key: cord-0871767-sxjtwvjl
authors: Kim, Agnus M.
title: Psychiatric hospitalization in Korea, 2011-2020: the impact of the Mental Health Act revision of 2017 in consideration of the COVID-19 pandemic
date: 2021-11-24
journal: Asian J Psychiatr
DOI: 10.1016/j.ajp.2021.102934
sha: 07666b60a8c967d438b41527dad7b0d862e57183
doc_id: 871767
cord_uid: sxjtwvjl

OBJECTIVE: This study was performed to examine the changes in utilization of inpatient and outpatient care for schizophrenia in Korea prior and subsequent to the mental health law revision of 2017 in consideration of the COVID-19 pandemic. METHODS: The number of outpatients and outpatient visits and the number of inpatients and lengths of stay for schizophrenia from 2011 to 2020 were obtained for National Health Insurance beneficiaries and Medical Aid beneficiaries, and their changes during the period were compared with those for other psychiatric disorders and all causes other than psychiatric disorders. With difference-in-differences analysis, the changes in utilization of inpatient and outpatient care for schizophrenia after the law revision in 2017 were analyzed with two comparison groups. RESULTS: While the number of inpatients and length of hospital stays for schizophrenia decreased between 2017 and 2019, the number of outpatients and outpatient visits for schizophrenia increased during the period. The decrease in inpatient care for schizophrenia after the revision is in contrast with the increase in two other groups. While the COVID pandemic in 2019 lead to the general decrease in health case use among the population, the decrease was most distinct for schizophrenia. Difference-in-differences analysis showed that the law revision was associated with the decrease in the use of inpatient care for schizophrenia. CONCLUSIONS: The mental health law revision in Korea led to a significant decrease in hospitalization of people with schizophrenia, and this effect was significant after adjustment for the effect of the COVID-19 pandemic.

In the latter half of the 20 th century, deinstitutionalization was the predominant policy in psychiatric care in the developed world (Fakhoury and Priebe, 2002) . However, against the trend of deinstitutionalization in developed countries, psychiatric bed number in Korea has greatly increased during the past decades with an ever-increasing dependence of psychiatric care on hospitalization. The number of beds in psychiatric asylums in Korea increased by 500% between the early 1960s and mid-1990s (Cho et al., 2017) , and The high dependence on hospitalization in psychiatric care in Korea is primarily based on governmental support for the expansion of psychiatric hospital beds, especially in the private sector (Jeon, 2002) . However, the exceedingly long length of stay of psychiatric patients in Korea was related to the Mental Health Act, which legalized involuntary admission and its extension with only nominal restrictions . This Act has been abused for involuntary hospitalization for unjustifiable causes and its arbitrary prolongation, which, along with the profit motive of psychiatric facilities, became a customary practice in Korea. Given the rising concern about this problem, the Constitutional Court in Korea declared that the law was incompatible with the Constitution in 2016 .

The Constitutional decision led to the revision of the Act in 2017. The revised law, the Mental Health and Welfare Act, primarily tightened the conditions for involuntary admission and the prolongation of stay. In the subsequent revisions of 2018, the Act further established grounds for deinstitutionalization by specifying conditions for community care. However, despite the general consensus about the need for the revision, the government and mental health professionals express different attitudes toward the revised law with the latter insisting that the revision added only administrative work without correcting fundamental problems. Furthermore, they offer different interpretations of the effect of the revision. Whereas the government emphasizes the decrease in involuntary admissions, mental health professionals insist that the apparent decrease is only due to the conversion of involuntary admissions to voluntary ones (Lee and Kim, 2018) .

The differing perspectives on the mental health law revision and its effect stem from different views on priorities of psychiatric treatment and involuntary placement and J o u r n a l P r e -p r o o f varying interests involved with the revision. However, while preventing unjustifiable involuntary admissions can be considered a primary purpose of the revision, the ultimate purpose of the law revision is to return psychiatric patients to the community (Ministry of Health & Welfare, 2020). Therefore, its effect needs to be examined in terms of the overall utilization of psychiatric care.

