Health Care System in Taiwan

1
Health Care System in Taiwan Measures Policies

• Group Members
• Peony CHENG, Dicky CHIU, Dick FOK, Peter KONG,
  Dorothy LAM, Timothy LUI, Amy WU

2
Presentation Outline

• Capacity Building Peter
• Access Timothy
• Cost Containment Peony
• Efficiency Dorothy
• Quality Assurance Dicky
• Further Coverage Dicky
• Questions Answers

3
CAPACITY BUILDING
4
Establishment of Medical Care Network

• The start of capacity building
• DOH initiated in1985 completed in 2000
• 15 years, 3 phases project
• Better distribution of medical resources
• Divided into 17 regions, 63 sub-regions

5
Medical Care Network

• Phase One Two
• 10 years (1985 1995)
• Develop primary secondary care
• Encourage private investment in rural and
  mountain areas
• Phase 3
• 5 years (1996 2000)
• Rehabilitation
• Long Term Care
• Psychiatric care
• Quality assurance

6
Medical Care Network

• Goals of the Project By 2000
• 13.3 physician /10,000
• 35 hospital bed / 10,000
• 10 psychiatric bed / 10,000
• 35.2 nursing home bed / 10,000 elderly

• Health Status At 2000
• 15 physicians /10,000
• 56.8 hospital beds / 10,000
• 6.7 psychiatric beds / 10,000
• 507 nursing homes for 14094 elderly

7
Number of Health Personnel Per 10,000 Population
Physicians
Dentists
8
Number of Health Personnel Per 10,000 Population
Pharmacists
Nurses
9
Primary Care

• Clinics
• Western and TCM mix
• Majority privately operated Western
• NHI contracted 88 of private clinics
• Public operates in rural and mountain areas
• 368 health stations
• 500 health rooms

10
Primary Care
Clinics
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Primary Care

• Dental Care
• 100 privately operate
• NHI contracted 97

12
Secondary / Tertiary Care

• Hospital
• Western and TCM mix
• Majority privately operated Western
• NHI contracted 90 of private
  hospitals
• Including teaching hospitals
  and tertiary care

13
Secondary / Tertiary Care

• Hospital
• 602 private 85552 beds
• 98 public 40924 beds
• 56.76 beds per 10,000 people

14
Secondary / Tertiary Care
Hospital Bed
15
Preventive Care/Early Detection

• Children Health
• Free vaccinations to infant/ children
• Hap B, poliomyelitis, measles, mumps, rubella,
  Japanese encephalitis, tuberculosis, diphtheria,
  pertusis, tetanus
• 6 health examinations for infant/children up to 3
  years old
• Starting from 1998, complete health record for
  all elementary school student

16
Preventive Care/Early Detection

• Vision check up for age up to 5 years old
• Myopia
• Strabismus
• Amblyopia
• Pre / Post Natal Care
• 10 free pre-natal screening
• Congenital metabolic disorder
• Thelasemia

17
Preventive Care/Early Detection

• Adult / Geriatric Health
• Preventive screening
• 40-64 once/3 years
• 65 once a year
• Cancer Control
• Cervical Cancer
• Annual Pap test for women age 30

18
Preventive Care/Early Detection

• Breast Cancer
• 1993 started education on self examination
• 2000 provided/conducted breast palpation to women
  30
• Oral Cancer
• 2000, started checking 500,000 habitual betel nut
  (??) chewers for oral cancer and precancerous
  lesions

19
Preventive Care/Early Detection

• Occupational Disease
• 6 occupational health centers
• Diagnosis, treatment, follow ups, assessment
• In 2000, 428 medical institutions for detection
  of black lung disease
• Free HIV screening treatment

20
Rehabilitation

• 147 hospitals for drug rehab
• 46 psychiatric rehab centers

21
Long Term Care

• 1996
• 91767 (5.34) of 1.69 million elderly unable to
  attend daily life
• Report of status of elderly issued by the
  Ministry of Interior
• 1998
• Department of Health issued a 3 year plan for
  long term care of the Elderly
• Budget of NT1.1 billion
• 10000 beds for the elderly

22
Long Term Care

• DOH Strategies 6 providing 1 financing
• Establish effective channels medical care
  social resources
• Provide dependent elderly their families with
  assistance
• Provide government funding consolidate private
  sectors and hospitals
• Encourage establishment of more nursing home
• Develop manpower for LTC
• Increase community care resources encourage
  home care
• Plan for LTC insurance

