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Saving Lives or Wasting Money?

Taiwan Overdosing on Health Care

Taiwan Overdosing on Health Care

Source:cw

Too many doctor visits. Too many prescriptions. Too many tests. Health care has become a for-profit machine in Taiwan that wastes resources. What is driving the machine and how can it be changed?

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Taiwan Overdosing on Health Care

By Ching-Hsuan Huang, Ming-Ling Hsieh
From CommonWealth Magazine (vol. 487 )

When Jiang Shao-ching saw the list of drugs a friend had been prescribed, he was stunned.

His friend, who had come down with a simple cold and runny nose after a turn in the weather, had been prescribed nine different medicines by his doctor. That's three times as many as Jiang usually hands out on average to patients with far more serious illnesses in his job as a pharmacist at the Koo Foundation Sun Yat-sen Cancer Center.

Of the nine drugs his friend was prescribed, three were bronchodilators, usually given to asthma sufferers to increase airflow to the lungs.  

"This usage of medication is really overboard," says Jiang, who suggested that the doctor may have been trying to please the patient because it's easier to cough up phlegm when one's airways are expanded.

But taking three kinds of bronchodilators comes with a side effect – an accelerated heartbeat – that is potentially dangerous to patients with irregular heartbeats or pre-existing heart conditions. So the doctor also prescribed Jiang's friend a drug to lower his blood pressure to keep his heartbeat in check, even though the patient was not suffering from hypertension.

Taiwan's Three Medical Excesses

In Taiwan, such expansive prescriptions are relatively common and symptomatic of a larger problem. In their scramble to secure resources from the national health insurance system and expand sales of services paid for by consumers out of their own pockets, hospitals have resorted to pumping up "medical service volume," resulting in three excesses affecting Taiwanese patients: too many prescriptions, too many tests and too many operations.

Just before noon at the pharmacy of one major medical center in Taipei, the "next-in-line number" has already exceeded 600 and the waiting area is packed with people. One elderly man who has just picked up his prescription is carrying a bulging bag containing seven packs of medicine. And those are just for his heart condition. He still has to get his medication for diabetes in the afternoon.

Taiwanese visit a doctor an average of 12 times a year, three times the frequency in the United States. Eighty percent of outpatients get a prescription that averages 3.2 kinds of medicine, far more than the one to two types of drugs usually prescribed per doctor's visit in Europe and the U.S.

As eye-opening as those numbers may be, they still may seem understated to the average person.

Almost every chronic disease sufferer in Taiwan has a well-stocked medicine chest at home, filled with big packs of medicine collected from frequent hospital visits.

Mr. Huang, who suffers from high blood pressure, gastric reflux and an enlarged prostate, is a typical example. Three drawers stacked together to look like a safety deposit box, measuring 30 centimeters high and 40 cm deep, are stuffed with medications of many different colors, 20 varieties in all. 

Doctors generously prescribe drugs, and Taiwanese patients love taking them, which many medical experts suspect helps explain why Taiwan has come to be known as the "kingdom of kidney dialysis." From urban areas to the countryside, signs for kidney dialysis centers can be spotted all around the country.

The prevalence and incidence of end-stage renal disease in Taiwan in 2008 were both the highest of any country in the world, according to the 2010 U.S. Renal Data System annual report. From 1996 to 2009, the number of kidney dialysis clinics rose 250 percent, and the number of beds in those clinics rose by a factor of eight.

Excessive prescriptions also reflect the stunningly great extent to which Taiwan's medical system wastes drugs.

Early this year, Control Yuan members Huang Huang-hsiung and Shen Mei-chen discovered after visiting Taiwanese hospitals and clinics that a quarter of the medicine dispensed to patients is not used. This waste costs the national health insurance system an estimated NT$30 billion a year, enough to supply lunches to all of Taiwan's elementary school students for three years. The most abused medicine is that used to treat gastrointestinal ailments.

The Medical Device 'Arms Race'

Meanwhile, efforts by medical centers to actively recruit patients and expand their turnover have become common, and even prestigious National Taiwan University Hospital (NTUH) has joined the fray. 

According to Department of Health statistics, Taiwan's hospitals averaged 44 percent more daily outpatient visits in 2010 than in 2000, while emergency patient visits were up 69 percent and the number of people undergoing operations was up about 50 percent over the same period.

