Abstract
Due to a worldwide paradigm shift from a medical-centered system to patient-centered care, there is a need to recognize actual (practical) medical service from laypeople. In South Korea, intrinsic healthcare use characteristics such as the “Herd Behavior” have led to waiting many hours for a short treatment time at metropolitan-based major hospitals. Illustrating individual perceptions of an ideal healthcare system should take precedence when defining this issue. This study aimed to explore and describe laypeople in South Korea’s perceptions of ideal healthcare services based on their utilization of medical services. This qualitative study was conducted with 13 members of the National Participation Committee using semi-structured interviews. Qualitative data were analyzed using the thematic analysis method and visualized through a word cloud generated with MAXQDA software. Six themes were derived from the visualized words and an incremental analysis to explore perceptions of desirable medical services. Participants struggled to find a suitable hospital without expert guidance and felt objectified for their money. They distrusted and didn’t want to speak in front of medical professionals. They wanted their essential needs to be met regardless of their economic status. This study provides a description portrait of laypeople’s experiences related to healthcare services in South Korea, where medical services are predominantly provided by private hospitals with public insurance coverage. Users’ desire for tailored information through an integrated medical system that has a strong emphasis on people-centeredness must be embraced.
Plain Language Summary
In the shift towards patient-centered care, understanding the views of ordinary people regarding healthcare services is vital. In South Korea, characteristics like following the crowd have led to long wait times at major hospitals. This study aimed to explore how ordinary people perceive ideal healthcare services based on their experiences. Thirteen members of the National Participation Committee were interviewed, and thematic analysis was used to analyze the data. Six themes emerged, revealing participants’ struggles in finding suitable hospitals without guidance, feeling objectified based on their financial worth, and lacking trust in and hesitating to communicate with medical professionals. They also emphasized the importance of having their essential needs met regardless of their economic status. The study provides insights into ordinary people’s experiences with healthcare in South Korea, where private hospitals are predominant and public insurance coverage exists. The findings emphasize the desire for tailored information and an integrated medical system focused on people-centered care. It is important to consider these perspectives to improve healthcare and meet the population’s needs.
Keywords
Background
The World Health Report, published by the World Health Organization (WHO, 2000), noted that responding to public expectations of the healthcare system is a socially important goal. Furthermore, prioritizing patients’ experiences and perceptions of health services is the first task in improving the quality of healthcare. This was presented as an essential factor in achieving patient-centered care (Organization for Economic Co-operation and Development [OECD], 2010).
In line with a paradigm shift towards patient-centered care, rather than an approach that focuses on medical institutions or medical staff, the Ministry of Health and Welfare in South Korea (hereafter, Korea) has established a basis for a patient-centered healthcare system, and the first “Patient Experience Assessment” was conducted in 2017. This was a large-scale survey of 10,000 participants over the age of 15 who had experienced medical services delivery and were selected by the stratified sampling method. The survey attempted to investigate respondents’ experiences beyond their current medical use (Hwang & Kim, 2018). Although these attempts reflected an effort to minimize the limitations of quantitative data, the measurement items were not able to show meaningful results except for waiting time, the kindness of the hospital staff, and satisfaction ratings. This implies that satisfaction with medical services is inherently difficult to quantify.
It is difficult to obtain thorough answers via quantitative surveys that measure phenomena from a positivist perspective. If satisfaction is measured using a Likert scale, patients are likely to report their satisfaction unless there are unusual circumstances (Carr-Hill, 1992; Crow et al., 2002). Thus, a high level of satisfaction does not equate to actual satisfaction. When there is no apparent dissatisfaction, a respondents’ selection of “satisfied” on a questionnaire cannot be interpreted as an actual measurement of satisfaction. The questionnaire format has inherent limitations when standardized results are interpreted. Patients’ satisfaction with medical services has nuanced attributes that cannot be easily quantified.
“Herd behavior” is a commonly used term in the health and medical field describing the characteristics of healthcare use in Korea, especially the pattern of a disproportionate number of patients seeking care at the “Big 5” hospitals in the major metropolitan area (Cho et al., 2019). Excluding rare and intractable diseases, tertiary hospitals accounted for more than 50% of health insurance medical expenditures for cancer, cerebrovascular, and heart disease and 60% of non-insurance-covered health service expenditures for cancer patients from 2006 to 2010 (Crow et al., 2002). The high proportion of expenditures in a small number of extra-large hospitals compared to the spending in other hospitals implies a low level of regional self-sufficiency for inpatient care services.
When patients travel to major metropolitan areas from suburban or rural areas to use a medical institution, they incur fatigue and travel-related expenses. Moreover, the average actual time with the doctor at tertiary hospitals was only 4.2 min, while the average waiting time at outpatient clinics was 20.8 min (Carr-Hill, 1992). Therefore, this phenomenon involves patients using large or specialized hospitals despite waiting a long time and being inconvenienced. As this issue has rarely been discussed in-depth from a public health or sociological perspective, how patients or users perceive an ideal healthcare system must be explored.
Individuals’ perceptions of an ideal healthcare system are challenging to elicit and conceptualize as healthcare system use cannot be adequately revealed through simple surveys and analyses of fragmentary episodes. Medical use and the doctor-patient relationship encompass cultural, social, and institutional aspects. Research should be conducted to capture patient perspectives in the context of the social environment in Korea.
