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FEATURE: BNHI monitors the cost of treatment

While doctors in this country decide the optimal course of treatment for their patients, another set of doctors monitors their decisions for the Bureau of National Health Insurance (BNHI) -- with an eye on the bottom line.

The role of the bureau's claim assessors (健保審查醫師) recently attracted media attention when an assessor chided a doctor for using an expensive antibiotic on a patient with terminal cancer.

Chou Hsi-hsien (周希諴), an attending physician at Chung Shan Medical University's affiliated hospice, decided to prescribe the antibiotic Mepem when a 50-year-old lung cancer patient in his care developed sepsis as a result of an infected lung last year.

He wasn't expecting the treatment log he submitted to the bureau to come back with an editorial comment.

"Why use a Ferrari in a hospice? A Yulon would do. Cut it! Cut it!" commented the assessor.

"Yulon" refers to Yulon Motors (裕隆汽車), a domestic car producer. Mepem costs NT$731 per dose, with a course of treatment requiring six doses a day over a week or more, Chou said, far more expensive than other antibiotics. However, its use was justified by the seriousness of the patient's condition, Chou said.

"It's a comment that betrays a lack of respect and understanding of hospice care," Chou said.

It is not clear which assessor wrote the comment since the bureau claims its assessors keep their anonymity in order to protect their independence.

Chou himself said that he has occasionally served as a assessor for the bureau.

Although hospice patients are covered by the bureau on a per diem basis and the assessment was for monitoring purposes only, the "Ferrari" comment resulted in widespread media coverage and condemnation.

In other cases, bureau assessors can determine whether or not medical care providers get compensated for the care they have already dispensed, making them a cost-control tool for the bureau.

According to Ko Wen-che (柯文哲), a specialist at National Taiwan University Hospital (NTUH), up to 11 percent of the claims submitted to the NHI by NTUH for ECMO (Extracorporeal Membrane Oxygenation) treatments are rejected by assessors.

"They don't necessarily have to give a reason [for rejecting the claim]," Ko said.

The decision whether or not to use ECMO, an emergency life-support system Ko describes as "buying time with money," needs to be made on the spot after a flash assessment of the patients' condition, Ko said.

In cases where assessors decide afterwards, based on records, that the use of ECMO was unnecessary or wasteful, the hospitals have to absorb the costs, Ko said.

Although the apparent callousness of the bureau assessor was what attracted media attention, the real story is the underfunding of the bureau, Deputy Minister of the Department of Health Chen Shih-chung (陳時中) said.

Chen agreed that the doctor who made the "Ferrari" comment acted insensitively, but said that the underlying problem that puts assessors in conflict with clinicians is pinched resources.

"One set of doctors see flesh and blood patients while the other sees costs, benefits and figures," Chen said.

"The NHI is more than NT$10 billion in the hole," Chen said.

With politicians unwilling to take the politically unpopular measure of hiking premiums, the bureau is strapped for cash.

"Healthcare expenditure accounts for around 10 percent of the GDP in OECD [Organization for Economic Cooperation and Development] countries. In the United States it is 17 percent," Chen said. "In Taiwan, on the other hand, our healthcare expenditure is only around 6 percent, with the national health insurance accounting for around 60 percent of that at less than 4 percent."

In addition to the unpopular peer-assessment monitoring system, doctors also have to accept compensation levels set by the bureau. As the bureau continues to provide comprehensive coverage on an increasingly inadequate budget, it has become necessary to slash doctor's profits to razor-thin margins, Chen said.

"As an inevitable consequence, some doctors are concentrating on procedures not covered by the bureau that they can charge patients on an out of pocket basis," he said. "Other doctors leave the system altogether for private patients."

"As long as the public is more concerned with individual stories instead of the big picture, our healthcare crisis will not be solved," he said.

After responding positively to treatment with Mepem, the 50-year-old lung cancer patient's condition improved to the point where he was able to receive home-based care.

He was able to spend Lunar New Year this year with his family. The fact that the patient is enjoying his days shows that prescribing the "Ferrari" treatment was the right thing to do, Chou said.

"The last that I heard, he was looking for friends to play mah-jong with," he said.
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