Sources of data

We used the Bigdata Open Portal Data database run by HIRA Service in Korea, which provides access to comprehensive health insurance claims data, allowing anyone to download and use statistics on resources and utilization of Korean medical services for research and education purposes [13]. We extracted, summarized, and analyzed annual aggregate statistics on indicators of interest over ten years between 2013 and 2022 (the most recent year when data is available as of June 8 2024) from the database. The authors did not have access to information that could identify individual participants during or after data collection. Given that the NHI coverage rate in Korea is approximately 97–98% [6], this research should be considered a census, not a sample survey.

Indicators of interest

To observe TKM healthcare resources, we selected the indicators of the annual number of medical institutions, beds, and medical doctors, which are separately summarized according to types of TKM institutions (TKM hospitals primarily for inpatients and TKM clinics primarily for outpatients). The number of beds is known to serve as a critical indicator for estimating healthcare service capacity [14]. The number of medical institutions and beds in TKM was also compared annually with those of the entire medical resource in Korea. We also examined the number of WM doctors in TKM hospitals and TKM doctors in WM hospitals to observe changes in cooperative healthcare service patterns. In Korea, it is possible to establish WM departments in TKM hospitals, or vice versa. If necessary, the data of the same indicators for WM hospitals and clinics, which are leveled similar to TKM hospitals and clinics, respectively in the Korean healthcare system’s hierarchy, were also compared.

To observe changes in the utilization of TKM healthcare services, we collected the number of patients & health insurance claims and medical expenses over ten years. All values are analyzed separately for inpatient/outpatient and TKM hospitals/clinics, as well as their aggregated totals. The medical expenses per patient or claim were calculated. Additionally, the annual rate of change and its average rate, i.e., the compound annual growth rate (CAGR) were calculated as follows:

Furthermore, we tried to overview the changes in TKM service patterns by analyzing the relative composition ratios of the respective diagnostic and therapeutic methods covered by NHI in Korea, in terms of the number of claims and their medical expenses. The diagnostic methods were categorized into meridian function test, pulse wave examination, Yangdorak test, and dizziness or psychiatric examinations, while the therapeutic methods were into manual acupuncture, electroacupuncture, cupping therapy, moxibustion, Chuna manual therapy, and others.

Data analysis and visualization

All data were analyzed using OpenAI’s ChatGPT 4.0 and R program 4.3.2 (R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing) To visually convey the characteristics of the data effectively, this paper presents changes in each indicator by bar and line plots rather than tables. Detailed data values are provided in the supporting information. Since this study aimed to identify trends in TKM utilization rather than test specific hypotheses, significance testing was not performed.

Ethics approval and consent to participate

All procedures were performed in compliance with relevant laws and institutional guidelines. Since the study did not involve the direct recruitment of human subjects or the analysis of individual participant data, the ethical review was exempted, including informed consent by the Institutional Review Board of Sangji University (Wonju, Republic of Korea) on June 7, 2024 (Approval No. 2024-08).

Changes in healthcare resources: TKM institutions, beds, and doctors

The aggregated proportion of TKM hospitals and clinics out of total medical institutions in Korea has remained relatively stable, averaging around 15.55% between 2013 and 2022. However, the number of TKM hospitals increased significantly from 212 to 546, with a CAGR of 11.08%, while TKM clinics grew from 13,100–14,549, with a CAGR of 1.17%. Considering that 1) the CAGR of all the medical institutions in Korea over 10 years was 1.87%, 2) the number of WM hospitals decreased from 1,415–1,398, and 3) the number of WM clinics showed a growth rate at a CAGR of 2.36%, it is notable that the number of TKM hospitals significantly increased and that of TKM clinics stayed mostly unchanged (Figs 1(a) and (1b)).

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Fig 1. Medical institutions and beds in Korea between 2013 and 2022.

TKM: Traditional Korean Medicine, WM: Western Medicine.

https://doi.org/10.1371/journal.pone.0321517.g001

The number of beds in TKM hospitals increased from 12,819–34,378, with a CAGR of 11.58%. Similarly, TKM clinic beds grew from 3,155–7,933, showing a CAGR of 10.79%. In contrast, the total number of beds across all institutions in Korea increased from 630,114–724,212, with a CAGR of 1.56%. During the same period, the number of beds in WM hospital and clinic decreased with CAGRs of -4.16 and -5.60%, respectively (Figs 1 (c) and (1d)).

