NHI stands for Taiwan’s National Health Insurance program. After seeing the movie Sicko (see here) which compared US healthcare to that in several other countries, I’ve been looking for a way to get a sense of how it compares to health care here in Taiwan. (I’m not the only one, Thoth Harris wrote a post along similar lines, albeit based purely on anecdotal evidence.) This has been difficult because Taiwan is not considered to be a country by the PRC-controlled UN, and so isn’t listed on the WHO report used in Moore’s film (according to which “the United States is ranked #37″, far behind most other industrialized nations). Taiwan is in fact running a national campaign to be included in the WHO, and their website says that “In 2000, The Economist listed Taiwan as the second-healthiest country in its ‘World Healthy Nations List.’” Unfortunately I have not been able to track down this list online. I was about to give up on the topic when Shashwati found this excellent article from the 2003 edition of Health Affairs, entitled “Taiwan’s New National Health Insurance Program: Genesis And Experience So Far.”
The article says that the program, established in 1995, closely resembled “the government-run U.S. Medicare program for the elderly and the single-payer health insurance programs operated by the Canadian provinces” and that “many of the problems encountered by Taiwan’s NHI have long been familiar to these programs as well.” As many of you may know, many democrats are now suggesting that the Medicare model now be extended to all Americans, so the Taiwan experience is definitely worth a closer look.
What I didn’t realize, although I should have when I think back on it, is that most of Taiwan’s health facilities are privately owned. (To be precise, “86 percent of hospitals (1999) and 65 percent of all hospital beds (2000)” are private, and half of the physicians have their own private clinics.) One problem with Taiwan’s medical system (as with just about everything else in Taiwan) is that it is “unevenly distributed geographically,” with very few doctors serving the Aborigine areas in the mountains. But the overall range of services and considerable amount of freedom of choice for the patients is quite impressive:
Benefits. The NHI’s benefits are comprehensive. They include inpatient care, ambulatory care, laboratory tests, diagnostic imaging, prescription and certain over-the-counter (OTC) drugs, dental care (except orthodontics and prosthodontics), traditional Chinese medicine, day care for the mentally ill, limited home health care, and certain preventive medicine (pediatric immunizations, adult health exams including pap smears, prenatal care, and well-child checkups). Expensive treatment for HIV/AIDS and organ transplants are also covered. This benefit package is much broader than that of the U.S. Medicare program.
Access and freedom of choice. More than 90 percent of Taiwan’s health care providers contract with the BNHI.22 Unlike U.S. managed care models, the NHI offers the insured complete freedom of choice among providers and therapies. There is no rationing of care, and there are no queues for care, as in the British and Canadian systems. The de facto absence of a referral system, so far, and the completely free choice of providers has meant that patients can go doctor shopping, and they often do.23 Furthermore, they can seek care at tertiary care institutions, regardless of the nature or severity of their illness.
Advocates of alternative medicine will be happy to know that “freedom of choice” among therapies includes traditional Chinese medicine, and there are numerous clinics and hospitals offering both traditional and western medicine.
Anyone who has seen Sicko will be particularly impressed with the following:
In 2002 Taiwan’s Supreme Court ruled that no one in Taiwan could be denied care because of lack of ability to pay. For those temporarily unable to pay premiums (for example, those who lose their jobs), the BNHI has a fund from which such people may take out interest-free loans to pay the premiums.
The system is not, however, without its problems. One is that doctors are rewarded for bringing in revenue, and this can sometimes lead to unnecessary procedures. The other is that hospitals can make up for lost revenue (due to price caps on their fees) by overcharging for drugs.
According to a December 2002 study report by the DoH, close to half of the doctors in Taiwan prescribe four to five drugs per visit for upper respiratory infections, and 10 percent prescribe more than eight drugs; in only fourteen of 103,024 outpatient visits did the doctor not prescribe any drugs. The CEO of a large private hospital told me that 44 percent of his hospital’s income is derived from the prescription and sale of drugs to patients.
Taiwan also has something else the US has been talking about, an electronic system for sharing medical records between care givers.
A revolutionary information technology (IT) innovation to improve the quality of the NHI’s system is the introduction in 2002 of the IC-Card, to replace the traditional paper card for accessing care. This credit card–size database contains important clinical as well as personal information on its holder. It will function as a communication tool between the NHI and providers and, once fully implemented, will also make it possible to electronically transfer medical records among providers (with the patient’s consent). This sharing of clinical information may help reduce the waste of duplicative services and curb that favorite pastime of Taiwanese patients: “doctor shopping.”
The article concludes with a discussion of some of the budgeting woes and problems of excess capacity. These are serious issues, but I just hope Taiwanese all see the movie Sicko before making any important policy decisions that might mistakenly seek to curb costs through US style reforms.