Sicko in Taiwan
Last year I wrote a post about Taiwan’s National Health Insurance program, having found a thoughtful article about the costs and benefits of Taiwan’s system. Now it seems that Taiwan’s system is getting even more attention, this time from a new PBS TV series: “Sick Around the World.” (All episodes of Frontline are available for free online viewing via the website!) Jonathan Cohn reviews the show and talks about health care in Taiwan:
The most interesting case study is probably Taiwan. A few years ago, when Taiwan decided to revamp its health care system, it studied other countries to determine which system might work best. Its conclusion? A single-payer system–one in which the government insures everybody directly–made the most sense.
Virtually alone among health care commentators in the U.S.–a category that includes me–Paul Krugman has been touting Taiwan for a while. The film makes it easy to see why. Today, the people of Taiwan have guaranteed access to health care–and, according to the film, it’s very good health care. There are no chronic waiting lists, like you find in Britain, and the care is very advanced. Among other things, Taiwan is among the world leaders in establishing electronic medical records–an innovation that should significantly improve care by keeping doctors and nurses better informed about patient histories and, no less important, avoiding potentially dangerous drug interactions.
Reid and Palfreman note, rightly, that the Taiwanese system isn’t as foreign as it seems: We actually have a similar program here in the U.S.–for the elderly. It’s called Medicare.
Now, over the past six months I’ve gotten to know Taiwan’s health care system better than I would have liked (don’t worry - everyone’s OK), and I have a pretty good sense of the good and the bad. The good is that one can go see any specialist just by showing up at the hospital and registering for an appointment. Its dirt cheap and you can see as many doctors and specialists as you like until you find something that works. The doctors are willing to do endless amounts of tests, and they dispense medicine generously (OK, that’s actually one of the bad things - but sometimes plenty of cheap meds is a plus). I’d say that the hospitals and doctors are all well trained and highly professional - even out here in the countryside.
On the other hand doctors here seem to see way too many patients in a day - far too many to give each one the time and care they need. Also, doctors rarely seem to talk to each other across specialties, and there is no framework for hospitals to share patient records unless you get the file out yourself and bring it to the other hospital. Doctors are used to assuming authority and don’t like being questioned and discourage second opinions. But when I think about these problems I don’t think they are unique to Taiwan. I think they are general problems with modern medicine - and don’t reflect on the benefits which come from having a single-payer system.
I have a relative who is a doctor in the US. He had a Taiwanese patient with leukemia. He told her to go home to Taiwan because he felt she would get better treatment there than in the US. She did, and she got better. I don’t know the facts of the case, but I’m sure the costs in Taiwan were quite manageable. I’ve paid no more than a couple of hundred dollars here for procedures which in the US would have cost thousands.
I’ve heard a lot of people from Canada, England, and Taiwan complain about their health care systems, and criticize those who paint too rosy a picture. Sure, but I think they grossly underestimate just how much worse the US is. Even if we are generous and assume that the systems are roughly comparable, Americans pay nearly twice as much as these other countries for care which is certainly no better, and possibly much worse. Few of the people who have said such things to me have actually watched Sicko. If you haven’t, I recommend that you do.
UPDATE: There was also this report on NPR:
To satisfy the patients in Taiwan, there’s no gatekeeper who controls access to specialists and no waiting lines.
If you woke up in Taiwan with shoulder pain, for example, Chang says that you would be able to see an orthopedic specialist the same morning, no recommendation from a general practitioner required.
“Our people don’t like the idea of gatekeepers. They want to decide by themselves,” Chang says.
Don’t Forget Your Smart Card
By consolidating so much — one government plan that covers everybody — Taiwan achieves remarkable efficiency.
Everybody here has to have a smart card to go to the doctor. The doctor puts it in a reader and the patient’s history and medications all show up on the screen. The bill goes directly to the government insurance office and is paid automatically.
So Taiwan has the lowest administrative costs in world: less than 2 percent.
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Comments
I think you should have mentioned a little about why it’s cheap and why they overprescribe medicine-it was designed to get people back to work.
Adam,
Presumably the US system is designed to get people to work as well. The difference is that one system makes people afraid to leave their jobs because they’ll loose their health insurance, whereas the other makes people healthy so that they can be productive. There are real fears in the US that universal health care will lead to greater labor militancy.
I don’t prefer the system that gets people to work through fear of losing health insurance. I think there could be improvements in Taiwan’s system though. It’s better now, but antibiotics are much abused.
