The Ministry of Health and Welfare on Feb. 2 announced that it would again postpone expansion of the diagnosis-related group payment system, nicknamed “Tw-DRG.”
The system classifies hospital inpatients into one of 1,716 groups. Patients in each group are clinically similar (based on disease and treatment needs, refined by differences in age, gender and complications) that are expected to use about the same amount of hospital resources. Hospitals then receive a predetermined payment for each patient in that group.
DRG systems are used in the US, Japan and Germany, but efforts to implement one in Taiwan have hit numerous road blocks since 2007.
The Bureau of National Health Insurance said in March 2007 that the system would be introduced over a four-year period, beginning the following year, but on Dec. 26, 2007, it announced the system was being shelved after protests from large hospitals.
The first phase of Tw-DRG was finally implemented in January 2010 with 164 groups, followed by the second phase in July 2014 with an additional 237 groups.
It was scheduled to expand to 1,716 groups next month.
Under the National Health Insurance payment system, only some hospitalization claims (401 groups) are paid by the DRG system. Most medical services are paid on a fee-for-service basis.
The ministry on Jan. 29 said that it would expand the Tw-DRG (temporarily excluding 53 groups), to cover 58 percent of all hospitalization claims, as of March 1.
However, physicians, medical reform groups and politicians across party lines once again objected, leading the ministry to postpone the changes just two days later.
The National Health Insurance Administration (NHIA) said that the system would benefit patients, sparing them unnecessary examinations, medications and inpatient stays, adding that hospitals would benefit by implementing standard operating procedures that would increase healthcare quality and efficiency.
It said the current fee-for-service system can result in more services for more payments.
“Under the ‘equal pay for equal work’ payment system, the more one does the more it earns, but under the ‘equal pay for equal diagnosis’ system, the better quality one provides the more one earns and patients also get better healthcare,” NHIA Medical Affairs Division head Parng I-ming (龐一鳴) said.
The NHIA said statistics showed that after the second phase of the Tw-DRG system was implemented, the average inpatient stay of those classified in the 401 group was reduced by 3.7 percent to 4.23 days compared with a year earlier.
The rates of referral on the day of hospital discharge, unscheduled emergency department returns within 72 hours of discharge and re-hospitalization after 14 days all dropped by 6.9 to 12.3 percent.
However, some are concerned that people with severe illnesses are likely to become “unwanted patients,” because hospitals would lose money if they treat patients with severe or complicated illness that require additional resources, or hospitals might try to save money by discharging patients before they are well.
A group from the Taiwan Society of Emergency Medicine visited NHIA Deputy Director-General Tsai Shu-ling (蔡淑鈴) on Feb. 5 to voice concerns over emergency room patients who often present with complicated or with multiorgan illnesses that can be difficult to diagnose.
The society’s representatives said that the system risks making patients with severe or multiple illness “unwanted” patients.
They said that emergency room patients should not be included in the system and that the government should not push for the expanded system without reasonable support measures.
The NHIA said that severe illnesses, including cancer, hemophilia, HIV, mental illnesses, rare diseases and others are not included in system, and that additional subsidies are given to hospitals for providing treatment to children and those in remote areas.
It also said that hospitals using additional resources to treat complicated cases could apply for additional payments, adding that the re-hospitalization rate and patients reporting refusals by hospitals for treatment would be monitored.
However, concerns over whether the NHIA could actually monitor the data remain.
Several physicians voiced their concerns on Facebook and in letters to newspapers about how the ambiguity of complicated cases under the system could cause extra stress on healthcare providers.
Legislators and physicians’ groups, including the Taiwan Medical Association and the Taiwan Hospital Association, also raised the issue that the NHIA had introduced a new coding system — International Classification of Diseases, 10th Revision, for inpatient procedures last month.
Hospitals are still unfamiliar with the new coding system and trying to cope with the Tw-DRG system at the same time would add to their stress, the associations said.
President-elect Tsai Ing-wen (蔡英文) and her administration will have to make the decision on when to expand the Tw-DRG system or whether further reform measures are needed.
Additional reporting by Staff writer
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