The preterm birth rate has increased, whereas the total number of live births in South Korea has decreased. The total number of preterm infants has increased slightly. Preterm births under 28 weeks of GA increased until 2015, to 752 infants, and declined after 2015. Earlier GA was strongly associated with increased healthcare resource utilization and medical costs in Korea, especially in the extremely preterm group10.
The total medical costs of preterm infants steadily increased throughout the study period. In 2008, the Korean Ministry of Health and Welfare established “The Service for National Support of NICU Installation and Management.” An agreement for raising the admission fee for the NICU was signed in 2013, which included a zero-deductible payment for the patient and the entire admission fee for patients requiring incubators. This development solved chronic deficits for hospitals running the NICU and contributed significantly to the healthcare of preterm infants by lowering neonatal mortality11,12. In the 2016 policy revision (The 14th National Healthcare Insurance Policy Board Congress), guaranteed admission fees were increased again and provided an expanded non-benefit practice. This increase remains significant when considering the Gross Domestic Product (GDP) per capita, which rose from $21,350 to $32,721 between 2008 and 202013.
Additionally, the costs of diagnostic tests and treatments have changed over time. However, the cost of medication has remained constant over time, including that of pulmonary surfactants and respiratory syncytial virus monoclonal antibodies (Synagis®, palivizumab), which are covered by national insurance since 201011,14,15. In 2018, more diverse surfactant agents were included in the national health coverage (other than Curosurf). Laboratory diagnostic costs have increased steeply since 2017. A new laboratory methodology called next-generation sequencing was included in the national insurance coverage for newborn congenital diseases from March 201716. Also, respiratory viral panel by polymerase chain reaction study has been included in the coverage since 2016. The expansion of laboratory studies performed in NICU has led to a dramatic increase in the costs in the laboratory category.
Ultrasonography is a useful imaging modality for neonates. Sonographic examinations have been covered by national insurance since 2016 and are routinely performed through discretionary grant payments from each patient. This coverage contributed to a steep increase in radiological costs from 2016. Other functional examinations, including electroencephalography, echocardiography, or video fluoroscopic swallowing studies, remained steady because fees were not raised during the study period.
Several previous works about economic burden with preterm birth have been investigated. Canada runs national health insurance model which is comparable with South Korea. Johnston et al., estimated in his paper that it costed $CAD 67,467 for each early preterm infant (less than 28 gestational weeks), $CAD 54,554 for moderately preterm (28–32 gestational weeks) and $CAD 10,010 for late preterm (32 to 36 gestational weeks) in year 201217. Rolnistsky et al., published 2 papers related to expenses of the NICU care in Canada. In these studies, extremely preterm infants (less than 28 gestational weeks) accounted $CAD 66,669 in 2011 through 2015 and in year 2010 through 2017, and total median cost per all NICU infant was $CAD 77,13218,19. Healthcare spendings in U.S. was even larger than national covered nations. Beam et al., reported median $291,029 expenditure was spent for each preterm infant born with 27 to 28 gestational weeks of age, $418,191 for 25–26 gestational weeks and $9,864 for 35 to 36 gestational weeks in year 2008 to 201620. Beam et al., also suggested that total cost has been rising through recent years as well.
Comparing with our data, it costed $29,101 for extremely preterm infant which is less than Northern American nations. But it is also noticeable that in non-extreme preterm, expense was $9,181 per infant, which was similar amount compared to previous studies from other nations. As total burden of preterm medical cost increases, we need more wisdom to invest strategies to address more portion to target earlier born infants.
While increasing medical burdens has been displayed throughout the entire study period, patient outcome improvement also been noted from Korean Neonatal Network (KNN) reports21. According to the KNN 10-year anniversary report, the survival rate increased from 84.9 to 89.3% between 2014 and 2020 and associated preterm morbidities have significantly decreased over the past decade. The 2020 Canadian Neonatal Network (CNN) report indicated a mortality rate of 90.5%.22 Given that the lower limit for resuscitation has remained consistent between two national cohorts past years, generally around 22–23 weeks of gestational age, this represents a significant improvement and is comparable to international standards.
Jin et al., studied first 6 years medical costs in preterm infants after discharge from NICU in Korea10. Rate of hospital admission was 75.6% in infants born less than 28 gestational weeks in 6 years and most of the costs was spent in the first year after discharge. In our data, we focused more on advanced period and re-admission happened 16% in 30 days, 24% in 60 days and 29% in 90 days after discharge in extremely preterm infants.
This study has multiple strengths including large population size, distribution of birth location and categorized expenditure by different purpose of medical utilization. However, several limitations should be acknowledged. Korean national insurance coverage is not 100% and there could be missing expenditure from uninsured portion from arbitrary out-of-pocket expenses. Second limitation is from weakness of the large claim data. We utilized ICD-10 codes to search preterm admission bills, but codes may not be perfect as incomplete data input may occur from different units. Third, large scale national data does not include patient’s individual data other than gestational age other than 28 weeks cut-offs and specific birth weight information. Fourth, different neonatal intensive care circumstances, clinical features, and disease spectrums may vary between countries. Our data only includes the South Korean population, which could make our results less generalizable to countries with different circumstances outside of South Korea. Lastly, our data claim started from the baby’s perspective, which limited the inclusion of maternal healthcare data. According to the Korean National Statistics Agency, the average maternal delivery age in South Korea has increased from 31.4 to 33.4 over the past ten years23. This change may have affected the overall outcomes and expenditures of neonatal intensive care. However, integrating maternal data was restricted due to unresolved confidentiality issues during our investigation. Recently, improved methodologies have been developed. Future studies that integrate maternal data will be more promising in terms of better adjustment of confounders.
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