I appreciate the comment of the Taiwanese health care system by Kerim Friedman. Great accessibility is the unique feature of the system. However, the accessibility is paid with a dear price of human lives.
Two major factors contribute to easy accessibility. One is that there is no formal referral system in Taiwan. Most patients can go directly to any hospitals and see a physician. As far as I know, almost all hospitals accept walk-in patients without prior appointment except Koo Foundation Sun-Yat-Sen Cancer Center in Taipei. The second factor is that the number of patients seen by a physician during a half-day clinic can be five times more than a physician in US. The average number of patients seen by a Taiwanese physician during a half-day clinic is around 80, and the number could go up to more than 100. The average number is 15 at major medical centers in US.
Taiwanese physicians are willing to see high numbers of patients because fee for physician per clinic visit per patient is low (currently NT$180 per visit or US$6.00), and 85% of Taiwanese physicians practice in large or medium-sized hospitals. Their salaries are floating and depend on the revenue they generate in the hospitals. The base salary is low or even zero. They are forced to see large numbers of patients in order to earn sufficient income. Consequently, time spent on each patient in clinics becomes very limited (less than 5 minutes) and the quality of care is severely compromised.
As rightly pointed out by Kerim Friedman, Most Taiwanese patients are easily satisfied with less than 5-minute clinic visits as long as they get the prescription drugs and the high-tech examinations they want. Patients are not aware of that short clinic visit could result in incorrect diagnosis and delay of proper and timely treatment at early stage of their illness. It is important to know that majority of illness do not pose immediate danger.
For those who envy the so-called Taiwanese efficiency in health care, they need to be aware of that the high efficiency is paid with lives of minority patients who fail to obtain timely medical attention and proper treatment. Under the current Taiwanese health care system, mortality rates of TB and cancer patients in Taiwan are ten times and 20-30% higher than US, respectively.
What we need is a health care system of Taiwanese accessibility and American quality.
KJ Kao,
Where do you get those mortality rates from? I’d like to see those numbers. I’m especially curious if they compare the population overall, or just those people who have health insurance. (40% of the US does not.)
In any case, I think one has to be careful picking and choosing individual diseases. The top killer in one country (Drug-resistant TB in Taiwan) is not the same as the top killer in another country (previously heart disease, now cancer in the US). It is much better to look at overall life expectancy rates.
I don’t know about Taiwan, but for Canada, France, and the UK, all of which are more like Taiwan than the US, the rates are better than the US, and their costs are about half what the US pays. So even if you think that the systems are roughly comparable (evidence suggests that they are better overall), they are still half as efficient.
From some hyperlink, I read your comment about the health system in Taiwan. I am very impressed.
I am studying in the US now, so I know both systems.
These is good health care system, but no perfect health care system.
If you are interested in the statistic data for mortality in cancer, I can email you. It is in the website of Ministry of Health, and it also has a township map to show mortality in each cancer. They include both Mandarin and English, you can easily to read it.
About TB, I studied it for a long time. It’s true no matter mortality, incidence. Taiwan is much higher than the US.
As for drug resistant TB(MDR-TB), according to some medical journal review, it is about 7%, which is not as high as China(for first treated patients, it is 10% in China) but is not good enough.
The Taiwanese should do more in the preventive medicine to decrease the expense in medical bills. The health system is so convenient that no one(doctors and patients) really care about the importance of preventive medicine. The National Health Insurance Bureau, Taiwan control the expense by restraining the budget of each hospital and clinic. This is adapted from Canadian health system to decrease the medical expense and impose the preventive medicine.
I will say that this system provides good and convenient services to the Taiwanese; however, we still need to do something to improve the quality and do more in preventive medicine.
By the way, I just noticed that you teach in Don Hua University. I am very curious and hope to know more why aboriginals have much higher TB prevalence, incidence, and mortality rates. They are higher than other diseases. I think it is a very complicated issues and cannot just use urban and rural disparity to conclude it.
HI Shih,
Actually, I think the low cost of medicine in Taiwan encourages preventative medicine. Taiwanese got to see a doctor even if they’ve just had a cold, whereas many Americans don’t see the doctor until it is already an emergency.
I don’t do medical research so I don’t know about the research on Aborigines and TB. However, I do know that Aborigines are generally poorer and live in under-served regions of Taiwan.