23
Long Term Care

• Elderly
• Chronically ill require home care
• 299 hospitals provide the service for 672,032
  person-cases
• Nursing Caring homes
• 507 institutions providing care for 14,094
  persons
• Day Care centers
• 19 centers providing care for 245,677 person-cases

24
Long Term Care

• Cancer Care
• Sun Yat-sen Cancer Center provides home care for
  patients
• Chronic Patient
• 8 chronic hospitals

25
Access

• Removable of Geographical Barrier
• Removable of Financial Barrier

26
Removable of barriers ( Geographical )

• Health station
• Residents in mountain areas and offshore
  islands rely heavily on local health
  stations and health
  rooms
• No. of health station in Taiwan (mountain area )
  368 (49)
• No. of health room in Taiwan ( mountain area )
  503 (200)
• Health stations are community-oriented and form
  the basis of primary health care ( e.g. general
  outpatient treatment, emergency medical care,
  educational programs, family planning and
  prevention )
• All health stations in mountain regions have the
  standard diagnosis, treatment, testing, X-ray and
  ambulance equipment.

27
Removable of barriers ( Geographical )

• Mobile medical team
• Since 1979, the government has been sending
  mobile medical team to remote villages on the
  regular basis
• In 1995, a boat was built for mobile medical
  treatment
• In 1996, helicopter landing pad
  was built in some remote areas
  to improve local emergency care

28
Removable of barriers ( Geographical )

• NHI
• Adjust payment by increasing the diagnosis and
  treatment fee for doctors and lowering the fee
  for residents in order to increase the healthcare
  accessibility in remote areas
• Telecommunications medical care network
• Established since 1989, 145 points of service in
  various remote areas in 1995
• Teaching hospitals, medical centers and regional
  hospital have joined the network and provide
  services to health stations in remote areas
• Provide medical personnel with educational and
  training opportunities

29
Removable of barriers ( Financial )

• NHI / Insurance Premium
• Premium Relief Fund is to assist public with
  financial difficulties to pay insurance premium
  by providing non-interest bearing loan
• Labor insurance will pay the premiums for those
  people who are unemployed
• Under the insurance premium contribution,
  category 5 ( Low-income group )
  do not need to pay the premium
• People who age above 70 do not
  need to pay the premium
• Some charity parities can offer assistance for
  those people who are unable to pay the premium

30
Removable of barriers ( Financial )

• NHI / Exemptions of co-payment
• Catastrophic diseases
• The catastrophic diseases, such as, cancer,
  chronic mental illness, haemodialysis
  congenital illness. These illnesses involve
  medical expenses too high for an average family
  to afford
• Child delivery
• Preventive health services
• Medical services offered at
  remote areas
• Low-income households
• Veterans

31
Cost-Containment

• Supply-side Strategies
• Global budgets
• Payment systems
• Administrative controls
• Demand-side Strategies
• Co-payment

32
Supply side strategies

• Global budgets
• Dental global budgets (1998)
• Chinese medicine (2000)
• Office-based ambulatory care (2001)
• Hospital (2002)

33
Supply side strategies

• Payment systems
• Include laparoscopic surgery, home
  iron-discharging agent pump, liver and lung
  transplantation in payment standard (1998 to
  1999)
• Case payment system of 50 like DRGs
• Some pilot projects of capitation payment in
  remote area and outlying islands
• Drugs payment systems

34
Supply side strategies

• Administrative controls
• Penalties on healthcare providers proven to
  misuse medical resources
• Holds regular audits and
  reviews on various projects
  and announces major violations

35
Demand side strategies

• Co-payment of hospitalization
• Co-payment rate is 5 to 30, with higher
  co-payment rate for longer duration of
  hospitalization
• Upper ceiling for the entire
  calendar year is NT 40,000 (10
  of average national income)
  in 2002

36
Demand side strategies

• Co-payment for outpatient services
• Additional co-payment on drug expenses, frequent
  users and rehabilitation therapy from 1999 to
  2001
• Pharmaceutical co-payment max. NT 200
• Freq. user co-payment max. NT 100
• Physical rehab. co-payment max. NT 210
• Increase co-payment in academic and regional
  hospital on Sept 1 2002
• Regional hospital - from NT100 to NT140
• Academic hospital - from NT150 to NT210
• Co-payment for lab exam increased from 0 to
  max. NT300

37
Efficiency

• Use of IT
• Contracting Out
• Competition

38
Use of IT (1)

• Digital accreditation procedures
• BNHI set up the cross-branch operation at one
  counter system
• NHI internet
• Voice service systems
• National Health Insurance IC
  Card

39
Use of IT (2)

• On-line data exchange of all banks
• Search functions for important medical orders in
  various medical institution via internet
• Broadband Networks for NHI
  network

40
Use of IT (3)

• Electronic patient records and medical
  information standards
• Develop major health care information
  applications
• Filmless environment
• Internal Management Document Mgt, Personnel
  Mgt, Admin Support Mgt.

