Control Yuan member Huang Huang-hsiung (黃煌雄) has taken it upon himself to give the National Health Insurance (NHI) system what he calls a “general health check.” Huang concludes that there are two keys to reversing the exodus of doctors from the five major hospital departments — general medicine, surgery, obstetrics and gynecology, pediatrics and emergency medicine. First, he proposes raising the NHI’s standard payments for doctors working in these five departments, as laid out in its fee schedule. Second, he says we should strive for more rational allocation of criminal responsibility in cases of medical malpractice or mishaps.
Although these two prescriptions can improve the situation to some extent, they will not get to the root cause of the problem.
The main problem with Taiwan’s NHI system is that not enough resources are put into it. Aside from assigning more resources to the NHI, the service’s fee schedule should be adjusted to reflect the time and effort that doctors put into their work. The question is, will doing so induce more doctors to work in these departments and improve the quality of care? The answer is no.
Taking nursing staff as an example, since 2009, the Department of Health has dedicated NT$4.7 billion (US$157 million) to nursing, yet only a very slight improvement has been seen in the number of nursing staff. Why is this?
The reason is simple: The NHI system does not pay medical funding directly to medical personnel. It pays it to hospitals, and hospitals then decide how to distribute it. Apart from staff salaries, hospitals’ operating costs include water, electricity, air conditioning, equipment, depreciation, registration and cashier costs, administration, management and so on. Hospitals have never paid doctors’ salaries entirely in accordance with the NHI’s fee schedule.
The standard payment rates for the big five departments can be raised, but whether that means hospitals will raise salaries and improve the work environment for employees in these departments is another matter. That will not happen if hospital managers fail to change their mindset. If they keep on spending money on an equipment “arms race” or “territorial expansion,” or are content to increase their cash surplus, then no matter how much standard payment rates are raised, it will be of no use.
Other than the five big departments, other hospital departments such as ear, nose and throat and dermatology can easily generate profits, as can expensive medical examinations. Hospital managers have a fundamental responsibility to use available surpluses to make up for shortfalls and ensure that staff in all departments enjoy reasonable salaries and an acceptable balance of work and rest.
Accordingly, the Department of Health should set a standard to the effect that as long as a hospital is making a profit — and that is true of large and medium hospitals at present — it must pay its medical staff reasonable salaries and provide them with an acceptable working environment. There should be a rule that hospitals must recruit a certain number of resident physicians each year. If hospitals do not comply with these and other relevant conditions, they should not have their accreditation renewed.
Everyone in the medical profession would be happy to see standard payment rates increased, but people should also think about where the money comes from. Hopefully, Huang can help think up ways of solving the NHI’s financial problems; otherwise his “general health check” for the NHI may alleviate some of the symptoms, but it will not fix the cause.