According to a survey carried out by officials of the Control Yuan, less than 100,000 people in Taiwan, or under half a percent of the population, are patients using respirators, extracorporeal membrane oxygenation (ECMO) or renal dialysis, yet more than NT$60 billion (US$2.03 billion) is spent on these items each year. That is about 20 percent of the National Health Insurance (NHI) program’s total annual expenditure. This figure suggests a distortion in incentives that should not be overlooked.
The doorway to NHI payouts is a narrow one. In the past, the doorway to higher education was very narrow; it was hard to get in but easy to get out. Similarly, it is hard for medicines and medical services to get into the payment doorway, but once they have got into the system there is no adequate long-term assessment mechanism for making sure that payouts give value for money.
The availability of NHI payouts for health treatment is an incentive that generates more medical treatment activity, and this may be why Taiwan is No. 1 in the world for the use of renal dialysis, respirators and ECMO, and indeed for Cessarean sections.
Assessment standards are determined by the Bureau of National Health Insurance (BNHI) or other sections of the medical establishment. Decisions about which kinds of treatment are economically efficient and which are ineffective are made in a top-down manner. While this may be effective to some extent in controlling costs, it is hard to be sure that people further down the line will not work out ways of getting around the policies decided at the top. This mode of decisionmaking could be criticized from various viewpoints.
For example, families of patients already receiving free medical care may criticize the BNHI for overlooking the dignity of life.
Managed care is based on a top-down way of thinking. The problem is that it tends to involve cost-cutting for its own sake, with the result that quality of life gets overlooked, yet costs continue to rise through other channels. For this reason, managed care has gradually become incapable of keeping the situation in check, and that is why collaborative care has come into vogue.
Collaborative care stresses shared decisionmaking in healthcare. For example, the Boston-based company Health Dialog has trained nurses to explain complicated medical procedures to health insurance clients via the Internet or telephone, so that they can make their own informed decisions.
Health Dialog’s experience shows that decisions made by fully informed patients usually save costs. For example, hospitals often advise women with uterine tumors to eliminate their pain by having hysterectomies, but patients elect not to have surgery when they learn that many symptoms disappear when they pass the age of 50. In fact, more women decide of their own accord not to have surgery than are classified as not needing surgery under a managed care system.
In other words, when patients are well informed, the number of people who elect to have surgery falls, and this in turn reduces the burden on medical personnel and saves medical resources.
Similarly, many men with prostate illnesses decide not to have surgery when they are fully informed about the death rates for prostate cancer and the possible side effects connected with the surgery, such as urinary problems and erectile dysfunction. Their motivation is not to save money for their health insurers, but concern for their quality of life, based on a full understanding of possible side effects.
Western medicine is mostly about treating symptoms. If someone has a headache, it treats the head, and if someone’s foot hurts, it treats the foot. This approach lacks a humanistic concern for the whole person, and no amount of managed care can change it. When, on the other hand, the insured — ie, patients — have a share in making healthcare decisions, they tend to choose relatively conservative and low-cost options.
Collaborative care starts out from the patient’s dignity of life and stresses open access to information and shared decision making. Furthermore, it can save as much as 30 percent in health insurance costs, compared with managed care.
The experience of collaborative care suggests that, rather than having medical authorities deciding what gets paid for by medical insurance, it would be better for the BNHI and its departments tasked with assessing healthcare payouts to communicate more with the public, help disseminate healthcare information and work to improve doctor-patient relations. By setting up collaborative care departments staffed by nursing specialists trained to provide patients with unbiased information and help them to make their own decisions, the BNHI could achieve a triple-win situation of care for life quality, respect for the medical profession and a sustainable national health insurance program.
Jason Yeh is an associate professor of finance at the Chinese University of Hong Kong and a visiting associate professor in the College of Social Sciences at National Chengchi University.
Translated by Julian Clegg
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