A few years ago, I characterized the prospective National Health Insurance (NHI) policy of “insuring major illnesses, but not insuring minor ones,” which the Cabinet was considering, as an “undead theory.”
This topic was taken up by several experts who asked how anyone could draw a line between major and minor illnesses. After that, the idea ceased to be a focal issue.
An “undead theory” is one that academic experts pronounce dead after they determine it to be invalid, but that is resurrected from time to time by non-experts.
One example was when medical specialists decided to play the role of economists by suggesting that the healthcare market should gradually raise the copayment limit in accordance with the “user pays” principle to avoid “wasteful non-essential” medical treatments.
The mass resignation in June at Chang Gung Memorial Hospital focused attention on the cost of medical tests and medication. Many physicians proposed increasing copayments as a way of avoiding “wasteful” treatment, making this a second “undead theory” in healthcare economics.
Tests, use of drugs and treatments can only get the stamp of approval after physicians have assessed a person’s health needs. This is standard healthcare procedure and shows that physicians are the main decisionmakers who carry out procedures on a patient’s behalf.
However, copayments give behavioral incentives to the patient. The underlying assumption is that patients must be the main decisionmaker with regard to their medical treatment. Such a policy gives rise to a number of serious basic contradictions.
First, if a patient uses “non-essential” treatments, the main responsibility for this lies not with the patient, but with the physician’s complicity or use of economic incentives instead of medical knowledge when prescribing a treatment method.
This kind of motive, which does not give prime consideration to the patient’s health, is contrary to medical ethics. It is also the reason the state must reform the reimbursement system to give physicians economic incentives to conserve medical resources, rather than incentivizing patients.
Second, since patients are not the main decisionmakers, any attempt to limit the use of medical treatments through patients’ copayments is unlikely to be very effective.
Third, the limited extent to which copayments can be effective includes both “essential” and “non-essential” medical services, because patients who lack specialized knowledge could make poor decisions that might be detrimental to their health.
Fourth, since increased copayments would mainly affect people who are in a weak position financially and physically, it would further exacerbate financial and health iniquities.
Fifth, the main reason copayments still exist in many countries is not to limit non-essential costs, but for insurers to generate substantial revenue without having to increase premiums, and for hospitals and clinics to improve cash flow management.
Sixth, as of 2015, 40 percent of the nation’s total health insurance expenditure came from the private sector, while 34 percent was paid out-of-pocket. These figures are much higher than in most industrialized nation and seriously detracts from the NHI’s second function of income redistribution. Raising household copayments might make this situation worse.
Finally, and most seriously, with this high percentage of private healthcare payment, the core value of social insurance — or “sharing financial risks” — will soon exist only in name. It is odd to see clinicians who work within the framework of social insurance claiming that its abolition would instantly embody the spirit of “user pays.”
Healthcare market reform cannot be fulfilled by more tinkering and sleight of hand. Showy moves and fancy footwork are not the right way to run a country.
Lee Jwo-leun is an associate professor at the National Taichung University of Science and Technology’s Department of Senior Citizen Service Management.
Translated by Julian Clegg
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