The total number of TKM doctors increased from 18,199–22,807 with a CAGR of 2.54%, which is similar to the change of WM doctors during the same period. However, the number of TKM doctors in hospitals grew from 18,199–22,807, showing a CAGR of 2.54%. The most interesting change appeared in the number of WM doctors working in TKM hospitals, which increased substantially from 91 to 559, with a CAGR of 22.35% (Fig 2).

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Fig 2. Traditional medical doctors in Korea between 2013 and 2022.

TKM: Traditional Korean Medicine, WM: Western Medicine.

https://doi.org/10.1371/journal.pone.0321517.g002

The annual values for each indicator are provided in the S1 Table, which presents the number of medical institutions, beds, and medical doctors in Korea between 2013 and 2022.

Changes in medical service utilization: patients, claims, and medical expenses

The total number of patients who submitted claims to HIRA for TKM services experienced a decrease from 13,346 thousand (2013) to 11,585 thousand (2022), with a CAGR of -1.56%, which contrasts with the number of patients in WM services remaining relatively stable over the same ten-year period (CAGR of 0.78%). It was shown that the patients had negative annual growth since 2015. However, there is a notable divergence when differentiating between inpatients and outpatients. The number of inpatients in TKM institutions increased from 114 thousand (2013) to 177 thousand (2022), with a CAGR of 5.01%, while the number of outpatients showed a CAGR of -1.62% (Fig 3 (a1)). This discrepancy becomes more pronounced when examining the patient numbers separately for TKM hospitals and clinics. The number of patients in TKM increased from 689 thousand to 849 thousand over 10 years (inpatients with a CAGR of 5.30% and outpatients with a CAGR of 1.73%) (Fig 3 (a2)), whereas the number of patients in TKM clinics decreased with a CAGR of -1.81% (Fig 3 (a3)).

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Fig 3. Patients, claims, and medical expenses for TKM services between 2013 and 2022.

CAGR: Compound Annual Growth Rate, TKM: Traditional Korean Medicine, WM: Western Medicine.

https://doi.org/10.1371/journal.pone.0321517.g003

The number of claims showed a trend similar to the change in patient numbers. Total claims in TKM institutions decreased from 101,126 thousand in 2013–91,302 thousand in 2022, with a CAGR of -1.13%. However, when separating inpatient and outpatient claims, inpatient claims increased significantly with a CAGR of 9.57%, while outpatient claims decreased with a CAGR of -1.17% (Fig 3 (b1)). Analysis of claims by institution type revealed that claims for inpatient services at TKM hospitals increased by approximately 9.99% (Fig 3 (b2)), and outpatient claims increased by 2.36%, contrasting with the decline in claims at TKM clinics (Fig 3 (b3)).

The total medical expenses reimbursed to TKM institutions increased from 2,109 billion Korean won (KRW) in 2013–3,153 billion KRW in 2022, with a CAGR of 4.57%. This growth appears to be driven by increased medical expenses associated with inpatient care (CAGR of 14.40%). Excluding 2020, the year the COVID-19 pandemic began, there has been a positive annual growth rate every year since 2013 (Fig 3 (a3)). The significant increase in inpatient expenses is more pronounced when looking into the data of TKM hospitals, separately. In TKM hospitals, inpatient expenses rose from 128 to 430 billion KRW, with a CAGR of 14.34%, while outpatient expenses increased from 71 to 143 billion KRW, with a CAGR of 7.97% (Fig 3 (c2)). In contrast, inpatient expenses in WM hospitals grew at a CAGR of 5.25% and outpatient expenses grew at a CAGR of 9.41% during the same period, highlighting a distinguishing trend in expenses change between TKM and WM institutions.

The medical expenses per patient in TKM institutions increased from 158,000–272,000 KRW. Notably, the expenditures per inpatient rose significantly from 1,189,000–2,572,000 KRW, with a CAGR of 8.95%. The expenses per claim also increased from 20,855–34,526 KRW with a CAGR of 5.76%, which is lower than the annual growth rate of 7.35% observed in WM institutions.

It is noteworthy that all indicators, including the number of patients, claims, and medical expenses, showed a serious decline during the coronavirus disease 2019 (COVID-19) pandemic (2020–2021). Still, there was a substantial increase in claims and medical expenses for inpatient care at TKM hospitals and clinics during the same period despite the overall decrease.

