In early April, National Health Insurance Administration (NHIA) officials reviewing uterine myomectomy and hysterectomy data were startled to discover suspicious figures reported by Taipei Medical University Hospital, which reported zero figures to the NHIA on surgical procedures using the da Vinci robotic surgical system.

The da Vinci procedure is a minimally invasive form of surgery, using a robotic arm known by that name.

Liu Wei-min, the physician best known across Taiwan for using the da Vinci procedure, heads up the gynecology department at Taipei Medical University Hospital. Liu has stated that since 2012, he has conducted over 2,000 da Vinci procedures, most of which were hysterectomies. This is considered a world record number of procedures.

“I’ve done the most (da Vinci procedures) in the world,” said Liu during an interview last August with CommonWealth. It is upon this perceived authority in this area that Taipei Medical University Hospital has become an international da Vinci training center.

Thus, when NHIA director general Lee Po-Chang noticed that Taipei Medical University Hospital, home of the world’s highest number of da Vinci procedures and Liu Wei-min’s specialty, had reported zero procedures to the NHIA, “We couldn’t believe what were seeing.”

Upon further investigation of the data, the NHIA discovered that Taipei Medical University Hospital was not alone, and that while conducting da Vinci procedures, 38 hospitals and clinics around Taiwan had charged patients NT$180,000 to $220,000 in out-of-pocket fees, while submitting requests to the NHIA for coverage in the name of laparoscopy (a more conventional form of minimally invasive surgery).

This reached 7,810 cases over a period of five years, resulting in NHIA payouts of NT$350 million in false and inflated costs reported by these medical institutions.

So how did the figure of 7,810 cases come about? “We had some of the data in our hands, which we were able to extrapolate. Think about it: The company that makes the da Vinci Surgical System (Intuitive Surgical) would never give us the individual data for any particular hospital that uses da Vinci, as that is a company secret, and they protect their clients,” relates Lee.

Lee admits that the NHIA does not have any way of knowing about certain data that goes unreported by hospitals. “So we have corresponding codes (for da Vinci procedures), which we crunch together to analyze what sort of volume the hospitals are handling.”

For instance, the NHIA visits various public health centers in the districts in which the hospitals are located to ask for information on how much money various hospitals submit when they report out-of-pocket da Vinci procedure expenses. This is because hospitals that charge out-of-pocket money from patients must report the fees to the district health center. “Then we take a look at how much money each hospital informs us about or reports for da Vinci procedure reimbursements,” Lee explains.

“Hospitals don’t take funds for da Vinci procedures from patients and National Health Insurance at the same time! They charge patients equipment, material, and maintenance fees related to da Vinci procedures, and submit expenses to the NHIA for laparoscopy costs, because national health insurance doesn’t cover da Vinci procedure costs!” wrote an emphatic Lee Wei-min on Facebook.

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Diving into the NHIA’s explanation, da Vinci procedures cover 36 different applications, but only radical prostatectomy is eligible for reimbursement from the NHIA. For other surgical items, diagnostic, hospital room, examination, medicine, and anesthesia fees are covered by National Health Insurance. However, the patient must bear surgery and special materials fees.

Taking the example of a uterine tumor removal, if the doctor uses the da Vinci procedure but submits to the NHIA for reimbursement for laparoscopy, in addition to collecting the out-of-pocket fee for da Vinci surgery from the patient, it can also recoup NT$20,789 from the NHIA. When that figure is prorated by an average of 0.8 to 0.9, it is equivalent to exchanging for less than NT$20,000 in cash.

The biggest part of the controversy is that National Health Insurance currently does not approve reimbursements for uterine fibroid removal (myomectomy procedures) that meet the standard for da Vinci procedures. And since patients cough up upwards of NT$220,000 out of their own pockets, why do doctors and hospitals submit for reimbursements from the health insurance system in the name of other types of surgery?

Asked these questions by CommonWealth, Liu Wei-min stated that he had not received any official communications, but rather learned about the parameters for reporting for da Vinci procedure reimbursement during a hospital staff meeting. As for routine filing for NHI reimbursement, this is normally handled by the hospital’s insurance department.

Nevertheless, in Liu’s view, the da Vinci procedure is merely an upgrade to the established laparoscopy procedure. “Just like laparoscopy was at first, hospitals didn’t know what to do when there was no code for filing (for NHI payments). And since I actually did remove a uterus, all I could do was report it as a conventional hysterectomy, and the patient paid for extra costs like equipment and materials. This went on for around seven or eight years.”

Liu Wei-min sees patients paying out of pocket as “being punished” for electing to undergo a da Vinci procedure. “Everything else, like hospital beds, tests, and radiology, is covered by health insurance. The gap here is just too big!” he laments.

“But you aren’t telling me that you’ve gone ahead and done a da Vinci procedure, so when I look at the information I’m completely in the dark,” counters Lee Po-Chang.

Facing accusations that National Health Insurance’s failure to cover da Vinci procedures is “lagging behind the times,” Lee retorts, “He may be upset, but I’m really pissed off.” “As director of the National Health Insurance Administration, of course I want to maximize the use of health insurance resources,” he exclaims.

Should da Vinci procedures be included in NHI coverage? According to Lee, such questions should be determined by returning to the national health insurance’s Health Technology Assessment (HTA) mechanism.

With limited health insurance resources available, new medical technology must be subjected to the HTA process, involving a two-phase evaluation by experts to judge whether national health insurance should cover a given medical technology based on its efficacy, cost-effectiveness, and economic impact.

The HTA board conducted discussions on da Vinci technology in 2013, 2017, and 2018, ultimately determining that it “does not meet local economic benefits” and therefore opted to exclude the technology from NHI coverage.

The only exception has been for radical prostatectomy procedures, covered under NHI since 2017, as statistics show that the da Vinci surgical technique is safer and more effective than conventional open style prostate surgery.

Lee Po-Chang believes that whether or not to include da Vinci procedures under NHI coverage deserves further discussion, but that the contents of existing filings to date should be clarified, and that “unnecessary” health insurance expenditures must be be recovered first.

An emotional Lee said, “The National Health Insurance Administration and medical community have always maintained the principle of credibility. Did you do what you reported having done? Nobody knows. And this can lead to the issue of inflated and false reporting.”

The day before our interview, Lee attended a high-level gathering at which there was no shortage of former minister-level officials. One such attendee was a former minister of health and welfare, who expressed his admiration and approval of Lee’s willingness to get to the bottom of inflated da Vinci procedure reporting without fear of offending others.

“Everyone knows there are a lot of irregularities and abuses (of Taiwan’s National Health Insurance system), but nobody dares do anything about them,” he said. “But I think that unless you go out and get rid of them, the National Health Insurance system cannot be saved,” he added emphatically.

According to reports dated April 27, in the wake of the emerging row over inflated cost reporting for da Vinci surgical procedures, the National Health Insurance Administration has set a April 19 deadline for the 38 hospitals and clinics allegedly in violation to come clean.

Taipei Medical University Hospital, suspected of making false reports worth the most money, has returned nearly all the offending funds, amounting to NT$120 million, the highest figure for related incidents. Shuangho Hospital, operated under the direction of Taipei Medical University Hospital, has returned all of its offending income.

Translated by David Toman
Edited by Sharon Tseng