No one thinks that their illness is minor. For the most part, people think that their illness is really awful, and they would prefer not to pay to see a doctor.
I used to be the superintendent of the Ministry of Health and Welfare’s Tainan Hospital. I would advise patients to sign up for more tests and examinations so that the hospital could apply for reimbursement from the National Health Insurance Administration (NHIA). However, later on, I became director-general of the NHIA. In that position, the emphasis was on properly using National Health Insurance (NHI) resources by reducing unnecessary medical procedures. I understood that government officials have a responsibility to take care of the public’s health by making good use of resources. It was a typical example of how a change of position can make one see things from a completely different point of view.
Taiwan’s healthcare reform must implement tiered services, with the separation of medicine and pharmacy, ie, separation of dispensing from prescribing, and it must be supported by copayments, which means that the user, ie, the patient, pays part of the costs. This allows for the reduction of unnecessary medical procedures and effectively lowers the burden on the healthcare system and its staff.
People in Taiwan visit a doctor on average 14 times per year, compared with about five times in other countries. Every outpatient visit or hospitalization requires the work of physicians and nurses, while tests and examinations are carried out by laboratory technicians and radiologists. They are all part of the real-world medical ecosystem.
The strain they feel from being endlessly busy cannot be solved by a meager salary increase. The single-insurer and global-budget systems devised by our public health predecessors 27 years ago have indeed created a Taiwanese healthcare miracle.
We can take pride that our healthcare system is one of the best in the world, but clinical staff are gnashing their teeth and feel that the NHI is squeezing them dry.
With everyone constantly trying to increase the volume of business, the result is that the points awarded to medical providers exceed the global budget. This leads to the devaluation of points. On the other hand, if everyone reduced the amount of unnecessary medical procedures, the global budget would be higher than the number of healthcare points, and the value of each point would increase. As a result, we could still get the same amount of money without having to work ourselves to exhaustion.
Current mainstream thinking in the medical community is to extract more money from the global budget. However, under a balanced budget, this means that NHI premiums must be increased. Government policies must consider the nation’s finances as a whole.
The question of whether business owners are willing to bear the cost of increased NHI premiums is not one that the medical community can solve by discussing it among themselves. More discussion is needed as to whether these realities are being adequately communicated to the public.
Before the Lunar New Year, then-premier Su Tseng-chang (蘇貞昌) confirmed that NHI reform would involve copayments, which was good to hear. When copayments for medicines were implemented in July, almost everyone accepted it, and there was no sign of a backlash or protests.
Some years ago, to implement tiered healthcare, we established a medical treatment cloud database known as Medicloud, which shares information about patients’ treatment histories among medical centers and clinics so that they and their patients can cut the number of duplicate tests, examinations and prescriptions.
However, until such time as copayments are required for unnecessary tests and examinations, there would still be room for improvement.
NHI reform requires everyone’s joint efforts. Without a beginning, there will be no chance for change. As a member of Su’s staff told me, every era comes to an end, and sometimes there is no way to avoid it.
As the Diamond Sutra tells us, there is a natural cycle of birth and death. I have recently come to feel that everyone has their own cloud in the sky. If we sincerely respect one another and wish each other happiness, we can naturally let go of the entanglements deep in our hearts, pursue a boundless life and calmly face the arrangements that life makes for us. Let us encourage one another to do so.
Lee Po-chang is a chair professor of Taipei Medical University’s College of Public Health and director of the university’s Research Center of Health and Welfare Policy.
Translated by Julian Clegg
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