For the past five years, I have had the privilege of living and working in Taiwan, progressing from a Gold Card holder to an APRC. As a project manager at the Koo Foundation Sun Yat-Sen Cancer Center (KFSYSCC), I have not only observed the Taiwanese healthcare system but also actively participated in shaping its future. Through initiatives like the New School for Leadership in Healthcare and the Huang Scholarship program, I have been involved in training future healthcare leaders, ensuring they are well-equipped to tackle the pressing challenges ahead. One such challenge that has emerged is healthcare quality transparency. 

As Taiwan stands on the cusp of a critical presidential election, it is time to place this issue under the spotlight. The focus on healthcare quality is not only a moral obligation but a financial necessity. Investing in healthcare quality transparency can help realize healthcare savings and argues for its prioritization in the next president's policy agenda.

The Current State of Taiwan’s Healthcare 

The National Health Insurance (NHI) system in Taiwan has been widely recognized as a successful model for providing healthcare coverage to over 23 million residents. Since its establishment in 1995, NHI has offered affordable and equitable access to a comprehensive package of healthcare services.

In Taiwan, various voluntary systems exist for measuring healthcare quality on a national scale. The National Health Insurance Agency (NHIA) collects and evaluates data on quality-of-care provided by individual healthcare facilities, such as age-adjusted five-year survival rates for various types and stages of invasive cancers. This data serves as a basis for internal benchmarking, enabling hospitals to compare their performance regionally, nationally, and by hospital type. 

The data and reports available to hospitals are not made public. While NHIA does disclose a handful of healthcare performance metrics (e.g., inpatient surgical site infection rates, heart attack mortality rates, use of antibiotics more than 3 days after surgery), the general public cannot meaningfully use this data. Statistics are aggregated across hospital regions and hospital types, hindering the public’s ability to conduct direct, disease-specific comparisons between different healthcare facilities. Furthermore, few hospitals voluntarily release their own data on quality of care. This lack of transparency creates a considerable obstacle for patients navigating a healthcare market that is both regulated and minimally competitive.

A Personal Experience: The Opaque System in Action

I have a friend who was recently diagnosed with breast cancer. This event put me in the unique position of witnessing firsthand the challenges of choosing a healthcare provider within Taiwan's opaque system. In the United States, one could easily consult an array of public data sources to evaluate the quality of cancer care offered at various institutions. One can find things such as performance metrics, volume of services, survival rates, independent ratings, and patient reviews—comprehensive information to make an informed decision. In Taiwan, such resources are scarce and hard to find.

Most medical guides in Taiwan simply advise choosing a hospital that has passed the cancer diagnosis and treatment quality certification or to opt for a hospital closer to home. Some recommend certain popular physicians, but there are no measures associated with why they should be chosen. The lack of concrete, comparative data compelled my friend to rely on word-of-mouth recommendations and anecdotal information. 

Eventually, she asked to leverage my connections within KFSYSCC to gather information. She found that the center has a robust breast cancer program with specialized care and treatment options with outcomes published in KFSYSCC’s annual reports and in peer-reviewed major journals. While this resolved her personal dilemma, it reinforced a larger, systemic issue: the absence of transparent, publicly available healthcare data in Taiwan.

Consequences of Limited Transparency

This lack of quality transparency is problematic for several reasons. For one, it is difficult for patients to make informed decisions about where to seek care. Patients and their families cannot review survival or mortality rates, making it impossible to determine which hospitals provide better care. Secondly, there is little external pressure to invest in better patient care.

Currently, there are no entities in Taiwan that are similar to the Leapfrog group in the United States that publishes hospital safety grades and advocates for healthcare transparency, accountability, and quality improvement. 

Failure to provide quality data puts a strain on the global budget. In Taiwan, NHIA pays fee-for-service rates for many healthcare procedures irrespective of the healthcare facility visited by the patient. Unbound from significant financial constraints and with no primary care gatekeeping mechanism, patients have the autonomy to choose any healthcare facility and specialist. Because performance and outcome indicators are not available, patients rely on non-performance related criteria such as location, reputation, academic credentials, availability, and providers’ stated expertise. Selecting facilities with lower-quality services puts pressure on Taiwan’s global healthcare budget as complications, overutilization, and suboptimal management of disease unnecessarily add to the country’s healthcare expenditure. 

A lack of transparency also leads to increased healthcare spending. In the absence of accountability for the quality of care provided, providers lack the incentive to enhance the effectiveness of their services. To address this, NHIA implemented one performance-based payment method for cancer in 2001, a bundled payment for breast cancer patients. Notably, breast cancer bundled payment programs in Taiwan demonstrated superior outcomes while successfully maintaining costs even as fee-for-service provider payments eventually exceeded bundled payment pricing. However, despite these achievements, participation in breast cancer performance-based programs remains voluntary, and NHI’s performance-based payment coverage of other diseases is limited. Fee-for-service continues to be the primary payment system employed by NHI. 

The inefficiencies perpetuated by a lack of transparency not only have human costs but also financial repercussions. A system that fails to make quality metrics transparent perpetuates a cycle of wasteful spending. Patients may end up defaulting to the most expensive options, falsely equating cost with quality, or to the most convenient choices, which may not offer the best care. Institutions, knowing they are not being closely scrutinized, may lack the urgency to streamline services or eliminate redundant or ineffective treatments. Ironically, this can exacerbate costs for both the healthcare system and the patient. Though NHI has made strides with its performance-based bundled payment models for conditions such as breast cancer, the scope is limited. Until these payment systems are expanded and integrated with a more transparent quality reporting mechanism, inefficient spending will persist, hindering the overall progress of Taiwan's healthcare system.

Impact on Chronic Conditions

Amidst escalating healthcare costs and the inefficiencies of fee-for-service models, the issue of managing chronic conditions introduces an additional layer of complexity to Taiwan's healthcare system. Chronic disease accounts for about 30% of total healthcare expenditures and affects a quarter of the population. Data from 2020 reveals that the average utilization rate for outpatient services stands at 14.2 visits yearly per individual, with physicians seeing more than 50 patients in a half-day outpatient clinic session. This yields an average consultation time of approximately five minutes per patient.

Such limited interaction constrains the scope of investigation into patients' chief complaints and minimizes opportunities for comprehensive discussion and counseling. This curtailed approach is particularly detrimental to the effective management of chronic diseases, frequently resulting in redundant visits and consultations, thereby further taxing an already burdened healthcare infrastructure.

This situation serves as a critical case study, illustrating how transparency deficits extend beyond operational inefficiencies to significantly impact the quality of patient care, especially for those suffering from chronic conditions. The introduction of transparency protocols for healthcare outcomes and relevant metrics has the potential to be a transformative force, providing a vital evaluative framework for assessing the efficacy of patient-doctor interactions in Taiwan.