This study was performed to examine the impact of the Mental Health Act revision on the health service use of psychiatric patients. As the revision mainly concerns involuntary admission and long-term hospitalization, patients with schizophrenia, who account for about half of all psychiatric admissions and two-thirds of long-term psychiatric admissions in Korea (JI Park et al., 2008; Supreme Prosecutors' Office Republic of Korea, 2017) , can be considered the most relevant population. Therefore, health service use for schizophrenia was examined in comparison with other psychiatric disorders and causes other than psychiatric disorders. This study is composed of two parts. First, the change in the utilization of inpatient and outpatient care for schizophrenia was assessed from 2011 to 2019 in comparison with other psychiatric disorders and causes other than psychiatric disorders. Second, using difference-in-differences analysis, the changes in utilization of inpatient and outpatient care for schizophrenia after the law revision in 2017 were analyzed with other psychiatric disorders and causes other than psychiatric disorders as comparison groups.

This study was performed with population-based data from Korea. The Korean population is composed of 97.1% of NHI beneficiaries and 2.9% of MA beneficiaries. Whereas the NHI beneficiaries pay a monthly premium and copayment of 20 to 60% (National Health Insurance Service, 2021b), the expense of MA beneficiaries is covered with no or nominal amount of out-of-pocket payment. Regarding reimbursement, while the fee-for-service has been the standard payment model in Korea, the payment of the Medical Aid beneficiaries for psychiatric care has been fixed-perdiem since the introduction of National Health Insurance in 1977 . Although the fee-for-service was introduced for outpatient psychiatric care of the MA beneficiaries in 2017, the payment for inpatient psychiatric care for the MA remains fixed-per-diem (Lim et al., 2018) .

Comprising only 2.9% of the total population, MA beneficiaries use about 9.7% of total health care expenditures in Korea. This reflects the frequent use of services by MA patients rather than the number of patients as demonstrated in 3.3%, the percentage of MA patients among the total number of patients in Korea (Health Insurance Review & Assessment Service, 2016a, b) . However, this does not apply to psychiatric patients, especially schizophrenia inpatients. The number of MA schizophrenia inpatients is about 61.1% of total schizophrenia inpatients, which is translated into 60.6% of the total expenditure for schizophrenia inpatient care (Lim et al., 2018; Service., 2017) . The high proportion of schizophrenia inpatients among MA beneficiaries can be due to long-term ailment-driven poverty. However, this figure is also highly likely to be linked to fixedper-diem inpatient payment which can cause unnecessary lengthening of hospitalization J o u r n a l P r e -p r o o f and to the susceptibility of MA beneficiaries to involuntary admission .

Considering this difference in characteristics between the NHI and MA psychiatric patients and their susceptibility to involuntary admission, the change in service use before and after the law revision was separately analyzed for the NHI and MA.

As the main change in the revised law concerns the requirements for involuntary hospitalization and its lengthening, the population which can be most affected was selected as the treatment group. As schizophrenia accounts for 45% of all psychiatric Table 1 presents the number of inpatients and outpatients for schizophrenia, other psychiatric disorders and causes other than psychiatric disorders between 2011 and 2020.

The number of inpatients and outpatients for schizophrenia increased before the Mental Health Act revision in 2017 by 0.3% and 3.3% respectively during 2015 and 2017. After J o u r n a l P r e -p r o o f the revision in 2017, the number of inpatients for schizophrenia decreased by 2.3% while the number of outpatients for schizophrenia increased by 3.6% in 2019. This is in contrast with other psychiatric disorders and causes other than psychiatric disorders of which the number of inpatients increased by 2.1% and 4.9% respectively during the same period. When compared by the insurance status, the decrease in the number of inpatients for schizophrenia was greater in the National Health Insurance beneficiaries than in the Medical Aid beneficiaries (Figure 1 ).

The hospital stays and outpatient visits for schizophrenia demonstrate a trend similar to the number of patients ( Table 2 ). The total hospital stays for schizophrenia after the revision in 2017 decreased by 0.4% in 2019 while the total outpatient visits for schizophrenia increased by 5.8% during the same period. Unlike in the case of schizophrenia, the total hospital stays and the total outpatient visits for other psychiatric disorders increased after the revision in 2017. However, whereas the number of patients who used inpatient care for schizophrenia increased before the revision and decreased after the revision, the total number of hospital days for schizophrenia decreased during both periods. When compared by the insurance status, the decrease in hospital stays for schizophrenia was greater in National Health Insurance than in the Medical Aid beneficiaries as in the case of the number of patients (Figure 2 ).