The specific data for each indicator are provided in the S2 to S4 Tables, which present the number of patients (S2 Table), the number of claims (S3 Table), and medical expenses reimbursed by national health insurance (S4 Table) in Korea between 2013 and 2022.

Changes in medical service utilization: distribution of medical examination or treatments used in TKM

Meridian function tests consistently held the highest proportion of claim counts and medical expenses over 10 years, followed by pulse wave examination, Yangdorak test, personality examination, dizziness examination, and dementia examination. Meridian function tests dominated both inpatient and outpatient services. Yangdorak test showed a decreasing trend in both claims (5.69% in 2013 to 3.39% in 2022) and expenses (3.26% in 2013 to 3.07% in 2022), whereas pulse wave examination (8.27% in 2013 to 16.79% in 2022 for claims, 10.92% in 2013 to 14.93% in 2022 for expenses, respectively) and personality examination (0.21% in 2013 to 1.26% in 2022 for claims, 0.78% in 2013 to 5.02% in 2022 for expenses, respectively) exhibited growth. Dizziness and dementia tests remained minimal throughout the period (Figs 4 (a) and 4(b)).

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Fig 4. Distribution of medical examinations and treatments of TKM between 2013 and 2022.

The unit of the Y-axis is %.

https://doi.org/10.1371/journal.pone.0321517.g004

Manual acupuncture had the highest proportion of claim counts and medical costs, followed by cupping therapy. Manual acupuncture dominated both claim counts and costs, but its composition ratio decreased over the ten years (59.48% in 2013 to 50.05% in 2022 for claims, 63.05% in 2013 to 47.72% in 2022 for expenses, respectively). In contrast, cupping therapy showed increases in claims (12.76% in 2013 to 15.09% in 2022) and costs (16.93% in 2013 to 21.65% in 2022) over the ten-year period. Electroacupuncture and moxibustion therapies also demonstrated a substantial increase in usage. The most notable change was observed in Chuna manual therapy. The treatment began to show claims in 2019 and revealed a steep increase of 51.8% in claim counts and of 64.4% in cost for 3 years (2019–2022) (Figs 4 (c) and 4(d)).

The specific data for each indicator are provided in the S5 and S6 Tables, which detail the claims and medical expenses for TKM examinations (S5.1 and S5.2 Tables) and treatments (S6.1 and S6.2 Tables) in Korea between 2013 and 2022.

Key findings

This was a repeated cross-sectional study using comprehensive health insurance claims data from HIRA in Korea, aiming to analyze the changes in TKM utilization over the last decade (2013–2022).

Significant growth was observed in the number of TKM hospitals (CAGR of 11.08%) and beds (CAGR of 11.58%), while the number of TKM clinics remained relatively stable. The total number of TKM doctors increased (CAGR of 2.54%), but the number of WM doctors working in TKM hospitals rose more substantially (CAGR of 22.35%) over the decade. The total number of patients utilizing TKM services decreased (CAGR of -1.56%), primarily due to a decline in outpatient. However, inpatient claims (CAGR of 9.57%) and medical expenses (CAGR of 14.40%) saw significant increases. Total medical expenses for TKM institutions also increased, driven by the rise in inpatient care costs. About the changes in the composition of TKM diagnostic methods, meridian function tests consistently held the highest proportion of claims and medical expenses, while pulse wave and personality examinations showed growth over the decade. Among treatment methods, manual acupuncture maintained the highest proportion but decreased over time, whereas cupping therapy, electroacupuncture, and moxibustion therapies demonstrated increases in usage. Notably, Chuna manual therapy exhibited a steep increase in claim counts (51.8%) and in costs (64.4%) since 2019.

Implication of the results

First, the observed decline in the number of patients and claims for TKM service over the past decade can be interpreted in terms of the changes in the overall population of Korea. The official population increased slightly from 50,429 thousand in 2013–51,673 thousand in 2022 (CAGR of 0.98%) [15], resulting in a decrease in the proportion of TKM users relative to the total population from 26.5% to 22.4%. This seems relatively more decrease, compared to the previous studies on TKM utilization conducted in other countries [16] such as Taiwan (26.8% in 2011) [10], the United States (42.1% in 1997) [8], and Denmark (24% in 2021) [17], and the CAGR of patients in WM institutions (0.78%) during the same period in Korea. The significant slowdown in population growth may have had a more substantial impact on the utilization of TKM.

