Taiwan's Health System
Four Thorny Issues for the New Health Minister
Taiwan's new health minister Wen-ta Chiu faces a task both daunting and urgent: reforming the problem-ridden public health care system. Four big issues are particularly pressing.
Four Thorny Issues for the New Health MinisterBy Ming-ling Hsieh
From CommonWealth Magazine (vol. 466 )
In late January, Taiwan's top watchdog body, the Control Yuan, issued a sweeping report on the debt-saddled National Health Insurance (NHI) system. In its pages are many challenges awaiting Taiwan's new health minister Wen-ta Chiu.
The voluminous report, authored by Huang Huang-hsiung and other Control Yuan members, contains 55 suggestions as to how public health care could be improved.
In particular, four major problems need to be tackled immediately.
Problem 1: Medical School Graduates Scorn General Medicine
In the past medical students used to focus on the four major fields of general medicine and primary care – internal medicine, surgery, obstetrics and pediatrics. But since Taiwan instituted the universal, compulsory NHI system in 1995, these disciplines have suffered a severe exodus.
Taking surgery as an example, the Department of Health projects that 250 physicians need to train as specialized surgeons every year to meet demand. But between 2001 and 2009 an annual average of only 157 physicians were licensed as surgeons, falling 40 percent short of the target.
Instead, medical school graduates are heading for less exhausting and more lucrative specializations such as otolaryngology (Ear, Nose & Throat), dermatology and ophthalmology. At the Chung Shan Medical University Hospital in Taichung, the Control Yuan investigators were told that more than 100 applicants competed for a single dermatologist's position that became available at the hospital.
The main reason for this trend, the report notes, is comparably meager pay in the four major medical fields, given that these jobs involve a long period of training, long shifts, overtime work, many medical disputes and a high number of inpatients.
Problem 2: Unequal Medical Care as Community Hospitals Vanish
Fourteen years after the inception of the NHI system, the number of hospitals at various levels is still on the increase, except for local community hospitals, whose numbers have shrunk by 183 or one-third during that period.
Quite a number of the remaining 385 community hospitals have been transformed into dialysis centers, specialized mechanical ventilation units (that care for patients requiring assisted breathing) or psychiatric hospitals, while just about 60 percent are still traditional general hospitals.
As a result, many remote areas might not have access to essential primary care. Hsieh Wen-huei, honorary chairman of the Taiwan Community Hospital Association, points to the dismal situation in the town of Beidou in Jhanghua County. Currently, the local Cho Hospital can only maintain nighttime emergency room services with financial support from the Department of Health's Medical Care Development Fund and doctors from the Changhua Christian Hospital in Jhanghua City. But the emergency room does not have an X-ray technician or a pharmacist. The situation is similar in Tianjhong, another town in Jhanghua County.
Hsieh points out that the NHI system allows hospitals of different levels to provide the same services, yet reimburses them differently for services rendered. These reimbursements fail to consider that community hospitals actually have to bear higher costs for medicine, equipment and personnel, because they are small and based in remote areas. Since people are universally covered by the NHI, they are free to go see the doctor of their choice. As a result, Hsieh laments, patients flock to the big hospitals, while community hospitals struggle to survive.
He warns that unless the NHI system is reformed, medical care will remain top-heavy, medical expenses will continue to rise, and health care for the disadvantaged in rural areas will be neglected. Under such conditions the NHI "will become an elusive dream."
Problem 3: Writing Prescriptions to Boost the Bottom Line
In what is widely perceived as evidence for a decline of professional medical ethics, doctors have long relied on supplementing their income by writing prescriptions. When procuring prescription drugs in large quantities, hospitals are able to negotiate large rebates. As a result, they may pay less for a certain medicine than the NHI reimbursement price, conveniently making a profit.
Six drug price investigations by the Bureau of National Health Insurance (BNHI) in the past have helped to save NT$28 billion in prescription drug costs. But as soon as the BNHI investigates and lowers reimbursement prices, many hospitals press drugmakers for further rebates to secure profits. As a result, drugmakers are so much under pressure to lower prices that some have even pulled out of the Taiwanese market altogether.
Hospitals are so bent on making money from prescriptions because the NHI pays comparably little for professional medical services such as diagnosis fees, therapeutic procedure fees and surgical fees, the report concludes.
Chang Ly-yun, chairwoman of the Taiwan Healthcare Reform Foundation, denounces these entrenched practices, arguing that in the end the patients are the victims. Chang believes that once clinics or hospitals can make money when prescribing drugs, they have an incentive to prescribe patients more medicine than necessary, leading to such problems as "patients taking medicine they shouldn't take" and "patients taking medicine they don't need."
Problem 4: Who Gets a Piece of the Limited NHI Pie?
Presently, just 0.33 percent of the population require dialysis or assisted breathing machines, but 12 percent of the entire NHI budget are spent on these medical procedures. The 3.61 percent of the population who ail from severe illnesses utilize 26 percent of the NHI budget.
Pointing to dialysis, Control Yuan member Huang questions whether medical care resources are spent in a reasonable manner, given that the number of dialysis centers has multiplied 3.57-fold in 13 years with the total number of hospital beds in such facilities increasing 9.25 times. The NHI allocates an independent budget to dialysis as a "medical specialty." Over the past several years, health care expenses for dialysis have increased more than for any other medical specialty. Hsieh believes that the utilization of medical resources needs to be reconsidered with regard to which circumstances make dialysis advisable, how the procedure is to be funded by the NHI, and how the costs of dialysis treatment compare to its benefits.
The questions that Chiu will have to answer as Taiwan's new health minister are, "How, who, and how much to pay?" These are much more difficult and more crucial issues than merely balancing the NHI budget.
Translated from the Chinese by Susanne Ganz