Methods
Aim
The purpose of this study was to holistically explore a desirable medical system, and patient-centered perceptions of healthcare. This study aimed to analyze the attributes of the ideal medical system through interviews in the context of the Korean medical system.
Research Question
The main research question was “What are the desirable aspects of medical services that users hope to experience?” We explored the lay public’s thinking patterns and perceptions regarding medical use and desire for healthcare services in Korea’s unique sociocultural context and institutional background. The paradigm underlying this study is symbolic interaction, in other words, the main research question is how to implement the desired healthcare system in the light of the medical use experience so far within the context of the social environment to which the participants belong.
Participants
In qualitative research, it is important to select participants who can provide rich information about their experiences (Hennink & Kaiser, 2022). Participants who could express their relevant experiences vividly were selected using purposive sampling.
Interviews were conducted with members of the Citizen Council for Health Insurance, who were expected to have a significant interest in the healthcare system. The citizen council for health insurance, operated by the National Health Insurance Service (NHIS), is a public participation system that presents the public’s opinions on the health insurance system and plans to strengthen insurance coverage. This study was introduced to the 90 members who attended the eighth National Participation Committee. It excludes interested parties such as private insurance workers, public insurance workers, medical supply experts, other hospital workers and related workers, etc. to collect the opinions of the general public. A brief explanation of the study and participation method are notified by sending a notice of participation by e-mail to all “Citizen Council for Health Insurance,” and then applicants who wish to participate in the interview are selected. A total of 13 participants were willing to voluntarily participate when the purpose of the study and the method of participation were explained orally and in writing. All 13 people were included in the study. Group interviews were conducted four times according to the schedules of the participants as much as possible. However, one individual interview was conducted for a participant whose schedule did not fit.
In total, 13 members of the National Participation Committee participated in the study from September 8th to 11th, 2018. Face-to-face interviews were conducted for 60 to 90 min over five sessions: one individual interview and four focus group interviews (FGI).
Table 1 provides a summary of the gender, age, residential area of the 13 interview participants. The age of the participants was evenly distributed from the 20s to 60s, and the distribution of residential areas was to cover the whole country, including S-metropolitan, G-province, K-city, J-province, D-city, and C-province. The participants were graduate students, housewives, office workers, counselors, and corporate presidents, corresponding to various occupational groups.
Overview of the Interview Participants.
Note. IDI = individual interview; FGI = focus group interview.
Data Generation
Semi-structured interviews were held in a seminar room at a medical school, and each interview took about 1 hr to 1.5 hr. About 10 min before each interview participants used a pre-distributed notepad to draft their thoughts on the factors and characteristics of “Good doctors,”“Hospitals I would prefer to visit,” and “A desirable medical system.” Thus, participants were allowed to organize their thoughts before the interview.
Before asking about the ideal medical system, the interview questions assessed the characteristics of an optimal hospital and a good doctor. We first talked about good and not good hospital experiences, the characteristics of a doctor one would want to see, and the attributes of a hospital one would want to go based on the interviewees’ experiences.
The study explored the contours of what participants considered to be a desirable medical system by starting with their recent experiences of hospital use. In the Korean context, this is a commonly accepted question that was familiar to the patients. Next, the interview prompted them to elaborate on their thoughts. The main interview questions were constructed after a discussion between a medical school professor and an individual with a doctorate in nursing. The two researchers have previously conducted qualitative research together and published their study in a journal article. The interviewer acted as a facilitator during the focus group interview (FGI) process and maintained field notes. The researchers held meetings once every 2 weeks, and the interviews were stopped when data saturation was reached. The researchers decided the exit point at which observing more data was not led to discovery of more information related to research question. Finally, member-checking was conducted for those who participated in the interview.
All interviews were conducted in Korean. Transcription was conducted by the main researcher. Afterwards, in order not to lose nuance in the process of analyzing the data and deriving the results, a nursing professor who attended school in the US and worked in a hospital, who is fluent in both English and Korea, translated the data.
Ethical Considerations
This research was approved by the Hospital Biomedical Research Institute (IRB No. 1803-066-929) on January 31st, 2018. The purpose of this study was explained to all interviewees before the interview. Written consent for the recording of the interview was obtained. After the interview, the recorded audio file was transcribed. The researcher used the transcripts only as research data, and in the process of writing the transcripts, the interview data were coded so they could not be traced to an individual.
Data Analysis
In this study, thematic analysis was the main data analysis method, and descriptive content analysis using word frequency was partially performed for triangulation verification. In addition to subject analysis, which is a traditional method, various attempts have recently been made through digital representations (Corti et al., 2016), so a method of visualizing qualitative data was also attempted at the same time. These new attempts were accompanied by the process of quantifying qualitative data. We tried not to be overwhelmed by the numbers trapped in positivism, the paradigm that is the basis of the qualification process. Researchers focused on revealing the participant’s voice rather than superficial facts in the process of finally agreeing on the research results.
In recent years, studies have attempted to conduct word cloud analyses using text network analysis, which quantitatively analyzes text data (Park, 2020; Pokorny et al., 2018). This analytical tool enables an intuitive understanding by expressing relative weights using font sizes in an image. To generate a word cloud from the transcribed qualitative data, a morphological analysis of word forms with meanings rather than word units is required; therefore, postpositions, exclamations, and meaningless repetitive phrases were deleted. The refined data were entered into MAXQDA, a qualitative data analysis program, and frequency analysis was performed using only words that appeared twice or more using the word cloud function.