Concerning the COVID-19 pandemic in 2020, health care utilization decreased in general in three groups except for the increase in outpatient care use for other psychiatric disorders. The number of inpatients and outpatients for schizophrenia decreased by 10.1% and 3.5% respectively between 2019 and 2020, which were more remarkable decreases than other psychiatric disorders and causes other than psychiatric disorders.

The hospital stays and outpatient visits for schizophrenia decreased by 1.6% and 3.1% respectively between 2019 and 2020. The decrease was more notable than for other J o u r n a l P r e -p r o o f psychiatric disorders and less notable than for causes other than psychiatric disorders.

The outpatient visits for other psychiatric disorders increased by 5.5% between 2019 and 2020. The negative beta-coeffient for Post*Treatment in difference-in-differences analysis shows that the number of patients and utilization in both inpatient and outpatient care for schizophrenia decreased significantly compared to other psychiatric disorders (Table 3) .

The difference-in-differences analysis with causes other than psychiatric disorders shows that the number of inpatients and hospital days for schizophrenia decreased compared with the general population while the number of outpatients and outpatient visits for schizophrenia increased compared with the general population (Table 4 ).

This study examined the impact of the Mental Health Act revision on the psychiatric health service use for schizophrenia. Both the number of inpatients and length of stay for schizophrenia decreased after the revision while outpatient care increased after the revision during 2017 and 2019. The decrease in inpatient care for schizophrenia after the J o u r n a l P r e -p r o o f revision is in contrast with the increase for other psychiatric disorders and causes other than psychiatric disorders. While the COVID pandemic in 2019 lead to the general decrease in health case use among population, the decrease was most distinct for schizophrenia. The difference-in-differences analyses also suggest that the use of inpatient care for schizophrenia decreased after the revision compared with the two comparison groups, and this effect was significant even after adjustment for the effect of the COVID-19 pandemic.

This study shows that the revision of the Mental Health Act led to a significant decrease in the inpatient care use by its most relevant population, people with schizophrenia, and an increase in their outpatient care use. These results demonstrate that the law revision, despite the arguments concerning the effect of the revision, brought about some desired effects. Not only decreasing the inpatient care use, the revision also led to an increase in outpatient care use for schizophrenia, which can be considered a transfer from the inpatient care demand.

The more salient decrease in the inpatient care use due to schizophrenia among the National Health Insurance beneficiaries compared with the Medical Aid beneficiaries indicates not only the greater impact of the revision on the former but also the high chronicity of schizophrenia among the Medical Aid beneficiaries. The high chronicity is also revealed in the proportion of Medical Aid beneficiaries among people with schizophrenia. Although acounting for 2.9% of the total population, the proportion of Medical Aid beneficiaries as inpatients for schizophrenia was 57.8% as of 2019. In terms of hospital stay, the Medical Aid beneficiaries were responsible for 71.8% of hospital stays due to schizophrenia.

The study finding is in line with the decrease in compulsory admissions after the revision in another study which reported that the proportion of compulsory admissions was 31.5% J o u r n a l P r e -p r o o f in 2018, lower than 64.3% in 2016 (Yoon et al., 2019) . A considerable part of compulsory admission is supposed to be converted to voluntary admission with a 28.4% decrease in the former and a 26.9% increase in the latter. However, the overall decrease in admission among people with schizophrenia demonstrates that the law led to a meaningful decrease in admission among the most vulnerable population and not a simple conversion to another form of admission.

The decrease in the number of psychiatric admissions and involuntary admissions after the revision is consistent with many developed countries in North America and Europe (Fakhoury and Priebe, 2007; Rothbard and Kuno, 2000) . (Freeman et al., 1985; Rothbard and Kuno, 2000) . However, while the decrease in psychiatric beds was evident in most countries which adopted deinstitutionalization and was generally accompanied by a decrease in involuntary hospitalization and the entire psychiatric hospitalization, the reduction in beds did not translate into a decrease in admissions in some countries. For example, whereas the number of psychiatric beds in the UK decreased drastically through the 1970s and 1990s (Freeman et al., 1985; Rothbard and Kuno, 2000) , the number of psychiatric admissions and the number and proportion of involuntary admissions continued to increase since the 1980s in the UK (Keown et al., 2018; Wall et al., 1999) .

Germany, despite declining bed numbers since the 1970s, showed an increase in psychiatric admissions and a stable proportion of compulsory detention since the 1990s, which is attributed to the shortened length of stay (Salize et al., 2007) .

