Sensationalist headlines about the healthcare system being on the verge of collapse may have more to do with attracting attention and selling newspapers than the real situation. Nevertheless, the healthcare system does have plenty of problems, including staffing, doctor-patient relations and discontent among healthcare workers, which are causing a crisis in the National Health Insurance (NHI) system. To avoid a gradual collapse of the healthcare system, the Department of Health recently convened a conference to review the state of the nation’s health services and come up with a strategy for resolving the crisis.
According to data gathered by the health department, the number of medical specialists in the country has increased 1.57 times over the past decade. Even in the field of gynecology and obstetrics — which is vulnerable to a falling birthrate and malpractice disputes — the number of practitioners has risen by 21 percent, while the number of practitioners in emergency medicine has shot up 322 percent.
So why is there a shortage of doctors in the so-called “big five” specialties — internal medicine, surgery, gynecology, pediatrics and emergency medicine? A health department analysis suggests that factors contributing to this shortage include the falling birthrate, a rapid increase in hospital beds, lack of incentives to join these specialties under the NHI system, over-frequent reviews and inspections, heavy workloads, high risks and an unattractive lifestyle. For example, four of these major specialties — internal medicine, surgery, gynecology and pediatrics — account for 85 percent of malpractice disputes, with 80 percent of the doctors involved facing criminal charges.
During the 17 years since the NHI program was launched, the healthcare market has developed in the direction of large-scale operations. The number of hospital beds has increased by 21,000 over the past 10 years. More than 60 percent of medical specialists now work in hospitals, including 38 percent of pediatricians and 87 percent of doctors specializing in emergency medicine.
Unfortunately, Taiwan has yet to establish a referral system, therefore patients are accustomed to visiting any hospital or clinic they like. There is a big overlap between the illnesses attended to by medical specialists in hospitals and those handled by doctors who run their own clinics, so these two groups of doctors compete instead of cooperating with each other.
It is common these days for doctors to see 50 patients in one clinical session. A lot of people think that this kind of healthcare quality is a product of the healthcare demand created by the system and doctors working hand in hand. No wonder that when the health department proposed a policy of increasing NHI payments for specialties that are in difficulty at the conference, it was immediately met with harsh criticism from one of the doctors present, Hsieh Yen-yau (謝炎堯).
“The medical profession needs to do some introspection. It should not blame members of the public for visiting doctors so frequently,” Hsieh said. “Doctors often ask patients to do follow-up appointments in order to get paid more examination and diagnosis fees ... A lot of doctors perform surgery at the drop of a hat, implanting cardiac catheters and stents.”
“It is an out-and-out scam,” Hsieh added.
Actually, making some changes to the system could greatly reduce these kinds of problems. After all, doctors are often critical of their colleagues. Neurologists sneer at neurosurgeons, saying that they can operate on people from the lumbar spine up to the neck without making any improvement, or even making things worse, before they are willing to refer a patient. Gynecologists sometimes accuse their colleagues of poking around their patients’ bodies and wielding scalpels willy-nilly to remove harmless uterine fibroids and ovarian cysts.
Examination and treatment fees have become badly devalued in Taiwan. A recommended umber of clinical appointments has been set in vain. Hospitals get paid the same fee whether a doctor spends three minutes or 30 minutes with a patient. Hospital department managers naturally prioritize business performance and doctors cooperate by prescribing treatments that are not covered by the NHI.
Patients are as helpless as flies caught in a spider’s web. Doctors and nurses who do not enjoy the dignity of not being paid what they deserve have to resort to other measures, such as acting as sales representatives for medicines and medical devices. After all the medical education they received, when graduates start working in a hospital, they run up against a brick wall and knock themselves dizzy. It is a very awkward situation to be in.
Taiwan has only 1.8 doctors for every 1,000 people — significantly lower than the average of 3 per 1,000 for all Organisation for Economic Cooperation and Development member countries. If Taiwan wanted to reach the UK’s level of 2.4 doctors for every 1,000 people, it would need to train more than 3,200 doctors every year, but at present only 1,500 people graduate from medical schools each year in Taiwan. The nation needs to train 2,143 specialists a year, so it is no wonder that graduates from medical schools in the Philippines, eastern Europe and other countries are to be found working in many Taiwanese hospitals of all sizes; it is Adam Smith’s invisible hand at work.
Despite these problems, the health department is unwilling to increase student places in medical schools. The government’s strategy for the future is to cut the number of medical specialists trained to 1,670, while reviving the system of public funding for medical students in the hope of increasing the enrollment of resident doctors in the “big five” specialties. Whether this policy proves effective will be revealed over the next few years. Doctors’ choice of specialty is affected by complex factors, including personal inclinations and market supply and demand.
Taiwan is proud of the NHI program, but the system is beset by financial difficulties. In this period of healthcare discontent, the health department is boldly facing the challenges, but its policies are unlikely to achieve the desired results.
Chiang Sheng is an attending physician in the Department of Obstetrics and Gynecology at Mackay Memorial Hospital.
Translated by Julian Clegg
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