Taiwan’s emergency care capability has drawn worldwide attention.

It was widely perceived as a miraculous achievement of Taiwan’s health care system that only three percent of the victims who sustained severe burns in an explosion at the Formosa Fun Coast amusement park in 2015 died. Another world-baffling fact is that Taiwan, an island with a population of 23 million people, recorded 7.7 million visits to the emergency room last year.

Taiwan can pride itself on an NHI system with universal coverage that is affordable and delivers top-quality medical care. But because it is so affordable, people exploit the system. As a result, the situation in emergency departments has become untenable, an issue that was at the core of the mass resignation of emergency room physicians at three branches of Chang Gung Memorial Hospital in June. 

NHI Abuse Creates ER Bottlenecks

It is 9 p.m. on an August evening and the emergency room at the Linkou Chang Gung Memorial Hospital, which operates round-the-clock every day of the year, is teeming with people.

A nurse pushes a hospital bed with a frail, thin elderly person into an observation room. A digital display at the entrance lists the number of patients waiting to be admitted to hospital as “100 people.” Sometimes this number soars to 200 or even 300.

Around the corner, patient numbers flash at the doors of several rooms offering “urgent outpatient clinics.” Among those waiting for their numbers to be called is a middle-aged man in a wheel-chair and a young mother holding a crying child. None of these patients are in critical condition that would warrant emergency care or urgent care, but they have all come to the emergency department to see a doctor.

This is a typical everyday situation at the Linkou Chang Gung Memorial Hospital, which has the highest emergency care volume in all of Taiwan.. An average of about 600 patients flock to the emergency department every day, which adds up to nearly 220,000 patient visits per year.

The hospital’s development into the leading provider of emergency care is owed to the vision of its founder Wang Yung-ching. 

Chen Rih-chang, whose dismissal as director of the Linkou Medical Center’s emergency department triggered the subsequent resignation wave, remembers how Wang more than 20 years ago expressed his outrage at the dismal situation of emergency care in Taiwan. Chen, who meanwhile has become deputy superintendent of Tao Yuan General Hospital, quotes Wang as saying: “Why does the place where treatment is most urgent and most needed use the most junior physicians to see patients?” As emergency rooms were not considered important at the time, they were often staffed by internal medicine and surgery interns or residents who were working shifts.

In 1992, Chang Gung Hospital broke with tradition by establishing emergency care as a specialty, with attending physicians providing round-the-clock services in several shifts while also training emergency care specialists. Subsequently, other hospitals in Taiwan followed suit.

This means that Taiwan’s emergency care specialty is almost the same age as the NHI program, which was launched in 1995. Over the past two decades, emergency care has saved countless lives in Taiwan regardless of the patient’s financial status thanks to universal NHI coverage.

Yet due to the design flaws of the NHI system and citizens’ habitual visits to the ER for even minor ailments, the emergency departments are overcrowded and stretched to their limit. This is one reason why Taiwan’s health care system faces a massive crisis.

Presently, emergency rooms across Taiwan register 7.7 million visits per year, up 66 percent since the inception of the NHI. NHI expenditures for emergency care have risen annually since, reaching 21.6 billion NHI points (roughly equal to NT$20 billion) last year, which amounts to a NT$3 billion-point increase in five years.

Moreover, emergency room visits focus on hospitals that are classified as medical centers such as Chang Gung Memorial Hospital, National Taiwan University Hospital and Veterans General Hospital. “They crowd into these few hospitals although there are other hospitals nearby. They blindly believe that they need to be treated at a major medical center. You say there is overcrowding; where do we face overcrowding?” asks Shih Chung-liang, director of the Department of Medical Affairs at the Ministry of Health and Welfare, as he picks up his mobile phone. A look at the real-time emergency room monitoring system on the display reveals that emergency room utilization is extremely uneven across the island. In Taipei City, for instance, the emergency rooms at Taipei City Hospital and other regional hospitals are not overcrowded at all.

ER Crisis No. 1: 
ER Visits for Non-Critical Conditions 

While the emergency rooms in medical centers should be reserved for last-resort treatment of severe, life-threatening conditions and injuries, they are overrun by patients whose ailments require all but urgent care.

In 2015, 85 percent of patients seeking help at the emergency rooms of medical centers were triaged as level three to five, non-critical cases, an increase of six percentage points over 2014.

“It’s really troublesome,” remarks Shih, who used to work as ER specialist, as he grabs a sheet of statistics. With a heavy sigh, he notes that “abuse” is one of the reasons behind the NHI crisis. “Too convenient, to cheap, no need to wait, the system faces enormous problems,” observes Shih. 

Many citizens, it would appear, consider NHI-covered emergency care as a year-round 24/7 service like the “always open” 7-Eleven convenience stores. Like a McDonald’s Drive-thru, walk-in emergency rooms provide instant service, completing examination, blood test, X-ray and other necessary steps within 20 minutes.

