ref.=etc.)	Overseas Korean	0.163*	1.18	0.065*	1.07	0.049*	1.05
	Low-skilled employment	-0.046	0.95	0.235*	1.26	0.060*	1.06
	Permanent residency	0.219*	1.24	-0.037	0.96	-0.016	0.98
	Student	-0.638*	0.53	-0.157*	0.86	-0.215*	0.81
	Marriage	0.466*	1.59	-0.078*	0.93	0.053*	1.05
Residency period (ref.=under 1 year)	1-3	0.330*	1.39	-0.113*	0.89	-0.409*	0.66
	3-5	0.119*	1.13	-0.065*	0.94	-0.394*	0.67
	5 or more	0.017	1.02	-0.164*	0.85	-0.531*	0.59
Place of residency (ref.=outside)	Metropolitan area	-0.026	0.97	-0.147*	0.86	-0.005	1
Beneficiary type (ref.=employees)	Family members of employees	0.285*	1.33	0.369*	1.45	0.243*	1.28
	Self-employed	-0.013	0.99	0.354*	1.42	0.211*	1.24
	Household members of self-employed	0.258*	1.29	0.379*	1.46	0.279*	1.32
Disability (ref.=none)	Disabled	0.748*	2.11	1.447*	4.25	0.975*	2.65
CCI (ref.=0)	1 or more	0.878*	2.41	0.276*	1.32	0.379*	1.46
Chronic disease (ref.=none)	Present	0.692*	2	0.463*	1.59	0.532*	1.7

* p < 0.0001

Factors affecting outpatient services.

The results of the two-part model analysis for outpatient services can be found in Table 4. Among the predisposing characteristics, females exhibited a higher likelihood of using outpatient services compared to males (OR = 1.66), with longer periods (+ 30%) and larger medical bills (+ 31%). As age increases, individuals tend to have a lower likelihood of clinic visits compared to the age group younger than 20 years old. Furthermore, while the duration of outpatient services tends to increase with age, it is noteworthy that the longest durations were observed in individuals younger than 20 years old. Compared to individuals younger than 20 years old, those aged 50 to 64 years old tend to spend larger medical bills (7%), while those aged 65 years and older spend even larger amounts (43%).

Compared to individuals of other nationalities (the reference group), such as Vietnamese, Chinese, Uzbekistani, American, and Canadian enrollees exhibited a higher likelihood of using outpatient services, longer duration, and higher medical bills. However, Vietnamese enrollees exhibited a lower likelihood of using outpatient services (OR = 0.9), with a shorter period (-7%) and smaller medical bills (-5%). Among the predisposing characteristics, females exhibited a higher likelihood of using outpatient services compared to males (OR = 1.66), with longer periods (+ 30%) and larger medical bills (+ 31%). As age increases, individuals tend to have a lower likelihood of clinic visits compared to the age group younger than 20 years old. Furthermore, while the duration of outpatient services tends to increase with age, it is noteworthy that the longest durations were observed in individuals younger than 20 years old. Compared to individuals younger than 20 years old, those aged 50 to 64 years old tend to spend larger medical bills (7%), while those aged 65 years and older spend even larger amounts (43%).

Compared to individuals of other nationalities, such as etc. nationality (the reference group), Chinese, Uzbekistani, American, and Canadian enrollees exhibited a higher likelihood of using outpatient services, longer duration, and higher medical bills. However, Vietnamese enrollees exhibited a lower likelihood of using outpatient services (OR = 0.9), with a shorter period (-7%) and smaller medical bills (-5%).

Among the enabling characteristics, individuals with higher rankings of insurance premium exhibited a greater likelihood of using outpatient services for longer durations and incurring larger medical bills compared to those with the lowest rankings. Individuals with residency statuses of marriage, overseas Korean, and permanent residency exhibited a higher likelihood of using outpatient services for longer durations and incurring larger medical bills compared to the reference group (etc.). While individuals classified as low-skilled employees and foreign students exhibited a lower likelihood of using outpatient services for shorter durations and incurring smaller medical bills. Individuals residing in Metropolitan areas were more likely to use outpatient services (OR = 1.04) for longer durations (+ 6%) and incur larger medical bills (+ 13%) compared to those residing outside of Metropolitan areas. Compared to employee beneficiaries, family members of employees showed a higher likelihood of using outpatient services (OR = 1.12), with longer durations (+ 7%) and larger medical bills (+ 14%). Meanwhile, self-employed individuals were less likely to use outpatient services (OR = 0.42), with shorter durations (-5%) and smaller medical bills (-1%).