These varying consequences of deinstitutionalization demonstrate that psychiatric bed reduction, decrease in psychiatric hospitalization, and decrease in involuntary hospitalization do not necessarily involve one another and can occur on different bases.

For example, bed supply can be controlled by government policy or market conditions, but compulsory admission is based on legislation which stipulates the terms for it.

Furthermore, even the effects of change in legislation were so variable that some countries saw an unexpected increase in compulsory hospitalization after the change in the law. However, considering that bed reduction was a commonly preceding element of deinstitutionalization in many countries, the mental health act revision in Korea can be considered an attempt at deinstitutionalization by changing the requirements for compulsory admission rather than decreasing bed size first. Whether this attempt would lead to a bed reduction in the private sector would depend on the will of government and the general population, which would not let the revised law be bypassed by makeshift measures, and, most of all, the implementation of the complementary part of hospital beds: preparation for receiving patients into the community.

This study has limitations. First, given that the revision was effective since the end of May in 2017, a more accurate assessment of the effect of the revision would have been possible when the utilization was measured by the month. However, considering that the revision became effective in the middle of the year, the assessment by year can also be appropriate for measuring the effect without partiality. Second, concerning the difference-in-differences analysis, the treatment and comparison groups, ideally, should differ only in treatment with other conditions similar. Given the characteristics of the treatment in this study, which is universally applied to patients with schizophrenia across the nation, it is not possible to come up with an ideal control group, the population with schizophrenia who are not under the influence of the revision. Given the situation where the control group, while being homogeneous with the treatment group and not under the influence of the revision, is absent, alternative groups could serve to measure the effect of the treatment. In that respect, the comparison groups in this study can be considered appropriate to examine whether there was a significant change in health care utilization for schizophrenia after the revision as the comparison groups are under less or no J o u r n a l P r e -p r o o f influence of the law revision.

Both in terms of its duration, number and compulsory nature, psychiatric admission in Korea needs to be wholly revised. The revision of the Mental Health Act to the Mental Health and Welfare Act can be considered as the first step to correct the situation. This study shows that the revision led to a significant decrease in psychiatric admission of the most relevant population, people with schizophrenia. While further efforts should be put into decreasing unnecessary admission, more resources should be devoted to the care of the deinstitutionalized patients in the community, which should be the priority of the health policy in Korea.

The author thanks David Gore for his comments. I am deeply grateful to Ji Hye Park of the statistics department of the National Health Insurance Service for her invaluable help for data management.

Competing interests: The author declares that she has no competing interests.

J o u r n a l P r e -p r o o f Tables   Table 1. 

A survey about people with severe mental illnesses in asylums. National Human Rights Commision of Korea

The process of deinstitutionalization: an international overview

Deinstitutionalization and reinstitutionalization: major changes in the provision of mental healthcare

Mental health services in Europe: 10 years on. World Health Organization. Health Insurance Review & Assessment Service, 2016a. Medical Aid statistical yearbook

Policy Assessment of the Mental Health Act

Structural causes and maintenance factors affecting long-term hospitalization of the mentally ill National Human Rights Commission of Korea

The incidence of schizophrenia and schizophrenia spectrum disorders in Denmark in the period 2000-2012. A register-based study

One year after the revision of the Mental Health Act

Improvement of the quality assessment of payment for Medical Aid psychiatric care

Korea's increase in suicides and psychiatric bed numbers is worrying, says OECD. Organization of Economic Co-operation and development, Paris. Organization of Economic Co-operation and development, 2014b. OECD Health Policy Studies, Making Mental Health Count

The Success of Deinstitutionalization: Empirical Findings from Case Studies on State Hospital Closures

Mental health care in Germany

Statistics for classification of diseases (three-digit codes)

Supreme Prosecutors' Office Republic of Korea

Trends in the use of the Mental Health Act: England, 1984-96

The Assessment of the Mental Health and Welfare Act

Table 2. Hospital stay and outpatient visits, schizophrenic patients and general population, 2011-2020 Year Change (%)

Table 3. Difference-in-differences model for number of patients (Treatment group: people with schizophrenia, Control group: people with mental illness other than schizophrenia

Table 4. Difference-in-differences model for number of patients (Treatment group: people with schizophrenia

The author declares that there is no conflict of interest.

I thank David Gore for his comments. I am deeply grateful to Ji Hye Park of the statistics department of the National Health Insurance Service for her invaluable help for data management.J o u r n a l P r e -p r o o f