Qualitative thematic analysis is a method of extracting concepts from detailed descriptions of phenomena, rearranging the relationships between each concept, and finally deriving a central theme by inductively describing the relevant phenomenon (Braun & Clarke, 2006). Data analysis was done using MAXQDA, faithfully open-coding, and applying clustering procedures. Final themes were derived after dividing the data into semantic units and combining common attributes again. The results of the qualitative research provide in-depth insight into a specific phenomenon considering the overall situational context. This study revealed the situational context for theme extraction. (Table 2).
Emerged Themes on the Ideal Health System from Laypeople.
Results: Thematization and Visualization of the Ideal Medical System
The process of deriving the results of this qualitative study involved the incremental stages of description, analysis, and interpretation. The results of the word cloud visualization and thematic analyses were described and interpreted concerning theories explaining the use of medical care and previous studies.
Frequency Analysis and Visualization by Area
The content of the five interviews conducted with 13 members of the National Participation Committee was divided into three areas: “Hospitals I would prefer to visit,”“Good doctors,” and “Preferred healthcare system.” A word cloud image was created to visualize words after frequency analysis.
The results of the first area, “Hospitals I would prefer to visit,” are shown in Figure 1. The most common word that appeared in this part of the interviews was “big” (12 times), followed in order by “patient” (eight times), “talk” (six times), “person” (five times), and “local” (five times), accounting 18.8% of the total. The interviewees said that they used a nearby hospital for minor illnesses, but they preferred a “big” hospital when they were seriously ill. Participants often did not know which hospital they should go to, but if a lot of other people used a certain hospital, they would perceive it as appropriate. In addition, respondents wanted hospitals to prioritize patients, provide patients with a place to rest, and sincerely listen to patients.
Results of word cloud analysis: hospitals people prefer to visit.
In terms of physical accessibility, respondents stated that people who live in the “countryside” have fewer options than those who live in S-city, so they often go to hospitals in S-city Respondents indicated that the countryside was inadequate for older individuals or as a second home.
The second analyzed theme was “Good doctors,” and the results of the word cloud analysis are shown in Figure 2. In this theme, the most commonly extracted word was “kindness” (19 times), followed by “explanation” (17 times), “patient” (13 times), and “trust” (12 times). The four words accounted for 24.2% of the extracted words. These findings confirm that personal characteristics and qualities took precedence in the characteristics of a good doctor, in particular, “kindness,”“explanation,” and “trust.”
Results of word cloud analysis: good doctors.
Finally, the results of the word cloud analysis of the desirable medical system are shown in Figure 3. The five most frequent words (“national,”“regulation,”“program,”“need,” and “benefit”) all appeared seven times, followed by “health insurance,”“benefit,”“linkage,” and “physician training system,” which appeared five to six times. These nine words accounted for 29.4% of the total.
Results of word cloud analysis: desirable healthcare system.
Regarding the desirable medical system, the words “direction” and “values” were prominently expressed. Respondents indicated that it was “necessary” for the “nation” to be more actively involved in the provision, management, and regulation of essential medical services and to provide practical “programs in the long-term perspective.” Opinions were divided regarding whether policies should be implemented universally or if they should prioritize those who need benefits more urgently according to income and disease severity. No definitive conclusions on this issue were reached during the interviews.
Healthcare respondents hoped that health insurance coverage would be expanded and treatments carried out individually at each hospital would be integrated. The interviewees indicated that hospitals did not treat patients in an integrative manner, which could be resolved with a primary healthcare system. Treatment could be linked if patients’ medical and family histories could be incorporated into the primary healthcare system.
Thematic Analysis
Adventure to Find Fancy Medical Services
As respondents linked their symptoms to a disease, they sought new treatment methods or hospitals. This process was like a patient or caregiver embarking upon a new adventure in the absence of an appropriate guide. To minimize the risk, they thought it would be more reliable to visit a familiar or frequently used hospital. In the Korean medical system, the process of searching for information about hospitals is a patient responsibility.
Some people went through the process of visiting hospitals near their residences, identifying the medical department related to their symptoms by guesswork, or remembering hospitals close to home. Those who prepared meticulously in advance pre-identified the hospital they wanted to use by scrutinizing the attitudes of medical staff and the flow of hospital services while visiting the hospital with their family members or acquaintances. In addition, participants became familiar with the names of specialized fields and information on specialized hospitals through the mass media or social networking services (SNS) and learned about the hospitals’ reputations and gathered anecdotal information from acquaintances. Additionally, a new service provides outpatient appointments for tertiary hospitals.
Gap Between the Information That I Have and What I Need
As the internet and SNS are widely used, patients can obtain a lot of information by searching blogs and personal websites before going to the hospital. A participant described spending 3 days and 2 nights looking for information while contemplating which hospital to visit for her father-in-law’s illness. The participant said that she could find detailed information about medical expenses, doctors’ reputations, and hospital equipment through internet searches. However, the information obtained in this way is limited because it is not generally applicable, since each patient has a unique disease progression and condition.
Last year, one of my relatives had a severe illness—cancer—so I could feel it my bones for the first time in my life. I didn’t have anyone who had cancer on my mother’s or my father’s side of the family. I didn’t know anything about it because it was my first time seeing it. First, I had to find a hospital, so I went online for two nights and three days, then I was able to find all the information; the most experienced doctor in surgery, the most trusted hospital, the duration of waiting time, which steps to take to get admitted, all of this information was all over the internet. (Interview participant #13, Female, 50s)
Shortcut to Large Hospitals: Personal Connection
The interviewees thought they would eventually need to go to a tertiary general hospital for treatment due to painful symptoms, so visiting a large hospital in the first place would ultimately save time and money. That is, presenting to a small hospital for treatment is likely to result in a referral to a large hospital, it would be better to save time and money by going to a larger hospital upon first recognizing their symptoms.