Among the need characteristics, individuals with a CCI greater than 1 and chronic diseases were more likely to use outpatient services for longer durations and incur larger medical bills compared to those without them. While disabled individuals were less likely to use outpatient services (OR = 0.77), once they used them, they tended to use them for longer durations and spend more on medical bills compared to non-disabled individuals.

Table 4

Result of two-part model analysis of outpatient services
Variable		1st part		2nd part
		Utilization		Count of visits		Costs
		β	odds ratio	β	exp(β)	β	exp(β)
Sex (ref.=male)	Female	0.504*	1.66	0.261*	1.3	0.272*	1.31
Age (ref.=under 20)	20–34	-0.554*	0.57	-0.553*	0.58	-0.018	0.98
	35–49	-0.697*	0.5	-0.545*	0.58	-0.052*	0.95
	50–64	-0.714*	0.49	-0.400*	0.67	0.066*	1.07
	65 or older	-1.255*	0.29	-0.236*	0.79	0.361*	1.43
Nationality (ref.=etc.)	China	0.318*	1.37	0.257*	1.29	0.199*	1.22
	Vietnam	-0.104*	0.9	-0.074*	0.93	-0.053*	0.95
	Uzbekistan	0.051*	1.05	0.088*	1.09	0.123*	1.13
	USA	0.241*	1.27	0.214*	1.24	0.255*	1.29
	Japan	-0.015	0.99	0.083*	1.09	0.132*	1.14
	Canada	0.475*	1.61	0.239*	1.27	0.264*	1.3
	Taiwan	-0.033	0.97	0.217*	1.24	0.186*	1.2
Insurance premium rank (ref.=1Q)	2Q	0.322*	1.38	0.017*	1.02	0.006	1.01
	3Q	0.134*	1.14	0.019*	1.02	0.011	1.01
	4Q	0.274*	1.31	0.041*	1.04	0.045*	1.05
Residency status (ref.=etc.)	Overseas Korean	0.572*	1.77	0.079*	1.08	0.107*	1.11
	Low-skilled employment	-0.051*	0.95	-0.092*	0.91	-0.121*	0.89
	Permanent residency	0.780*	2.18	0.161*	1.17	0.147*	1.16
	Student	-0.273*	0.76	-0.143*	0.87	-0.163*	0.85
	Marriage	1.043*	2.84	0.215*	1.24	0.262*	1.3
Residency period (ref.=under 1 year)	1–3	1.073*	2.92	0.394*	1.48	0.327*	1.39
	3–5	1.075*	2.93	0.409*	1.5	0.300*	1.35
	5 or more	1.237*	3.44	0.478*	1.61	0.349*	1.42
Place of residency (ref.=outside)	Metropolitan area	0.039*	1.04	0.059*	1.06	0.122*	1.13
Beneficiary type (ref.=employees)	Family members of employees	0.114*	1.12	0.070*	1.07	0.130*	1.14
	Self-employed	-0.869*	0.42	-0.053*	0.95	-0.013*	0.99
	Household members of Self-employed	0.021	1.02	0.041*	1.04	0.070*	1.07
Disability (ref.=none)	Disabled	-0.350*	0.7	0.489*	1.63	1.207*	3.34
CCI (ref.=0)	1 or more	2.084*	8.04	0.507*	1.66	0.560*	1.75
Chronic disease (ref.=none)	Present	1.839*	6.29	0.540*	1.72	0.611*	1.84
* p < 0.0001

This study investigated factors influencing healthcare utilization, including both inpatient and outpatient services, for foreign beneficiaries of NHI in Korea by employing Andersen's behavioral model framework. The results showed that need characteristics, such as disability, CCI, and chronic disease, were the most influential factors for both inpatient and outpatient services.

More specifically, individuals aged 65 years and older were less likely to use healthcare services, but once they utilized them, they tended to spend more on medical bills. Senior foreigners appear to face greater barriers in accessing healthcare services compared to the younger generation, as they may experience dual challenges associated with aging and being foreigners. Therefore, as the population of senior foreigners in Korea is expected to grow in the near future [2], access to healthcare services for them needs to be improved so that they can treat their symptoms early enough.

