A few days ago, the Department of Health (DOH) announced a preliminary list of hospitals that will be allowed to apply directly to the National Immigration Agency on behalf of medical tourists from China to make trips to Taiwan for health checks and medical cosmetology treatment.
Last week the first group of Chinese visitors, consisting of high-ranking officials and hospital chief executives from Liaoning Province, arrived in Taiwan on a tour of inspection. Before long, the DOH will announce a second list that will include more eligible hospitals.
From now on, big hospitals around the nation will be involved in the travel agency business, arranging trips for Chinese visitors to attend hospitals in Taiwan.
The worrying thing is that when hospitals start operating as travel agents, there is a risk of them developing a two-tier approach in which existing differences in the quality of healthcare service will become even more pronounced.
Medical tourism epitomizes the industrialization and marketization of healthcare. The continuing expansion of paid-for services has for a long time been squeezing out the development of many important kinds of healthcare provision. It is foreseeable that, as medical tourism gets more competitive, hospitals will vie among themselves for a bigger slice of the cake.
No matter how often the DOH insists that medical tourism will not influence the healthcare services available to the public under the National Health Insurance (NHI) framework, it is hard to believe it. What has already been happening is that the overall development orientation of many hospitals has been adjusted or distorted to some extent by the trend toward a profit-oriented business model.
When people walk into hospitals in future they may find two drastically different standards of service — be it the furnishings and decoration provided, the kinds of service on offer or the fees charged.
In one place you might find wealthy patients being attended to in sumptuous surroundings by specially selected tall, slim and handsome medical personnel who greet them with a bow and a smile, while in another you might find sick people groaning in pain, while meager NHI payouts make it hard for hospitals just to maintain the basic levels of service required to keep their licenses. In these places, patients might be attended to by overworked medical staff worn out from being on duty for many days in a row, or there may be a high staff turnover rate.
Another scenario that awaits us is that there will be two separate classes of healthcare personnel. When healthcare services have been divided into medical tourism on the one hand and NHI services on the other, the flow of medical personnel between them will definitely not be in accordance with the DOH’s repeated assurances that it will not cause staff shortages in the four key departments — internal medicine, surgery, gynecology and pediatrics. The DOH says that it will retain sufficient staff in each area of specialization through imposing a quota system, but this seems unlikely to work.
Work conditions for healthcare personnel have yet to be improved, making it difficult for these four major branches of medicine to recruit staff.
If in future there is an ever-widening gap between work conditions in the medical tourism and NHI sectors, it is bound to interfere with the appropriate deployment of healthcare personnel. Worse still, it will also give rise to a hierarchy among healthcare professionals.
The third threat facing us is a widening divide in medical ethics. The first group of hospitals that gained approval to accept Chinese medical tourists includes many of Taiwan’s leading hospitals and medical studies centers — the very places that bear the onerous burden of medical education in Taiwan.
Students in these teaching hospitals receive guidance in medical ethics and public health, in the expectation that they will serve the public in the spirit of helping and caring for their fellow human beings, yet at the same time their teachers are getting more involved in for-profit business. One wonders how medical college teachers would explain their own actions to students of medical ethics.
Medical tourism, which has as its core services health tests and medical cosmetology, presents severe challenges with respect to medical ethics. Health checks are not just a kind of commodity to be sold by the roadside. The most important thing is not what kind of expensive and intricate high-tech equipment is used, but who does the testing, what tests they do and what is done after the tests are completed. Only through long-term understanding between doctor and patient and proper follow-up procedures can health tests have their optimum effect.
Medical tourism packages do not make it easy to establish long-term relationships between doctor and patient. A lot of tests serve no real purpose and might even cause iatrogenic harm. Besides, the test results may cause unnecessary worry to the people who take them.
One-off therapeutic encounters are not likely to lead to partnerships that include follow-up consultation and treatment, or the continued care and maintenance that should be provided for medical cosmetology patients.
More serious still, when medical tourists come to Taiwan carrying wads of money, expecting to buy their way to health, the incomplete medical tests and cosmetology treatment they pay for are likely to get doctors and nurses embroiled in many more medical disputes than they currently face.
Liu Chieh-hsiu is a physician in the department of family medicine at National Taiwan University Hospital.
Translated by Julian Clegg
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