If you go to a small hospital, they tell you to go to a bigger hospital. You end up going to a university hospital. It is exhausting and I spend all my money and time. I think it’s better just to go to a big hospital in the first place (Interview participant #9, Male, 50s)
Respondents living in the provinces said there was a difference in the quality of medical services and diagnostic and treatment methods provided in the major metropolitan area and local small and medium hospitals. For the interviewees, the high quality of medical services was an important selection criterion that went beyond geographic and economic concerns. They expressed that they were reluctant to live in a rural area because they were worried about not being able to receive treatment immediately if they became ill.
The most reliable hospitals in Korea are concentrated in the major metropolitan area and have famous professors and medical staff in each department. However, it is difficult to make an outpatient appointment at a large hospital and the waiting period is long; thus, participants reported personally asking a hospital employee they knew to make an appointment.
The life insurance products provided by private companies now include a service that makes outpatient appointments at tertiary hospitals if a special contract is added at the time of subscription. If a specific disease is suspected, these services indicate that they can make an appointment for patients quickly, allowing them to make an outpatient appointment at three or four hospitals. Participants wanted to sign up for these services because they could receive substantial benefits even if they paid additional money. In fact, the participant who used the outpatient appointment service was ill but said that this service, which was recommended by an insurance company, would provide substantial comfort.
Even though it was difficult to make an appointment at a big hospital, it seemed that there was a system or a contact network that could do this right away within a few days. It seemed like there were a few seats saved for one life insurance company. The system was connected between a big hospital and a life insurance company. (Interview participant #13, Female, 50s)
Preferable Hospital: More Crowded, Newer, and More Renowned
The main hospital selection criteria, such as accessibility, affordability, and quality, were indeed important criteria for the interviewees. In case of an emergency, participants hoped to go to a hospital that was geographically close and could respond quickly. It was possible to find out about “acquaintances” through hospital staff or price discounts. In addition, there was a tendency to seek tertiary hospitals or specialized hospitals that specialize in specific severe diseases.
When participants did not have any hospital information, they went to a hospital where many others went or to one equipped with cutting-edge facilities and equipment. Numerous factors were involved in choosing a hospital.
More People Flock to Crowded Hospitals
An interviewee stated that others may choose the same hospital without knowing the exact reason. The larger the hospital, especially if it is considered to be a high-quality institution, the more crowded it will be, and the more patients wait to be seen, the more patients will have a psychological expectation that there will be something worth waiting for at the hospital. In other words, even if the waiting time is long, the presence of many patients in the waiting room elicited a certain degree of trust. However, this tendency disproves the argument that there are few opportunities to obtain actual information about the hospital.
So, I thought about why people are like that… You know those restaurants where people stand in line for a long time, and it’s not even delicious (laughs), but they still go and eat. They all stand in line because they expect something good while they’re waiting in line (Interview participant #12, Male, 50s).
Fascinated by State-of-Art Facilities and Cutting-Edge Equipment
Respondents stated that when they encountered a large hospital with good facilities and large-scale capital, such as advanced medical equipment, they expected that the hospital facilities and equipment would be rigorously managed. They said that seeing advanced medical equipment is a reminder that the hospital is well-managed. In contrast, if they encountered an old and discolored machine that had been used for more than 10 years, they would doubt that disinfection procedures were properly performed in the hospital.
Usually, the good facilities are kept clean. Because they pour a lot of money into it. Who wouldn’t take care of it, because they have all fancy medical equipment? They’re trying to use it for a long time, I think all of the parts of management are linked together (Interview participant #1, Female, 20s).
Since little time is spent interviewing patients or performing a physical examination, and treatment is chosen based on blood tests and imaging, patients also focused on how the test results were obtained and whether the test was up-to-date. This concern is reflected by the fact that the selection criteria also depended on the diagnostic modality performance.
Last Hope for a Reputable Hospital
The interviewees stated that they would like to receive treatment at a tertiary hospital if they had enough money and were given the opportunity. This reflected the desire for the best treatment. Rooted in this desire was an expectation that a high-level general hospital in a major metropolitan area like S-city would provide excellent treatment, unlike other hospitals.
Respondents hoped that if they were diagnosed with a serious disease they would try innovative treatments by finding a hospital that engages in clinical research. However, they also replied that they would be able to accept the judgment that treatment was impossible if the decision was made at a hospital considered to be among the best in the country. Patients’ treatment depended on the ability of the staff to practice medicine and the systematic management of the tertiary hospital.
If you are financially capable, then who wouldn’t want to go to a big hospital? First of all, money is important, but if their kid is sick, even if they don’t have money, they all try to go to a big hospital. Trying everything that they could. If the best-known hospital says there’s nothing they could do, then they’ll accept the call. (Interview participant 11, Male, 50s).
Although medicine is advancing rapidly, research-oriented hospitals that combine cutting-edge medicine and the latest medical technology offer the best treatment in the current situation, with existing limitations.
Desired Doctor: Ideal Medical Team
The interviewees hoped that doctors would be professional, trained in a systematic education system, and provide sufficient explanations based on their expertise. Patients also hoped that they could take the initiative in their treatment and discuss directions after consulting their doctor.
