Rise in NHI premiums not enough

By Liu Ching-ming 劉競明  / 

Fri, Mar 26, 2010 - Page 8

National Health Insurance (NHI) premiums are set to rise next month, but will there be a corresponding increase in the quality of treatment that people receive when they visit the hospital?

Medical treatment in Taiwan seems to revolve around the concept of seeking the services of a “famous doctor” — the one that has the most patients. Think of it in terms of a designer brand: There has to be a good reason why it’s so popular. The analogy of the popular restaurant would serve equally well: Savvy people know that there is a direct correlation between the number of customers and the quality of service.

As such, when people need to see a doctor they tend to choose a well-known, reputable hospital where — ideally — they don’t have to wait long to register, are able to see the doctor straight away and can pick up their prescription without having to wait in line. It would also be a bonus if they could get the treatment for free. The most important thing, however, is that the doctor will be able treat their complaint without too much fuss, or prescribe a pill that will ease their ailment straight away.

So how should we assess the quality of treatment received in Taiwan? For some, it’s a case of “the bigger, the better:” Large volumes of traffic through the system are perceived to be an indication of the high quality of service. However, in a bid to boost their numbers, NHI-registered hospitals have been accused of ­distorting or bypassing conventional medical treatments to raise their performance. As a result, we hear of outpatients complaining about having to wait around to see the doctor, collect their prescriptions and pay their fees, only to be rushed out the door almost as soon as they get in, having little time to describe their ailments or discuss how they may be treated.

From the very start, the national health insurance system that Taiwan is so proud of, which provides low-cost medical treatment, has disregarded doctor’s fees. With the consultation fee set at a mere NT$218, doctors working at these hospitals have to see a large number of patients if they wanted to receive a salary commensurate with their qualifications.

A few years back, the Bureau of National Health Insurance introduced its “Reasonable Load for Outpatient Services” policy to address this issue. That led to other problems, however. First, some patients complained that they couldn’t get to see the so-called “famous doctor” of their choice even if they waited in line first thing in the morning. Second, some said they were prepared to wait in the hospital for the best part of a day if it meant they would get to see the doctor they wanted to see. Faced with these complaints, hospital authorities backed down, increasing the workload of popular doctors to avert the risk of losing their patients to the competition.

What about the behavior of patients? There are doctors who are willing to spend some time listening to what patients have to say, give them a thorough check-up and explain what they need to know about their problem. Before you knew it, however, patients waiting outside become increasingly impatient.

They start grumbling, and pretty soon someone is knocking on the door protesting, in a loud voice: “Are you going to see any patients today or what? Why are you taking half an hour on a single patient? What are you? An intern or something?”

This fast-food approach to medical treatment may well be convenient and inclusive, but it makes it impossible for a doctor to take good care of a patient.

Consider also that consultants specialize in different fields, and sometimes may be unable to treat a patient straight away after finding that he or she needs to see a specialist in another field. This could mean that a patient may have to go from one department to another, seeing maybe three doctors in one day.

In this case, setting up special departments that feature a specific combination of specialties might be a good idea. This is one avenue that hospital administrators can explore to improve the quality of medical treatment provided after the health insurance increases come into effect.

People sometimes talk about how good US clinics are, but is there such a difference between how they do things over there and how things are done here? In the US, people first visit a general practitioner, who then refers them to a specialist. The treatment is therefore very private and tailored to the needs of the individual. Patients get a thorough check-up and the type of care that they need, and there are no limits on the time spent on the consultation (with initial consultations lasting at least 30 minutes), or restrictions on how many patients can be seen. The problem is that this does not come cheap.

As I see it, we are unlikely to see much improvement in the way things are done here, or in the quality of the healthcare provided under the current health insurance system, unless patients agree to pay the full costs of a preferential service or the international medical departments like the specialist outpatient clinics that China has. If we can have a system that combines a personal medical savings account system with personal health promotions and health management initiatives as a mechanism for paying health insurance, we might be able to keep the rising costs of public healthcare under control. I believe this is the way to tackle the root of the problem.

Liu Ching-ming is an attending physician and assistant professor in the Department of Obstetrics and Gynecology at Linkou Chang Gung Memorial Hospital.