National Health Insurance System
The National Health Insurance (NHI) is the backbone of Taiwan's healthcare system. It is necessary to understand this system before looking further into other issues in Taiwan's medical care. However, any discussion on a complex subject such as the NHI must be preceded with caution. In this section, we will attempt to reveal flaws within the NHI system that we have observed or received complaints about. And perhaps through our efforts, more academic and government agencies will come forward to conduct further researches or reforms on those issues.
I. The NHI Fee for Service system and its crises
The National Health Insurance is operating based on a fee for service (FFS) system. The patient will only need to pay small amount of price set by the Bureau of National Health Insurance (BNHI) for each medical service received; and the rest of service payment will be covered by the BNHI. Doctors and hospitals contracted with NHI make bulk of their income through this mechanism.
On the other hand, in order to prevent unlimited spending, the BNHI introduced "the global budget system" to modify the FFS mechanism. The global budget put an expenditure cap on each medical field (eg hospitals, western medicine, Chinese medicine, etc). If the total services performed exceeded the field's budget quota, the FFS reimbursement ratio would start to deflate, which would shrink payment for each service performed.
Thought the primary goal of the global budget was to restrict and reduce the unnecessary waste of the medical resources, we have observed some negative impacts this mechanism had to the healthcare quality:
– The deflation mechanism of the global budget will affect every contracted medical institutions; it does not matter whether you work under regular hour or not. If the total service exceeded the quota, the payment would shrink, in some circumstance the healthcare providers would tend to work extra hours or seek other ways in order to cover up the losses.
– The global budget has fueled the already growing profit-driven competition within the Taiwan healthcare environment since healthcare institutions have to look for other financial resources next to the limited global budget. In this sense, lucrative private practices are put before NHI services; making profits is more important than maintaining healthcare quality.
II. False and Excessive Claims by healthcare institutions under the NHI
Managerial flaws and the authority's lack of supervision have made the NHI system vulnerable to various kinds of abuses, the phenomenon which became more common after the implementation to the global budget. Following is a list of examples:
a. Unnecessary advertisement:
Unnecessary medical advertisement encouraging the patients to purchase medication or treatment that are not covered by the NHI
b. False reimbursement claim:
The false reimbursement claim is one of the most pervasive abuses within the NHI system. For example, a clinic might file a FFS reimbursement request for drug A when in reality drug B was prescribed, all because drug A was worth more FFS service payments. The false reimbursement does not limit to the drugs; any medication, medical equipments, or treatments covered by the NHI are targets of such exploitation.
c. Excessive medication:
We have received reports of hospitals performing or encouraging patients to undergo unnecessary treatments in order to receive more service payments. Some of these excessive medications were even performed under the expanse of patient’s health. For example, it was reported some hospitals "shared patients" by giving patient unnecessary “health-checks?before transferring him to another hospital for the actual treatment.
d. Work force shortage:
Several hospitals begin to cut down the number of employees (especially nurses) in order to limit the spending. During the process, the healthcare quality and patient safety were compromised due to the medical staff shortage.
III. Second Generation NHI and the Rise of NHI Premium Rate
The National Health Insurance is a system going through continuous evolution and changes. The financial imbalance, however, is the crisis which persistently plaguing the system. The implementation of the global budget, as indicated above, failed to address the problem.
The Department of Health and the BNHI is currently planning to alleviate the budget crisis by raising the insurance premium rate and introduction of the second generation NHI. Nevertheless, THRF believe the causes of NHI financial crisis are mainly rooted in the inefficient management and the lack of supervision from the government. The increase of premium rate would only put the burden of government's mistake on shoulders of the public. Thus we are currently against rise of NHI premium rate until the government is able to launch an effective reform to address some inherent flaws within the NHI system, such as obscure FFS reimbursement process, lack of information transparency, and lax quality standards.
Other Issues and Reforms
There are many other challenges faced by Taiwan's healthcare system. Many of them predate the introduction of the NHI. Overall, the current healthcare crises are mainly the result of lack of government supervision, information disparity, unchecked commercialization, and other policy failures. Most these problems are correlated, for instance, the corporation-influence on Taiwan's hospitals might be accelerated by the lack of official supervision, while such supervision weakness might be the result of a failed policy.
Fundamentally, we can classify the crises of Taiwan's healthcare into three categories: the flawed policy, lack of information transparency, and substandard healthcare qualities. And because these problems are entangled with each other, it is hard to carry out an effective reform without a drastic change in the current system. Knowing such difficulty, we choose to focus our advocacies on the individual issues first. Hopefully with several fundamental improvements, we will be able to push for a larger scale reform in the future. The following is the list of major advocacies from the Taiwan Health Reform Foundation:
1. The Fiscal Supervision for the Health Institutions in Taiwan
There is currently no effective government policy to regulate hospital’s financial activities. As more corporations join the healthcare business, the rapid unchecked commercialization is hurting both the quality of medical care and the budget of the National Health Insurance.
2. Medical Malpractice
The medical malpractice crisis in Taiwan is a multiple dimensions issue that range from flawed court system to mutual distrust between the health providers and the patients.
3. Healthcare Staff Shortage
The healthcare staff shortage has been a perpetual problem in Taiwan. Insufficient staff creates threat for both medical staff and patients.
1. Medical Record Accessibility
Accessing ones own medical record is not an easy task in Taiwan. Many healthcare institutions still refuse to provide the complete medical record to the patients.
2. The Surgery Consent Forms
The unnecessary and ill-diagnosed surgeries are hurting patient’s right in Taiwan, and the information obscurity has been a major factor.
3. Drug Prescription Reform
Drug scripts in Taiwan generally lack of information and clear format, which make them vulnerable to abuses.
4. Medicine Bag Improvement
Medicine bags in Taiwan are made by plastics or paper containing prescribed drugs. These bags play a major role in providing crucial medical information to patients.
Due to lack of regulation, most drug bags are labeled with limited information. A clearly labeled drug bag will help improve the drug safety in Taiwan.
1. Pediatric Drug Improvement
Children's medicine in Taiwan is usually modified version of the adult drug. The dosage and quality of these modified drugs varies from clinics to clinics since there is no clear guideline, and children’s health is under threat of substandard medication.
2. Dialysis Treatment Improvement
Number of dialysis patient continues to increase in Taiwan with more than 20 billion NT$ were spent on dialysis NHI coverage on the yearly bases. However, the budget on the dialysis care has not been used efficiently, and the patient is still receiving low quality treatment despite of huge government spending.
3. Hospital Shopping Alley Expansions
Profit-seeking frenzy is turning many Taiwan’s hospital into shopping malls. As the food court and shopping alley inside the major medical centers continue to expand, the patient’s safety is also being compromised.