Trust Based on the Doctor’s Qualifications
The interviewees expected doctors to be human but with expertise formed by experience with various patient cases. In Korea, from the interviewees’ perspective, a “professional” referred to a doctor with a university diploma displayed inside the hospital and experience in a large hospital. The doctor’s name on a diploma from a prestigious university gave confidence in the fact that he/she was a specialist and had a sense of personal vocation.
Most of all, doctors were expected to accept patients as individuals with a consciousness and decision-making rights and participate in a common decision-making process by accurately conveying medical explanations. The patient feels reassured if the doctor provided a detailed explanation using videos, images, or other modalities to explain why symptoms occur due to the current disease. A good doctor provides reliable guidance on future treatment directions and accepts the family’s opinions when making quick judgments in critical situations.
Engaging in a Sincere Relationship
The interviewees wanted doctors to move away from clerical and insincere attitudes, to empathize with patients, and to build mutual trust. They hoped to form a long-term, close relationship with the doctor by meeting them several times a year at intervals of a month or more so that they could actively inform the doctor about changes in their condition. Even beyond consultations related to specific disease-related conditions, respondents felt that regular visits would reduce the psychological distance between the doctor and the patient.
Respondents expressed that regular appointments would be necessary to build a trusting relationship and familiarity. If the doctor was already familiar with the patient’s personal or family history, they expected to receive appropriate treatment. The interviewees said that if a primary care physician or dedicated physician system, which is not present in Korea, is established, the inconveniences caused by redundant examinations, history-taking, reviews of current symptoms, misunderstandings, and incorrect prescriptions would disappear.
Of course, a doctor who explains well is a good doctor. And a doctor who performs surgery quickly is also a good doctor, but in an emergency situation, making judgments quickly is important so that the guardians can make a quick decision. And a doctor who respects the guardian’s opinion is also good in my view. I don’t know if you’ve experienced it before, but there aren’t many doctors who explain it well. Most of the explanations are given by the nurses, or doctors only explain about the costly procedures that they want to perform. After the explanation of the procedures, if it feels like excessive care from the perspective of a patient or guardian, I don’t want it. So, if I say that I will think about it, I felt like I was pushed away. Once the doctor told me that I needed an MRI, I told him that I had paid for an MRI from the last hospital and didn’t understand why I need another MRI. Then the doctor told me to go to the last hospital to get treatment. (Interview participant #4, Female, 40s)
Furthermore, when patients visited a hospital, they felt that it was inappropriate for the doctor to just prescribe medication. They expressed their desire to return to the hospital and receive treatment from the doctor again, with examples including manual blood pressure measurements or simple procedures such as nasal irrigation.
The interviewees said that they lost trust in medical staff when they came across media information about poor ethical behavior, including sexual assault and overtreatment, by medical staff. Respondents expressed a need for regulations that ensure character qualifications for medical personnel who directly deal with the human body. They also described their own needs and suggested practical policies. They proposed an entrance exam system requiring a personality test for final admission and the evaluation of college entrance exam scores when applying to medical school. Furthermore, they recommended introducing a retirement age system, prohibiting doctors from serving who cannot accept the latest medical knowledge or have a poor memory.
Is there some kind of regulatory system like the medical retirement system? As long as the doctor has the ability to properly care for the patient, he or she can continue to treat the patient. However, I wish the regulations were strengthened when the doctors were not able to treat patients. (Interview participant #3, Female, 50s)
The interview participants hoped to have a relationship where doctors make eye contact and acknowledge their existence. They said that the qualifications of the future artificial intelligence era are kindness and listening, which means that doctors are in the service industry. The interviewee had high expectations for doctors. The “human” attribute expected of doctors is added to the sense of ethics, morality, and sense of duty represented by the Hippocratic Oath. Some interview participants compared a doctor to a “saint.”
Obstacles Hindering Access to Appropriate Treatment
Challenging Journey to Find the Diagnosis
Interviewees had to visit various hospitals or departments to find the correct diagnosis for their symptoms. Male interviewees in their mid-50s said that it is necessary to visit at least three hospitals in the vicinity to know the exact diagnosis. One of the interview participants went to her usual obstetrics and gynecology office due to stomach pain, and the obstetrician found that it was not a gynecological problem, but could not find the cause of the stomach pain. Even though she had recently visited a developing country in Southeast Asia, she spent a long time waiting for an easy diagnosis.
My right belly hurt, so I went to the obstetrics and gynecology clinic for medical treatment, because it was where I had my regular examinations. They did an ultrasound and kept pressing it and told me that nothing was wrong. It was really hurting… They told me if I was really concerned I should go see a general surgeon. So, I did, next thing I know I was hospitalized for appendicitis. (Interview participant #10, Female, 20s).
If a patient does not have a disease that can be diagnosed in a specific department, there are many cases in which a drug is prescribed only as a temporary measure without specific guidance or a diagnosis suitable for their symptoms. Another participant stated that bleeding continued after defecation, so she went to the obstetrics and gynecology clinic and the internal medicine department for various tests, including an endoscopy.
Hopeless Waiting
Interviewees said that they were not welcomed by the medical staff and did not receive a prompt response even when they arrived at the hospital emergency room with emergent symptoms. One interviewee said that she went to the emergency room for acute hepatitis and appendicitis, but after the busy medical staff did not pay attention to her symptoms, she was transferred to another hospital for treatment. However, she said that even at the next hospital, it took a long time to receive test results and a diagnosis. The sick felt they had to wait a long time.