The patients pay a lump sum for the entire package. Patients who use the ER although they do not have a severe condition pay a registration fee of NT$300 plus a uniform co-payment of NT$550. For similar services in certain other nations, they might have to pay more than NT$10,000. 

ER Crisis No. 2: 
Long Waiting Lines for Hospital Beds

Research has yielded rather frightening results: Due to the overcrowding in ER, patient mortality could rise. Last year, for every 100 patients who were sent to ER with a critical condition such as myocardial infarction or stroke, 12 stayed in ER for more than 24 hours because no hospital bed was available. 

This is despite the fact that Taiwan’s acute hospital bed capacity is actually higher than that in almost half of the OECD countries, including Britain and Canada, with 3.4 beds per 1,000 residents. Chen compares the situation to that of a clogged water pipe, observing, “This is a problem of ‘admission’ and ‘discharge’.”. At the front end, patients crowd into the medical center, of whom a certain ratio is admitted to the hospital. However, when hospital beds are fully occupied at the back end, newly admitted patients cannot be distributed to other wards but must remain in ER until a bed becomes available.

The “hidden rules for hospitalization” that exist at all hospitals further aggravate the situation.

The Taiwan Healthcare Reform Foundation (THRF) points out that the hospitals' internal bed allocation systems are poor, saying that certain influential figures at hospitals have retained beds for VIPs, and hospitals have refused to take patients with multiple chronic diseases. Some hospitals are even forced to close wards because of personnel shortages. All these factors lead to very limited bed availability, so that patients must remain in the emergency department during their wait.

ER Crisis No. 3: 
Aging Society Strains Limited Health Budget

Over the past two decades, the NHI’s annual budget has risen from more than NT$200 billion to NT$650 billion this year. The problem is that Taiwan’s rapidly aging society puts additional strain on already limited health resources and hospitals as a growing number of “old, weak and poor” seek help at emergency rooms.

Chen Kuan-fu, attending physician at the Emergency Medicine Department of the Linkou Chang Gung, feels strongly about this, and he has hard figures from big data analysis to illustrate the trend. “The ratio of internal medicine patients in the ER is rising; we are getting many more elderly people, and the complexity [of cases] is increasing,” Chen points out. This also means that medical personnel need to commit more mental and physical efforts as well as resources to patient care.

However, after the Bureau of National Health Insurance implemented a global budget policy in 2002, effectively putting a cap on medical claim reimbursements, hospitals need to shoulder budget overruns themselves. 

“In Taiwan, the losses incurred at ER are greater the more patients they see,” asserts a Chang Gung Memorial Hospital administrator. The same goes for hematology and oncology departments, as well as other severe illness departments. Last year the hospital, which makes it a principle not to reject any patients, suffered a NT$3.66 billion cut in NHI reimbursements. The hospital was forced to shoulder these unpaid medical claims. 

Moreover, people who lack money or family support turn to emergency rooms when they need help. Some elderly people become frequent ER visitors after they suffer a fall, or simply because they are not able to manage their chronic diseases, putting additional pressure on NHI resources. 

Only when such patients get access to other forms of social support and assistance can our healthcare system function normally. “Medical care is only the downstream,” notes Shih, hardly hiding his frustration. “Many of these cases epitomize larger social problems.”

ER Crisis No. 4: 
Overwork and Personnel Shortages 

The overcrowding increases the workload of already overworked medical personnel.
“The system is designed to make a doctor’s visit convenient. The number of patients coming to see a doctor is much higher, and the workload (for doctors) is extremely heavy, but doctors don’t get paid accordingly, so that a large number of nurses and physicians leave the workplace,” reveals Wang Ming-jiuh, anesthesiology professor at National Taiwan University Hospital, adding that Taiwan currently suffers from a medical care crisis due to personnel shortages.

On top of that, the government keeps raising the bar for evaluations in a bid to improve the quality of medical care, but for hospitals that are already struggling for survival given NHI cost containment, this might be the last straw. 

“The demands from the competent authority toward the hospitals keep increasing while [NHI] payments have not risen. Our personnel costs keep climbing year by year, and they are climbing markedly," notes a former Chang Gung Memorial Hospital top administrator.

The hospital’s latest financial report shows that personnel costs as share of medical costs have risen 4 percentage points over the past five years. Many hospitals face the same problem.

“You (the government) demand these medical services but never talk about costs, be it costs for personnel, medication or treatment. That’s why Taiwan can offer a cheap NHI and people enjoy medical services that other countries can only provide after spending a lot of money. In the past, we all endured the pain, endured it until we couldn’t bear it any longer. The entire system is likely to collapse soon,” laments physician-turned-lawmaker Lin Ching-yi.

The recent mass resignation of emergency room physicians at Chang Gung Memorial Hospital is only the tip of the iceberg. Taiwan urgently needs to address the four major ER crises which undermine the proper functioning of its entire medical care system.

Translated from the Chinese by Susanne Ganz