One of the possible factors contributing to the reduction in TKM utilization in Korea may have been the impact of the COVID-19 pandemic, considering that the number of patients and claims experienced severe negative growth between 2020 and 2021(Fig 3). COVID-19 reduced access to healthcare services and altered health-seeking behaviors due to lockdowns, social distancing measures, and fear of infection in healthcare settings. Previous studies reported that the impact of COVID-19 on complementary and alternative medicine was considerable [18,19]. Another study also reported that Korea experienced a reduction of medical utilization in outpatient by 15.7% and inpatient by 11.6% in overall healthcare service [20]. A quantitative analysis such as an interrupted time-series analysis is needed to determine whether COVID-19 has influenced the changes in the number of TKM users in the future.

Second, the increase in medical expenses reimbursed to TKM services over the research period (CAGR of 4.57%), particularly driven by inpatient care, reflects an increasing reliance on TKM for more intensive treatments within the Korean healthcare system. The medical expenses per patient or claim also increased, suggesting payers are willing to spend more on TKM services. Even though the average rates of change are lower than those of WM institutions, they outpace general inflation in Korea. The Consumer Price Index (CPI) of Korea rose from 93.0 in 2013 to 107.7 in 2022 (2020 as the base year with CPI of 100) at a CAGR of approximately 1.57% [15]. This disparity indicates that the increase in TKM medical expenses is not merely a result of inflation but reflects a real increase in the cost and utilization of TKM services.

Third, this study indicates the growing importance of hospitals within the TKM system. Over the past decade, there has been a notable increase in healthcare resources for TKM hospitals, which is mirrored by the rise in the number of patients and claims in TKM hospitals. Several factors may contribute to this trend. As revealed in previous studies, patients prefer hospitals over clinics due to the perceived higher quality of care, advanced medical technology, and better-equipped facilities, as well as trust and the reputation of hospitals [21–23]. Another contributing factor may be the increasing interest in integrative or collaborative medicine in Korea. Although the Korean medical system is bifurcated into WM and TKM in terms of education, licensing, diagnosis, and treatment [3,4], there is a growing need for cooperation between the two medical fields. This is facilitated, for example, by establishing WM departments within TKM hospitals (not clinics), allowing for integrative or collaborative care. Public preference for collaborative care might have resulted in the growth of TKM hospitals, which is supported by one of the findings that the number of WM doctors working in TKM hospitals increased (Fig 2).

Lastly, there has been a diversification in the diagnostic and treatment methods provided by TKM over the past decade. Even though meridian function tests consistently held the highest proportion of claim counts and medical expenses, the expansion of personality examinations highlights the growing inclusion of psychiatric diagnostic tests in TKM. The treatment methods in TKM have also become more varied. While manual acupuncture is holding the highest proportion of claim counts and medical costs, other treatments such as cupping therapy, electroacupuncture, and Chuna manual therapy have shown significant growth. These changes are largely influenced by the evolving health insurance coverage for TKM. The inclusion of new diagnostic and treatment methods, such as Chuna manual therapy, in the NHI scheme has played a crucial role in their adoption.

The role of traditional medicine within national healthcare systems varies considerably across the globe. In the United States, complementary and alternative medicine (CAM) operates largely outside the conventional insurance framework, with utilization driven by consumer demand and out-of-pocket spending [24]. Mainland China has integrated traditional Chinese medicine (TCM) into its national healthcare system with government support [25]. Taiwan’s national health insurance system covers TCM services, contributing to its increased utilization in that population [26]. In contrast, the United Kingdom’s National Health Service (NHS) offers limited coverage for traditional medicine practices such as acupuncture, often relying on private insurance or out-of-pocket payments [27]. Korea’s TKM system, with its national health insurance coverage and distinct category of licensed doctors, represents a unique model that balances traditional practices with modern healthcare infrastructure.

In line with the World Health Organization’s strategies promoting traditional and complementary medicine [7], there is growing global recognition of its potential role in healthcare. In the United States, CAM has shown steady growth, with acupuncture being a popular modality [24]. Similarly, Taiwan has seen increasing use of TCM among older adults [26]. In mainland China, the TCM healthcare workforce has been greatly strengthened, especially in primary healthcare settings [25], reflecting the government’s emphasis on strengthening TCM services. Our study highlights the growing importance of TKM hospitals in Korea and the increasing integration of TKM with WM, suggesting a potential convergence of healthcare approaches. Further research is needed to understand the long-term implications of these changes on healthcare delivery.