Female foreigners tended to utilize both inpatient and outpatient services more frequently than males, whereas males had longer inpatient stays and higher medical bills. This suggests that females may seek medical attention more proactively, potentially averting serious illnesses. This aligns with prior research indicating higher healthcare utilization among females without an associated increase in medical expenses [7]. Variations in healthcare utilization by sex among foreign employees may stem from differences in workplace environments. Statistics Korea reports that male foreign workers are more prevalent in industries such as mining, manufacturing, and construction, where they face heavier labor burdens and higher risks of work-related injuries and mortality [13] compared to females, who are more commonly employed in wholesale/retail, food, and accommodation sectors [14].

Vietnamese individuals exhibited a lower propensity for using both inpatient and outpatient services; however, once hospitalized, they showed prolonged stays and incurred higher medical expenses. This phenomenon can be attributed to Vietnam’s cultural context, characterized by limited healthcare access, high medical costs, and substantial out-of-pocket payments, particularly after the privatization of Vietnam's healthcare system [15, 16]. Vietnamese wives residing in Korea tend to visit pharmacies rather than doctor’s office, further indicating cultural influences on healthcare-seeking behavior [17].

The length of residency significantly influences outpatient service utilization among enabling characteristics. Longer residency is associated with increased outpatient service usage and higher medical expenses. Conversely, longer residency negatively affects inpatient service utilization, resulting in reduced medical costs. Residency duration reflects foreign residents’ adaptation to Korean culture, with longer residency indicating better integration [18]. Therefore, greater integration correlates with higher healthcare service utilization, facilitating access to outpatient services and potentially preventing severe illness requiring hospitalization.

Residency status such as overseas Koreans, permanent residents, and marriage are associated with increased utilization of outpatient services, longer durations, and higher medical expenses. This trend extends to inpatient services. Permanent residency is typically granted to foreigners residing for at least 5 years with income surpassing a certain threshold. Overseas Korean status is granted to those who acquired foreign nationality after being Korean or to descendants of Korean nationals living abroad, though proficiency in Korean is required for eligibility.

Extended residency, elevated income, and proficient language abilities signify enhanced assimilation into Korean culture, leading to greater healthcare access. Marriage residency is awarded to those wedded to Korean nationals or raising children from such marriages, with pregnancy and delivery-related healthcare needs comprising a notable portion of their requirements. Moreover, marriage facilitates foreign spouses' adaptation and integration into Korean society, streamlining their access to healthcare services.

Low-skilled employees usually exhibit reduced demand for general health check-ups or treatment, primarily due to their youth and overall good health [19]. Similarly, foreign students tend to have lower healthcare service demand as they are typically in their twenties, a life stage associated with decreased healthcare needs across the lifespan [7].

Another notable factor among enabling characteristics was beneficiary type. Family members of employees and household members of self-employed individuals exhibited a heightened likelihood of utilizing both inpatient and outpatient services, leading to extended durations and increased medical expenses. However, family members of employees had a more pronounced effect on duration and medical costs compared to household members of the self-employed. This discrepancy can be attributed to eligibility differences between the two groups: household members of the self-employed are restricted to spouses and underage children, whereas family members of employees can include parents and siblings.

While this study delved into factors impacting healthcare utilization among foreign beneficiaries using Andersen's behavioral model framework, there are several limitations to acknowledge. Firstly, certain crucial factors such as Korean proficiency and social network were not accounted for in the insurance claims data. Secondly, the analysis was limited to a one-year timeframe, preventing a comprehensive understanding of utilization patterns.

It is worth noting that the study utilized total administrative data from the implementation of the mandatory enrollment policy for foreigners residing at least six months, thus representing the entire population of foreign beneficiaries. Additionally, by separately examining the likelihood and extent of healthcare service utilization, the results offer valuable insights into the healthcare behavior of foreigners, particularly given the expected growth of the foreign population in Korea.

NHI National Health Insurance

NHIS National Health Insurance Service

GNI Gross National Income

CCI Charlson Comorbidity Index

SD standard deviation

IQR interquartile range

OR odds ratio

Ethics approval and consent to participate

Approval for this research was obtained from the Institutional Review Board of National Health Insurance Service, approval number 2023-HR-06-001. Given that the study involved secondary data analysis with all personal identifiers removed, the need for informed consent was waived. The study methods were performed in full compliance with the relevant ethical standards and guidelines.