At the same time, hospitals have also engaged in a medical imaging equipment arms race. The number of MRI machines imported into Taiwan nearly doubled between 1997 and 2009, and MRI usage was up 370 percent.

Chang Gung Memorial Hospital, which receives about one-tenth of Taiwan's health insurance system's medical expenditures every year, has the largest number of outpatient visits and medical imaging devices of any medical institution in the country.

The neurology clinic at its Kaohsiung branch alone has 11 examination rooms. On a Thursday afternoon, when seven attending physicians are available to see outpatients, more than 100 patients are waiting outside the doctors' offices. Most of them are there because of headaches, and many will ask for an MRI or CT scan as soon as they walk into the doctor's office. Their fear is that without such tests, they won't be able to know if they have a growth in their brain.

"Doing a CT scan or MRI won't help their headaches," complains a frustrated C.C. Huang, one of the neurologists at Chang Gung's Kaohsiung branch, in the face of constant patient requests for such tests.

Ignoring the Risks

In fact, the headaches of 80-90 percent of the patients Huang and other neurologists see are either migraine headaches caused by a contraction of their blood vessels or tension-type headaches caused by stress or muscle tension.

"Patients only believe in things printed out by a computer or in the worst-case scenarios they hear about from their neighbors," Huang says.

Some patients think that because the tests will be covered by the national health insurance system, there is no downside to doing them. In fact, patients are exposed to the same amount of radiation in one CT scan as that emitted by 300-400 chest X-rays.

One senior medical worker compared the radiation exposure to "standing directly under the sun for a whole year."

MRI machines replace the radiation of computer tomography with electromagnetic waves. But at a time when a growing number of people are worried about the potentially carcinogenic effects of the electromagnetic waves generated by mobile phones, those concerns seem to be ignored when it comes to advanced imaging devices.

The Three Main Drivers of Medical Care Excess

1. Health Insurance System Distortions

Starting in 2002, Taiwan's national health insurance system began to rely on a global budgeting system, which caps the total amount hospitals can be reimbursed every year, to keep medical expenses in check. Today, the global budget has been divided into six regions in Taiwan. The volume of outpatient visits, tests, operations, and inpatient services at the country's hospitals are added up, and then each hospital is allocated a budget based on its share of the nationwide services provided. This creates an incentive for hospitals to compete on quantity to ensure they get a big enough piece of the pie.

As a result, hospitals have aggressively formed nationwide alliances, hoping to increase the scale of their operations. Veterans General Hospital has taken over veterans' hospitals around the country, and NTUH and Chang Gung have also set up several branches.

Another trend has been for hospitals to develop "out-of-pocket services" that are not restricted by the national health insurance system.

Tests paid for "out-of-pocket" have especially become gold mines for medical institutions. Testing centers have sprung up everywhere, offering a myriad of physical checkup packages catering to consumers' every need. Even NTUH, which is generally focused on teaching and research, has set up a completely new Health Management Center, hoping to "become the leading brand in health checkups."

2. Paying Doctors Based on Business Generated

As health care grows increasingly commercialized, doctors are gradually being paid as if they were salesmen working on commission.

In Taiwan, the vast majority of doctors' salaries are derived from the "results" they generate for the hospital: how many outpatients they see, how many inpatients they take care of, how many tests they conduct and how many operations they perform.  

"Results" count for even more in doctors' salaries at private hospitals. Base physician salaries at medical centers barely account for half of average monthly pay and, at some hospitals such as Buddhist Tzu Chi General Hospital, fall short of 20 percent of a doctor's total pay. Some regional hospitals, such as Min-Sheng General Hospital, do not pay their physicians a base salary at all.

"If my base salary is zero, everything depends on results. What do you think? Am I going to do a little extra treatment?" an attending physician at a big medical center in southern Taiwan says bluntly.

Beyond that, national health insurance pays little to doctors for basic patient examinations, and those payments have to be split with the hospital. It is far less lucrative to spend time questioning patients to diagnose their problems than it is to send them directly to the examination table or the operating table.

The national health insurance system reimburses hospitals NT$228 for basic examinations, of which roughly 60 percent, or NT$140, goes to doctors. But send a patient to do a 10-minute transcranial ultrasound, and the insurance system will pay the hospital NT$5,000, of which the doctor will probably collect 15 percent. In other words, a physician can make as much by ordering a single diagnostic test as he can from seeing 5.4 patients. 