I was so sick, sweating, but a medical staff just told me that I had to wait without any advice or decision. I had to sit and wait for another hour. I think waiting was difficult. (Interview participant #10, Female, 20s)
Becoming a Source of Revenue
A hospital is a legal non-profit organization, but the hospital director, who has to operate the facility, must seek profits. Therefore, market principles such as revenue generation are applied in hospital settings. Consumers who use hospitals are aware of this, and if new drugs are prescribed or additional tests are carried out, they immediately are concerned about over-care. The interviewees said the main focus when deciding a treatment plan was on whether the patient would agree to undergo treatment or the treatment would earn the hospital money, rather than promoting patient recovery.
I get used to it by thinking “It’s just people who do business.” I think to myself that this is unfair and why is it all such a high price? But then, all the medical equipment is brand new, the hospital is located in a downtown area, and the doctor’s profile is all fancy, then it’s a way to get a little more money… and they hire one or two more employees… um…. If you’re doing business in the neighborhood, then the doctor might not need more employees. I asked them why is the price different from this clinic and others, the doctor would just tell me that the manufacturing company is different…. the material is different. Honestly, I’ve never heard of an explanation of why the price is so expensive. The hospital staff just ask “Are you just going to receive the treatment in here [my hospital] Or not?” and that’s it! They only care about whether if the patients get a medical procedure in their hospital or not. (Interview participant #1, Female, 20s)
Desperate Countermeasure After Frustration
Turn to Silence
When going to the hospital to see a doctor, patients avoid speaking excessively because they could be seen as challenging the authority of medical professionals. Patients suffering from physical symptoms are concerned about the possibility of intruding on medical personnel’s territory if they suspect a diagnosis, which could lead to unpleasantness. They do not talk to the doctor about their concerns but rather search the internet before and after treatment or talk with the people around them. Participants described expressing knowledge of healthcare as a non-medical person as a disadvantage for receiving care.
I can’t talk enough when I see a doctor – they are supposed to listen to my words and give me additional explanations, but when I visit doctors, doctors are like, “we are specialists, and the patients are not.” I had pain in my ear and I thought that I had otitis media- But, we can’t mention that I might have otitis media. It’s like, why otitis media should be diagnosed by the doctor, who are you to make the call? - So, I have to keep quiet when I meet the doctor. When I say, “I think it is -,” they say something. “Why don’t you be the doctor here?” It’s harsh. (Participant 11, Male, 50s)
Self-Prescribed Treatment
In one hospital, the medical departments were divided into sections based on symptoms, and the institution did not provide integrated care.
Interview participant #13 visited orthopedic clinics and received only necessary X-ray tests, although she preferred to receive medical treatment for back pain. The interviewee said that she visits orthopedic clinics only to see if there are any remarkable abnormalities in her bones and that she has decided not to receive orthopedic physical therapy for an untreatable condition. Instead, she hoped to receive treatment for back pain from a traditional medicine clinic. The patient dealt with her disease in an integrated way by arbitrarily and selectively receiving the care she deemed necessary.
Last week, I went to the nearest hospital to see an orthopedic surgeon, and then I went to have an X-ray to see that there was nothing wrong with my bones. I went there only to get an X-ray. After checking that there were no problems with the bones, I immediately went to the oriental clinic (laughs), I went to the oriental clinic and received treatment for a week last week because I don’t need to drag it for a long time. (Interview participant #13, Female, 50s)
Privilege to Use Medical Care
Essential Healthcare in a Challenging Region
The interviewees stated that they perceived qualitative and quantitative differences in medical care between S-city and the provincial areas and that it is difficult to expect this gap to be reduced even though people pay the same insurance premiums nationwide. However, respondents believed that the medical gap between local areas and major metropolitan areas, such as S-city, could be resolved through government regulations and solutions from within the medical profession.
The gap between local and major metropolitan area s is something that even the president of this country can’t solve. This is an avoidable phenomenon, but from the doctor’s view, it seems that some regulations should be followed by doing an aptitude test or something like that. (Interview participant, Female, 50s)
Many medical practitioners prefer to go into the fields of dermatology and plastic surgery, which do not always directly involve life-threatening conditions, and medical students are reluctant to perform essential surgeries in urgent situations such as heart disease and severe trauma. The interviewees agreed that active incentives and regulations should be tried to encourage medical staff to work at clinics that provide essential services (e.g., cardiothoracic departments) and to increase the distribution of talented personnel in local areas.
Continual Care Irrespective of Power and Wealth
The interviewees expressed that patients should not receive care according to their power or wealth but choose hospitals based on guidelines and receive appropriate medical treatment according to their condition.
Respondents hoped that it would be possible to implement a structure wherein a single clinician could consistently handle the healthcare and welfare needs that arise as a person ages. In the current medical system, doctors who provide longitudinal primary care are specialists that only a few wealthy people can utilize. Instead, participants hoped to have a designated primary care physician who would provide care from birth to old age and refer patients to specialists as necessary.
People like me don’t have a consultant, a doctor who knows… I thoroughly looked for them, but couldn’t find them. (Interview participant #8, Male, 50s)
Interviewees said they would not visit the public health centers that have been established nationwide. They perceived the doctors employed at public health centers as less reliable since they have relatively little experience and are more aware of their role as administrative agencies. In addition, participants perceived the health checkups provided every other year through the Health Insurance Corporation as unnecessary since they only provided minimal medical services. One interviewee had to apply for additional tests due to their age and genetic risk factors, such as endoscopy and ultrasound, and she went to the hospital only when she felt that it was necessary.
