Clin Orthop Surg.  2023 Apr;15(2):241-248. 10.4055/cios21214.

Evaluation of Appropriateness of the Reimbursement Criteria of Korean Health Insurance Review and Assessment Service for Total Knee Arthroplasty

• Kim DH
• Jeong SY
• Yang JH
• Choi CH

• KMID: 2540443
• DOI: http://doi.org/10.4055/cios21214

Abstract

Background
We evaluated and compared South Korea’s total knee arthroplasty (TKA) reimbursement criteria set by Health Insurance Review and Assessment Service (HIRA) with other TKA appropriateness criteria to find additional criterion to improve its appropriateness by reviewing TKA inappropriate cases.
Methods
Two TKA appropriateness criteria and HIRA’s reimbursement criteria for TKA were adapted for use on patients undergoing TKA in one institute from December 2017 to April 2020. Preoperative data including 9 validated questionnaires on knee jointspecific parameters, age, and radiography were used. We categorized cases into appropriate, inconclusive, inappropriate groups and analyzed each group.
Results
Data on 448 cases that underwent TKA were examined. According to the HIRA’s reimbursement criteria, 434 cases (96.9%) were appropriate and 14 cases (3.1%) were inappropriate; superior to other TKA appropriateness criteria. The inappropriate group had Knee Injury and Osteoarthritis Outcome score (KOOS) pain, KOOS symptoms, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, and Korean Knee score total score with worse symptoms compared to the appropriate group classified by HIRA’s reimbursement criteria.
Conclusions
In terms of insurance coverage, HIRA’s reimbursement criteria was more effective in providing healthcare access to patients who had the most pressing need for TKA compared to other TKA appropriateness criteria. However, we found the lower age limit and patient-reported outcome measures of other criteria as useful tools in improving appropriateness of the current reimbursement criteria.

Keyword

Health insurance reimbursement; Appropriateness review; Total knee arthroplasty