Thursday, October 31, 2013

Taiwanese National Health Insurance system in crisis

By: Jacob Betzner
Produced & Edited by: Katie Foglia


Taipei City Hospital in Taiwan. Photo by Lord Koxinga via Wikimedia Commons.

Only 22 nations and the Vatican City recognize Taiwan as a fully independent country. The island, located off the southeast coast of China, boasts an extremely affordable and efficient healthcare system. When Taiwan lifted martial law in 1987, officials wanted to develop a strong, affordable healthcare system that would serve nearly 22 million citizens. 

National Health Insurance (NHI), a compulsory program, brought healthcare to all Taiwanese and required only a small percentage of annual household income. The government recently reformed the payment system for National Health Insurance premiums to cover growing costs. National Health Insurance in Taiwan resembles Medicare in the United States, but it is open to the entire population.

“In addition to the basic premium, the insured will be charged a supplementary premium of two percent for other incomes received, including large bonuses, income from professional practice, part-time wages, stock dividends, saving interest and rental income. Before the Second Generation of NHI, premiums were solely payroll based,” said Mei Wang, Associate Researcher with the Planning Division of the National Health Insurance Bureau.

Wang said National Health Insurance covers a wide variety of areas including inpatient and outpatient care, prescriptions, regular dental services, traditional Chinese medicine, mentally ill and nursing care and more expensive procedures on a case-by-case basis.

National Health Insurance gives citizens easy and quick access to doctors and prescriptions by using a fixed global budget, meaning the National Health Insurance Bureau pays a fixed amount to hospitals but only limits hospital visits for patients in extreme circumstances. 

Dr. Jen-Hsiang Shen of the Ministry of Health and Welfare said doctors receive only about 30 percent of the payment per procedure. The hospital or clinic invests the remaining 70 percent in new buildings and equipment, often buying from companies partly or fully owned by the hospital owners.

With the extremely accessible healthcare, patients flocked to hospitals and clinics. Currently, doctors work as many as 80 to 100 hours per week. “The National Health Insurance in Taiwan is the cheapest and the most effective health insurance in the world, and it has worked for 18 years in our country,” said Dr. Ping-Hung Lin, Vice General Secretary of the Taiwan Medical Labor Union. “However, it has caused the increasing demand of health of our people, which means increasing work of our medical staff.”

Dr. Lin gave several examples of doctors and nurses in Taiwan facing extreme stress. Nearly a dozen doctors and nurses died from overworking last year. Dr. Shen said Taiwanese culture contributes to doctors working extra hours, often for no pay. 

“There is a culture in Taiwan that if you haven’t finished your work when your hour is finished, you should keep finishing your job until it’s finished,” he said. 

Nurses suffer, too. Typically, one nurse monitors 20 or more sickbeds, and one doctor cares for more than 60 sickbeds throughout one shift. Dr. Lin and the Taiwan Medical Labor Union work directly with the government, drafting legislation to limit work hours in the hopes of improving the quality of care.

“The medical system in Taiwan is breaking down,” Dr. Lin said. “I can tell you the doctor life in Taiwan is miserable. I hope the [Affordable Care Act] in the U.S. won’t make the same mistakes as Taiwan. Cost down is wrong. The quality must be taken into consideration first.”
            
The number of doctors continues to decline. Many move to different countries like the United States, China or Singapore to work fewer hours for higher pay. Dr. Yuan-hung Wu, an oncology resident at Taipei Veteran’s Hospital, recently considered such a move.
            
“I am ready to apply for to practice in the United States, I’m ready to do that,” he said. “Many of my younger medical students, they have already gone abroad to practice right after they graduated. They are about 20 graduates in my college they are now working abroad.”

Additionally, doctors face heavy penalties and even jail time if found guilty of medical malpractice. In the United States, doctors face fines and the possible suspension of a medical license in civil court except in extreme cases like homicidal negligence. 

Dr. Shen said Taiwanese courts send nearly a dozen doctors to jail every year, in addition to imposing heavy fines. Dr. Lin said the risk of jail time and fines discourages medical students from entering crucial fields like surgery, emergency medicine and gynecology.

“The medical students, they do not want to go to these high-risk specialties. They go to dermatology or the plastic surgery or whatever, not high-risk surgery,” Lin said.

However, patients enjoy many benefits with the program. Patients pay a $3 to $5 USD co-pay, mostly to cover administrative costs, to visit a hospital or clinic. Staying in the hospital for an extended period of time costs a co-pay of only $70 to $120 USD per night. Fu-Long Kai, a recent college graduate currently serving a compulsory stint with the Republic of China Armed Forces, says National Health Insurance helps keep costs low for citizens.

“Everybody gives a little part of their salary and everyone can go to hospital and you don’t have to pay that much. You can see the doctor and get their proper surgery or the proper solution for your disease or something,” he said.
          
Dr. Wu said National Health Insurance allows doctors to provide care without worrying about insurance coverage. 


Chiu Wen-ta, the Minister of Health and Welfare.
Photo via Wikimedia Commons.
“We don’t have to consider their economic status, whether they are affordable to the treatment. We can do the treatment to the patient in need right away,” Dr. Wu said.

While National Health Insurance isn't perfect, it allows patients easy access to affordable and quality care, and doctors still earn, on average, higher salaries compared to average Taiwanese incomes. Dr. Lin and Dr. Wu both said the system needs some reformation to survive. Dr. Shen suggested subtle changes to help doctors in Taiwan perform at a high level without sacrificing efficiency.

“I think the government need to offer reasonable work hours, reasonable salary and reasonable staffing to keep doctors wanted,” Dr. Shen said.

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