3. Unholy Alliance among Hospitals, Doctors, Drug and Equipment Vendors

At the beginning of the year, a purchasing scandal erupted at hospitals directly supervised by the Department of Health (DOH), implicating more people than in any public hospital corruption case in Taiwan's history. From Keelung to the outlying island of Penghu, more than 40 people, including the superintendents and vice-superintendents of nine DOH hospitals, attending physicians, and businesspeople, were indicted on corruption charges involving NT$30 million in kickbacks. Among them was Huang Kun-chang, the ex-CEO of the DOH's Hospital Administration Commission, who prosecutors recommended be given a 25-year prison sentence.

"All one can say about their getting caught this time is that people have played the game for a long time without anything happening, and they relaxed and got careless," says a medical instrument vendor familiar with details of the case.

"These are the rules of the game. As long as there is buying and selling in the medical sector, there's no way to avoid the practice. It's just a matter of how prevalent it is," he added with a shrug of the shoulders.

Once hospitals buy expensive machines, they're bound to schedule as many tests as possible to recoup their investment. At the same time, having committed high "marketing" expenses to get the business, vendors hope hospitals will use the machines a lot so they can earn back their investment through maintenance and part replacement fees.

The ones who are helping the hospitals and vendors achieve their commercial goals are the patients.

Quick Return on Investment

One medical equipment vendor cites the use of X-ray machines as an example of how the system is played. The health insurance system reimburses hospitals NT$200 for every X-ray, so even if a patient shows up with nothing more than a broken finger, the hospital will "attentively" take four X-rays of the injured finger from every angle to be able to collect NT$800.

"Hospitals calculate the rate of return on equipment. X-rays of some parts of the body are done just to drive up volume," the vendor says. "They definitely can make back their investment within half a year."

When physicians order more tests than are necessary, it may not be just to fatten their paychecks or to bolster their reputations for being conscientious. The growing tension and conflict in the doctor-patient relationship has prompted some physicians to resort increasingly to defensive medical practices.

Growing Vulnerability to Lawsuits

NTUH pediatrician Ping-Ing Lee shakes his head in frustration as he talks about the abuse doctors are subject to today. He explains that the most difficult procedure for pediatricians is an IV drip, because locating veins in children can be a challenge. In the past, a pediatrician might search for a vein for more than half an hour, and the families would comfort the doctor, asking him if he wanted to take a break. But now? Lee says that if even one needle misses its mark, medical workers are cursed for "lacking medical ethics."

This adversarial relationship has led to an increasing number of medical-related lawsuits. An average of 1.5 malpractice suits are filed in Taiwan every day – the highest rate in the world. On the defensive, Taiwanese physicians prefer to conduct more tests than may be necessary to keep detailed records in case they get sued.

In coping with the growing tension casting a pall over the doctor-patient relationship, doctors need to not only communicate with their patients more, but also to communicate more effectively.

The Koo Foundation Sun Yat-Sen Cancer Center, for example, has launched an "individual care manager" system, where one person pulls together diagnoses from multiple departments and is responsible for all communications with the patient and the patient's family.

The Bureau of National Health Insurance (BNHI) has also begun to address the issue by providing systematic incentives and better management to effect change.

BNHI director-general Guey-Ing Day says there are already 190 hospitals, including Veterans General and NTUH, that have begun to streamline and simplify patient treatment. Under the initiative, patients with chronic illnesses who normally see doctors in more than one department no longer have to register separately every time they seek treatment. Instead, they are assigned one doctor to coordinate their care, reducing the hassle of getting care and ensuring that their prescriptions are evaluated holistically.

The BNHI has also taken the initiative to more closely manage patients with high numbers of doctor visits or hospitals that repeat medical imaging tests within a short period of time, by decreasing or disallowing insurance payments.

Still, too often when patients walk into a hospital, doctors, the hospital, the system and even the patients themselves all conspire to fight a battle of medical excess.

In such an environment, patients must reject the myth that "more treatment is better" and avoid the waste and risk that accompanies excessive medical intervention if they hope to intelligently protect themselves and their health.

Translated from the Chinese by Luke Sabatier

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Keywords:

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