Consent for publication

Not applicable.

Availability of data and materials

The data that support the findings of this study are available from National Health Insurance Service – National Health Information Database (NHIS – NHID), but restrictions apply to the availability of these data, which were used under license for the current study and so are not publicly available. The data are, however, available from the authors upon reasonable request and with the permission of NHIS.

Competing interests

None.

Funding

None.

Author’s contributions

Both authors contributed equally to conceiving the study, analyzing the data, and writing this paper.

Acknowledgements

None.

Kwon S. Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage. Health Policy Plan. 2009;24(1):63-71.
Byeon J, Cho J, Lee J, Lee J. Health Care Utilization of Foreigners Entitled National Health Insurance Service of Korea. Korea Social Policy Review. 2019;26(4):83-100.
Paek Y, Koh M. Embracing Migrants into the Public Medical System : the Involution of Migration Infrastructure in South Korea. Journal of The Korean Association of Regional Geographers. 2022;28(2):183-99.
In 2022, Korea hosted 2,245,912 foreign residents, with only 59.8% (1,343,172) registered under the NHI according to Ministry of Justice Korea and National Health Insurance Service.
Lee BS, Oh IK, Lee EM. Foreign residens't experience of Korean health care services. Journal of Korean academy of nursing administration. 2011;17(2):226-37.
Kim S. The conception and factors that affect the utilization of health care services among foreign migrant workers in Korea. Journal of Multi-Cultural Contents Studies. 2015;18:255.
Lee D, Kim K, Kwon S. The Determinants of Health Care Utilization of International Students in Korea. The Korean Journal of Health Economics and Policy. 2021;27(2):121.
Kyoung D-S, Kim H-S. Understanding and Utilizing Claim Data from the Korean National Health Insurance Service (NHIS) and Health Insurance Review & Assessment (HIRA) Database for Research. J Lipid Atheroscler. 2022;11(2):103-10.
Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis. 1987;40(5):373-83.
Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi J-C, et al. Coding Algorithms for Defining Comorbidities in ICD-9-CM and ICD-10 Administrative Data. Med Care. 2005;43(11):1130-9.
National Health Insurance Service. National Health Insurance Statistical Yearbook 20222023.
Diehr P, Yanez D, Ash A, Hornbrook M, Lin DY. Methods for analyzing health care utilization and costs. Annu Rev Public Health. 1999;20(1):125-44.
Kim J-D, Yu Y-S, Go B-S, Yang W-B. A Study on the Analysis and Countermeasures of Industrial Accident Deaths of Foreign Workers in the Manufacturing Industry. Journal of the Korea Safety Management & Science. 2023;25(2):39-48.
Statistics Korea. 2023 Survey on Immigrants' Living Conditions and Labor Force2023.
Ramesh M. Health Care Reform in Vietnam: Chasing Shadows. Journal of contemporary Asia. 2013;43(3):399-412.
OECD, Organization WH. Health at a Glance: Asia/Pacific 20202020.
Chun J-Y. A Phenomenological Research on the View of Health Among Vietnamese Immigrant Women in Korean Urban Areas. Journal of Convergence Consilience. 2023;6(2):217-36.
Yang PQ, Hwang SH. Explaining Immigrant Health Service Utilization: A Theoretical Framework. SAGE open. 2016;6(2):215824401664813.
Morris S, Sutton M, Gravelle H. Inequity and inequality in the use of health care in England: an empirical investigation. Soc Sci Med. 2005;60(6):1251-66.

No competing interests reported.

Download PDF

Editorial decision: Revision requested
02 Sep, 2024
Reviews received at journal
30 Aug, 2024
Reviewers agreed at journal
07 Aug, 2024
Reviews received at journal
23 Jul, 2024
Reviewers agreed at journal
23 Jul, 2024
Reviewers invited by journal
22 Jul, 2024
Editor invited by journal
11 Jul, 2024
Editor assigned by journal
10 Jul, 2024
Submission checks completed at journal
10 Jul, 2024
First submitted to journal
08 Jul, 2024

You are reading this latest preprint version

Factors affecting healthcare utilization among foreign beneficiaries of national health insurance in Korea

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Results

Factors affecting inpatient services

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Author’s contributions

Acknowledgements

References

Additional Declarations

Status:

Version 1