The national health insurance program is facing its most serious financial crisis since its implementation six years ago and premium rates are going to have to be raised to resolve it.
The latest report from the Bureau of National Health Insurance calculated that premium rates will need to be increased from the current 4.25 percent of a person's monthly salary (on average) to 5.38 percent. That translates to a 26 percent hike over the next five years, if the premium base remains unchanged. However, if the Legislative Yuan passes the bureau's plan to broaden the premium base, the rate will only have to be increased to 4.75 percent, a hike of about 11 percent.
Many solutions have been proposed to resolve the crisis, such as raising the wage ceilings for insurance policies, implementing partial payment of the insurer's medical bill, adopting a fixed budget for the system or raising the tax on alcohol and tobacco products. But few have suggested improving hospital management in order to to limit the waste of resources.
In recent years, Taiwan's medical expenditures have grown by a two-digit percentage annually. Some of that money must have been spent on long-term care patients in medical institutions, including those on ventilators.
Statistics show over 5,000 patients need ventilators to survive, including 13 percent of those who are hospitalized in intensive care units. To alleviate the shortage of ventilators, the Health Department introduced a transfer system in 1998 for patients who have to be on ventilators for long periods. This has helped somewhat, nevertheless, many patients still use hospitals as nursing centers, with stays lasting several years.
Most patients who refuse to be discharged from public hospitals have little chance of recovery. They not only waste the precious health care resources of these institutions, but also prevent these resources from being utilized by those who need urgent or emergency medical help. Medical disputes, influence peddling, the refusal of relatives to transfer patients to other institutions and a shortage of care-givers, are common reasons why patients using ventilators occupy hospital beds for long periods of time.
If the Department of Health and hospitals can get such patients transferred to nursing centers set up to care for chronically-ill patients, then financing the national health insurance program and the efficiency of medical resource management will benefit greatly.
The financial crisis of the health insurance system has escalated while many large hospitals run by large consortiums are making money hand over fist. The source of the problem, however, might be the public hospital system. Everyone knows that all public hospitals, regardless of their scale, have to comply with regulations imposed by different layers of government, resulting in rigid personnel management and inflexible operations policies.
In addition, pressure (influence-peddling) from high-ranking authorities and legislative bodies has forced public hospitals to accept "special patients" who need long-term care. Their beds are therefore no longer available to the "average" patient. The resulting financial burden of these patients makes it harder for public hospitals to compete with private facilities owned by big consortiums -- even though, despite the added costs, public hospitals have managed for years balance their budgets.
Private hospitals face no such burden since they can pick and choose their patients and maximize their profits accordingly; no wonder facilities owned by big consortiums have been making so much money. In other words, legal restrictions and requirements, rigid personnel management and influence-peddling for beds have contributed to the financial strain on the national health insurance program. They also ensure huge profits for the big private hospitals because the government is unlikely to allow public hospitals to close over financial problems.
If the government can free big public hospitals from some of the legal restrictions they face and allow more flexible personnel management and operational policies it would give them the discretion to reject patients who continue to occupy beds for long periods of time. This will improve the financial situation of the health insurance system.
Last year 10 medical research centers accounted for one-fourth of the total resources spent on health insurance. How can we restrict the inappropriate waste of medical resources without adjusting the management of big hospitals, especially public ones?If problems persist in the management of these hospitals, the wasteful policies will continue even if fixed budgets are adopted for the national health insurance program.
Kuo Cheng-deng is an associate professor at the School of Medicine at National Yang Ming University.
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