People who pay health insurance premiums want medical services to be provided to those who need them, but they complain about what they perceive as waste. One of the interviewees hoped that a powerful government would actively intervene to adjust the prices of hospital health services using economies of scale, allowing people to benefit. He expressed his willingness to pay public insurance fees if he believed that it would be as effective as private insurance.
Then if I pay 10,000 won [$10] here, I can get a bigger benefit if I pay 10,000 won here. Because the NHS can attract more people - even if you sign a contract with S-university, you can lower the 10,000 won bill to 5,000 won. That’s why it’s possible. But I paid 500,000 won, but I don’t have to do it if I get benefits here and there, and if the person who walks in gets benefits, I don’t have to do it. I paid for Korean health insurance to get fast and speedy treatment. It’s a matter for health insurance to think about. Before we run out of health insurance, the private insurance company is making a living. If the money goes up a lot, the public will get a lot of money. If the money goes up, the people will get a lot of money. If it comes out, they can give other benefits to ordinary people. We actually invested 500,000 won, but we were treated more than that, and with that extra money, we could afford to give aid to the lower class again. (Interview participant #9, Male, 50s)
In wasting unnecessary medical expenses for so-called “Nylon [fake]” patients or patients admitted to the hospital for insurance reimbursement even though the actual injury is not serious, the interviewees thought that small groups were more problematic because of the system loopholes. In their opinion, the system could not improve without reflection on the opinions of the patients, and a desirable medical system could be properly established only when the people’s consciousness matured. Nevertheless, specific factors that could cause this moral hazard must be anticipated before proposing a policy, and the side effects of the policy must be closely evaluated.
Discussion
An analysis of interviews about the characteristics of hospitals, good doctors, and a desirable healthcare system showed that patients in Korea took the risk of exploring hospitals that they thought were suitable without integrated guidance. Using the strategies they accumulated through medical experience as patients, participants tried to gather the combination of health services they needed to use the hospital in the way that they considered most appropriate and efficient. This strategy was applied by patients who grew desperate due to illness without any systematic guide to hospital usage.
Since there was no primary care physician or systematic guidance, it seemed essential for most of the interviewees to obtain information about the hospital through an internet search or acquaintances before their visit. Although the Health Insurance Review Agency (HIRA) has provided hospital assessment information since 2000 at the government level (HIRA, 2016), people commonly draw on their acquaintances rather than using official information.
Without receiving proper information about the hospital, general patients in Korea preferred large hospitals because they did not have an understanding of primary medical institutions (Jung et al., 2019). This study also found that the general public preferred large hospitals. Rather than a lack of understanding of primary medical institutions, participants expressed a reasonable preference for receiving care at a higher-level general hospital equipped with state-of-the-art medical equipment and specialists with an above-average educational background. This suggests that web data that provides detailed and systematic information about medical institutions should be built with a guide for using that data.
Though there is official information from the government, such as HIRA’s hospital assessment information, participants used the internet to search for information or utilized personal acquaintances. To deal with the predominant use of only major (“Big 5”) hospitals, detailed descriptions and comprehensible images of specific conditions are necessary. Building an intimate doctor-patient relationship through increasing technical and interpersonal competence is also crucial, which is hard to build because of South Korea’s institutional environment.
The information asymmetry between patients and medical staff is a feature of healthcare that causes the price of healthcare to be adjusted by consumers. To reduce the information gap relative to the medical staff, patients search the internet and consult acquaintances about hospitals or their symptoms before visiting the hospital. However, these methods are limited from a medical standpoint. From the patient’s view, the best explanations are provided when clinicians use detailed descriptions and easy-to-understand images that provide specific medical information related to their condition.
The professionalism of doctors has traditionally been achieved by self-regulation (Chestnut, 2017). This includes maintaining medical school admissions and internal regulations through professional associations. In Korea, through this internal control system, doctors have built a social reputation and credibility. However, the recent spread of information regarding hospital incidents and the active sharing of information among patients through online social networks has led them to want to help regulate these professional jobs (D. K. Kim, 2019).
Bendapudi et al. (2006), who studied patients’ perceptions of ideal physicians, described what patients expected of physicians in doctor-patient relationships as “technical competence” and “interpersonal competence.” Technical competence is the ability to understand an illness and explain it from a patient’s perspective, and interpersonal competence is the attitude of the medical staff toward the patient. In this study, similar characteristics that patients expected from doctors were extracted, and it is notable that in Korea, it is difficult to build trust due to the institutional environment. The participants of the present study expressed the desire for long-term relationships with doctors who would understand their conditions on an individual level.
Accessibility ranks highest among the characteristics of the healthcare system that patients with chronic conditions considered ideal according to a study conducted in Australia (Sav et al., 2015). Unlike Australia, where hospitals and outpatient offices are close to residential areas, in Korea, there is a greater desire for quality care at reliable tertiary hospitals and equal opportunities than for improved accessibility.
The participants also stated that it is bittersweet to face a situation in which the for-profit aspect of medical staff and operating profits are prioritized over their right to live. With more than 60% of healthcare institutions being commercially owned, there is a need to distinguish whether a treatment is recommended for strictly medical purposes or for profit (A. M. Kim et al., 2018). As participants discovered by exploring at least three hospitals, unnecessary medical services and diagnostic tests and excessive treatment are rampant, and hospital care is inefficient. These points characterize that Korean medical services are covered by public insurance but are mainly provided by private hospitals.