Kerim, I can understand that Americans are extremely unhappy with their health care system. It kills people because even though physicians are highly professionalized and powerful treatement available, sick people can’t afford to get treated. As you know, I am not American, but my impression is this creates huge apprehension. Access to health insurance is the topic of American TV shows and is a nagging theme in fictional stories written by Americans. Given this, I can understand why you feel a lot more confidence in the Taiwan system.
As you are seeing here, Taiwanese and long-term residents don’t have the same faith. We all know that doctors mess things up all the time. In addition to not having enough time, they will not refer you to other doctors or better-equipped medical centers when that is clearly what you need. The result of this is that patients shop around for doctors and habitually get multiple consultations on a condition. While you might think this is common sense, it is absolutely necessary here because you simply can’t count on getting proper advice and treatment from a physician.
In addition, the National Health Plan pays for all kinds of folk treatments that have no demonstrated efficacy. Sure all of this makes for patient confidence in the system, but this expanded range of options in combination with high accessibility and physician’s low credibility make the system far more expensive than its cost should warrant. In addition, it is great for that large portion of the patient body who have a condition that will disappear without medical intervention, but if you really have serious medical condition, it’s a big problem. It can take a long time finding a doctor who will take the time to diagnose and treat it properly. And in the meantime, you might die.
From my post: “Few of the people who have said such things to me have actually watched Sicko. If you haven’t, I recommend that you do.”
I’m a little confused by this. I had presumed the purpose of the post was to prompt a discussion of health care. I doubt anyone here questions how frightening access to health can be in the USA. Certainly I don’t. I think the point of most people here is to point out that Taiwan health care seems great as long as nothing is really wrong with you. When it is, you might find that you wish you were payiing a little bit more.
1. The problems with Taiwan’s health care are NOT the result of it being a single-payer system.
2. The problem in America is much worse than “sick people can’t afford to get treated.” The system is run by the insurance industry whose incentives are to only provide their product to the people who will never need it. They have been very effective at doing this, as the movie makes clear.
3. I think Taiwan’s system actually does pretty well, and you CAN pay a little more for private insurance to supplement the national insurance. In fact, I already do, although my experience so far is that we haven’t really needed it.
This isn’t to say that there aren’t problems with Taiwan’s system - but as I said above, I think a lot of these are endemic to modern Westernized medicine and are not unique to Taiwan. Even in the US I know many people who had to go to 4 or 5 different doctors before they got a correct diagnosis.
I’m sorry if I made it sound like I was saying any of this, and I realize the US system is systematically dysfunctional. But there is a strange kind of dysfunction in a health system that works primarily for its members who are not sick. And in fact encourages those who are not sick to use it while at the same time making it difficult or impossible for the truly sick to use full use.
One of the reasons that Taiwan NHI is so effective is that it is a relatively young system. I don’t have the figures available Taiwan NHI is running already in debt even though universal coverage is a relatively recent innovation.
None of this means that I think Taiwan should move toward a privatized or partially privatized system. But as I keep repeating, much of the system only appears functional because no one who is truly ill uses it.
I’m sorry if I made it sound like I was saying any of this, and I realize the US system is systematically dysfunctional. But there is a strange kind of dysfunction in a health system that works primarily for its members who are not sick. And in fact encourages those who are not sick to use it while at the same time making it difficult or impossible for the truly sick to make full use.
One of the reasons that Taiwan NHI is so effective is that it is a relatively young system. I don’t have the figures available, but the Taiwan NHI is already running in debt even though universal coverage is a relatively recent innovation.
None of this means that I think Taiwan should move toward a privatized or partially privatized system. But as I keep repeating, much of the system only appears functional because the majority of those using it are not ill.
I love the fact that in Taiwan you can go see a specialist directly. Even if you show up without an appointment the waiting time is not unreasonable. The problem is that sometimes you have to self-diagnose just to know which department to go to. In my experience GPs in Taiwan are simply no good. They’re really not worth bothering with.
I am not optimistic about Taiwan’s health care in the future for the simple reason that global budgeting, which came into effect a couple of years ago, severely limits the amount of money hospitals can spend. It’s designed of course to reduce waste, increase efficiency etc, but inevitably it’s going to reduce the quality of patient care, and worsen the problem of hospitals massaging their figures. Taiwan’s health care system is already in debt and it’s only going to get worse. Still, if I got seriously ill, I’d rather be treated here than in the UK, where the NHS seems to be at the point of collapse.
An anthropologist and documentary filmmaker, 
Very interesting. Thanks for sharing that program. I tend to be among those who believe the Taiwanese should be proud of their health-care system. I just hope it keeps on running the way it does.