COVER: PROFITING FROM THE PAIN
Medical professionals describe how the private sector can ease the aches and pains of Taiwan's healthcare system.
By Mat Matich
With more than 98 percent of the nation covered, Taiwan's National Health Insurance Program, and the healthcare system it supports, is one of the most comprehensive in the world. Dental, psychiatric, and almost any other type of medical care is offered under Taiwan's system with heavy subsidies. But there are problems, or shortfalls, with the system that many say could be solved with the help of the private sector. Of biggest concern, the Bureau of National Health Insurance (BNHI) is slow to approve reimbursements for new medical technology and many in the medical sector, particularly pharmaceuticals, say the government is slow or unfair in approving new devices and new medications. Here is a quick outline of what Taiwan's medical community sees as the major kinks in the nation's healthcare system and the ways healthcare professionals and officials believe business can pitch in (and make a profit). The Need for Speed When the National Health Insurance Program went into effect six years ago, Taiwan already had a modern healthcare system and all medical technology then in use fell under the BNHI's reimbursement umbrella. Today, Taiwan residents can use a wide range of very advanced medical technology at bargain prices. But healthcare technology providers say there are two problems with the current system, problems that can ultimately hinder a patient's access to new medical devices. For example, Taiwan is still slower at approving new technologies than international providers would like, although the island is making improvements by adopting many of the same standards commonly used in Western nations. The biggest complaint heard among medical equipment and technology providers is that Taiwan is adopting these international standards slowly, step by step, while they are promoting a faster, full-scale adoption of international standards. A far bigger problem is that the BNHI is slow to include new medical devices in its reimbursement program, meaning that if patients wish to use new, not-covered devices, they must pay the full price of use. But most say Taiwan's patients are too spoiled by the current BNHI to shell out large sums to make use of such new devices. "I can take my two children to the hospital for about US$5 and it is good healthcare," says the head of an international medical device company in Taipei. "Why would I pay more for a new procedure?" In addition, Taiwan law forbids doctors from requiring patients to use any medication or treatment not covered by the BNHI, a regulation meant to keep unethical doctors from fleecing trusting patients. The result, grumbles private sector suppliers, is that it is almost impossible to introduce into Taiwan medications or devices not covered by BNHI reimbursement. Dr. H. Sung Kuo, director of planning at the national Department of Health (DOH), counters that the present healthcare system easily admits new technology when it is truly necessary or presents a great advantage over previous systems. The system also puts the burden of filtering through new, less-proven technology on the private sector. If a procedure is worth the money, people will be willing to pay for it and eventually it may fall under the BNHI's program. Executives with international medical device firms in Taipei say the DOH is missing the point. While many new devices may cost more to use and have limited immediate advantages over older procedures, any improvement in medical care pays off significantly. If a new device can detect disease even slightly more quickly, it decreases the severity of the ailment and increases the patient's chance of survival, while also saving the BNHI money in future treatment, explains an executive with a U.S. medical device firm. In other words, Taiwan must invest in the best medical technology to remain effective and efficient. Quantity Over Quality Even officials at the DOH are quick to admit serious problems with Taiwan's medical culture. Doctors in Taiwan see far too many patients, far too quickly, offering little time to explain their diagnosis and prescriptions. "The average doctor in America sees something like 15 patients a morning," says Kuo of the DOH. "In Taiwan, many doctors see more than 100 patients in one morning before going to another hospital and seeing 100 more." The BNHI has taken steps to alleviate the situation. In January, the BNHI began paying physicians per-patient fees tiered according to the number of patients seen per day. For example, the BNHI pays doctors working at a clinic NT$230 per patient if the doctor sees 30 or fewer patients a day, NT$220 per patient for 31 to 50 patients a day, NT$180 for 51 to 70, and NT$120 per patient for 71 to 150 patients a day. If a doctor sees more than 150 patients a day he is paid only NT$100 a visit. The fees are different for hospitals, clinics, and doctor's offices, but the goal is the same: encouraging physicians to spend more time with patients. Despite these measures, many physicians still see as many patients as they can to boost their own salary. Patients, for their part, quite often expect a short visit and are satisfied if they leave with enough medication to take care of their immediate health problem. Kuo also complains that most doctors in Taiwan just do not know how to treat patients. It is not only that doctors do not take the time to explain their diagnosis to a patient, it is also that doctors do not know how to explain medical procedures in layman's terms. Not only do physicians see hundreds of patients a day, but many simply fail to sympathize with their patients. One homegrown solution for this problem is to train the next generation of doctors to be more attentive to patients' needs, says Dr. Sheng-Mou Hou, associate dean of academic affairs at National Taiwan University's College of Medicine. Hou is now training doctors to view their patients' ailments as more than just isolated medical problems. He encourages them to think of the person's emotional and social health as well before making a diagnosis. This, along with using the U.S. system of getting medical students out among patients quickly, will solve much of the problem, Hou insists. Dr. Tung-liang Chiang of the NTU says there could be a quicker fix for the shortcomings of Taiwan's doctors: Outside consulting from American healthcare management firms. But more than just buttressing doctors' bedside manner, Chiang says international healthcare companies can help Taiwan hospitals, clinics, and doctors integrate their services to both increase efficiency and improve quality of care. In the end, such improvements will prove good business, too, by attracting more patients. On the consumer side, more choice may eventually be offered. Dr. Chien-Tien Su of Taiwan Medical University believes Taiwan consumers may eventually be willing to pay for private alternatives to the National Health Insurance Plan. He says there is a need for services similar to American-style HMOs (healthcare management organizations). "People will be too busy to manage their own health and the [BNHI] is too cheap to do outreach," says Su. This will open the door to private clinics offering more convenient services. But Su sees this as a trend that will come in the future if consumer spending power outpaces frugality.