In the United States, most of the medical system is still operated by private hospitals, but there are active attempts by the state to create and provide private hospital associations. Statewide Health Information Network-New York (SHIN-NY) builds an integrated information system in New York that connects Regional Health Information Organizations (RHIO) and shares information on individual patient units (Kern et al., 2009). This can establish a basis for medical exchange and mutual work.
The interviewees hoped that the healthcare waste would be minimized as the people would be responsible for paying insurance premiums in this healthcare system. Rather than encouraging regular checkups run by the National Health Insurance Corporation at a basic level, it seems urgent to establish more definite and practical systems such as tailored medical checkups according to individuals’ life stages. A specific health checkup plan for each infant, adolescent, young adult, and elderly individual is needed.
In addition, due to the nature of the national health insurance premium system, participants were aware of the public nature of health insurance premiums and were particularly interested in waste-free, efficient operations and financial distributions. In Canada, where all medical systems are operated by the public, an innovative program in which patients apply for treatment and then adjust and refer to them through a web-based primary care system (Putera, 2017). This study suggests that it is necessary to establish an Integrated Delivery System (IDS) tailored to the Korean context: public health insurance exists, but medical services are provided by private medical institutions. The findings of this study indicate that community and medical resources (primary care, hospital) should be integrated, and close cooperation is essential according to the needs of the general public.
The subjects included in this study were members of a citizen council for health insurance; thus, the interviews were conducted among patients who had a long history of hospitalization or who often visited outpatient areas without serious diseases. The generalizability of the results is limited as the interviews mostly focused on outpatient care.
In Korea, where there is no primary care physician system and a high proportion of hospitals are for-profit. This study attempted to explore the perception and thought process of medical use and further explore the desire for the health care service. It is suggested to conduct a study that systematically compares the results of studies conducted in the context of various health systems, including those with primary care system or predominantly public healthcare service.
The ideal medical service according to Korean citizens varies based on their own perspectives. These perspectives are influenced by the social context where most medical institutions are for-profit hospitals, despite healthcare coverage being provided through social health insurance. Therefore, it is important to conduct research that measures and evaluates patient satisfaction, considering this specific and unique situation. Particularly, policy development that involves citizen participation should be based on research that reveals the viewpoints of citizens. These changes will lead to a new governance structure centered on medical service users. It is crucial to expand the improvement of healthcare policies that prioritize citizen participation, conduct research that emphasizes the need for citizen involvement, and further evaluate the impact of citizen participation in policy development.
Conclusion
This study shows the perceptions of an ideal medical system from a patient-centered view by asking the following three questions to quantify and extract themes: (a) Hospitals I would prefer to visit; (b) Good doctors; and (c) Preferred healthcare system.
The most frequent words were (a) “big,” (b) “kindness,”“explanation,” (c) “national,”“regulation,”“program,”“need,” and “benefit.” It can be derived from these common words and the interviews that patients preferred large hospitals because of the expectation of high-quality (“state-of-art”) medical equipment and specialists with a high educational background, which fits their perception of an ideal medical system.
Participants explored at least three hospitals to distinguish between the two. This is the result of a national healthcare system paid for by nationals and commercialized hospitals run by businesses. An Integrated Delivery System integrating community and medical resources can relieve this issue. Also, practical and palpable systems for individuals should be sought for efficient operations and financial distributions of the national healthcare insurance premium.
Footnotes
Acknowledgements
The authors would like to thank Dr. Juhwan Oh who is the principal investigator of this project and the interview participants who are the members of the Citizen Council for Health Insurance which is operated by the National Health Insurance Service (NHIS).
Abbreviations
NHIS = National Health Insurance Service; HIRA = Health Insurance Review Agency; SHIN-NY = Statewide Health Information Network-New York ; RHIO = Regional Health Information Organizations; IDS = Integrated Delivery System; IDI = Individual Interview; FGI = Focus Group Interview
Author Contributions
Conceptualization, S.-Y.Y.; methodology, S.-Y.Y. and E.E.S.; validation, S.-Y.Y. and J.-Y.K.; formal analysis, S.-Y.Y. and J.-Y.K.; investigation, S.-Y.Y., S.L.; resources, S.-Y.Y. and S.L.; data curation, S.-Y.Y. and S.L.; writing—original draft preparation, S.-Y.Y. and J.-Y.K.; writing—review and editing, S.-Y.Y., E.E.S., S.L., and J.-Y.K.; visualization, S.-Y.Y. and J.-Y.K.; supervision, E.E.S.; J-Y.K. is the guarantor. All authors have read and agreed to the published version of the manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was financially supported by “Development of Community-based Autonomous Cooperative Health Care Delivery Model Project (2018-0405-588-00),” which is a part of the Supporting Program for National Health Insurance Service (NHIS) funded by the Ministry of Health, Republic of Korea.
Ethical Approval
This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Seoul National University Hospital Biomedical Research Institute (IRB No. 1803-066-929) on January 31, 2018. Data collection was conducted after receiving approval from the ethics committee. Written informed consent was obtained from all the respondents to publish this paper before they participate this study.
Data Availability Statement
The qualitative data used and analyzed during the current study are available from the corresponding author on reasonable request.