41
Contracting Out (1)

• Dec. 2000, there were 16,332 contracted
  healthcare providers

42
Contracting Out (2)

• contracted pharmacies stood at 3,061
• contracted medical laboratories
  numbered 230
• contracted midwifery clinics numbered 18
• contracted community psychiatric rehabilitation
  facilities numbered 38
• contracted home care institutions (including home
  care services) numbered 304
• a total number of 19,983 contracted healthcare
  providers to meet different demands from the
  public

43
Contracting Out (2)

• 113,821 beds provided by NHI contracted
  healthcare providers
• 88.2 were acute beds, 11.8 are chronic beds
• By the end of 2001, 16,558 medical institutions
• Now 96.5 of all private and public
  medical care institutions have
  signed contract with the National
  Health Insurance .

44
Competition (1)

• Price
• Absence of sufficient price competition
• External
• Lack of external competition

45
Competition (2)

• Great Internal competition
• Under fee-for-service (FFS) medicine, the more
  clinicians do, the more money they make.
• Over 16,000 contracted health care providers
• Great demand for better hospital services
  economic growth
• Increase competitiveness and improve service
  quality by ISO, focusing group, customer
  satisfaction survey

46
Quality Assurance
47
Quality assurance in Taiwan

• Accreditation of quality of medical schools
• Reform of medical
  education small group teaching
  and problem- based learning
  (PBL)
• Problem arises
• ? disparities in the content of medical education
  between different medical school

48
Quality assurance in Taiwan

• Need to have objective
  measure of the quality of
  medical education.
• Call for the development
  of systematic method of
  accreditation of medical
  schools by the Ministry of Education (MOE)
  in 1997.
• Accreditation is done by National Health Research
  Institute (NHRI) since 1999.

49
Quality assurance in Taiwan

• Evaluation criteria
• Design and implementation
  of the curriculum
• Content of curriculum
• Evaluation of students
  academic performance
• Student recruitment, academic counseling, career
  planning and the overall learning environment
• Utilization of teaching resources funding,
  general facility, teaching facility, library and
  resources of clinical education.
• Website www.nhri.org.tw

50
Quality assurance in Taiwan

• Hospital accreditation
• Launched in 1978
• to upgrade the quality of medical care,
• to identify well-organized clinical training
  institutions for medical students and residents.
• Senior physicians, nurses,
  pharmacists and hospital
  management specialists
  visit and assess hospitals
  based on a set of standards
  and operational procedures.

51
Quality assurance in Taiwan

• Hospital accreditation
• Evaluation on the basis of the quality of
  personnel, facilities, hospital management,
  community services and the quality of medical
  care in various departments.
• Valid for 3 years and then apply for
  reassessment.
• By the end of 2000, 497 hospitals are qualified

52
Quality assurance in Taiwan

• Licensing for clinics
• Not subject to accreditation
• Apply for an operating license
• Requirements are set by local health station
• Subject to periodic inspection by local health
  station personnel
• Must be passed for the clinics to renew their
  licences.

53
Knowledge management in Taiwan

• Background of the development of e-health
  learning
• Medical resources are unequally distributed.
• Top 10 medical centers ¼ national health
  expenditure
• Rural areas medical resources and medical
  manpower are under-distributed.
• Why medical personnel reluctant to practice in
  rural areas ? (Chen, et al, 2001)
• Afraid of isolation.
• Lack of chance to receive continuing medical
  education.

54
Knowledge management in Taiwan

• Why e-health learning is needed in rural area in
  Taiwan?
• Medical resources poorly distributed
• Quality of consultation referral need
  improvement
• Peer communication among healthcare providers
  difficult
• Need to provide continuing medical education
  online
• Elderly, handicapped terminal ill patients
  convenient way to provide special healthcare at
  home

55
Knowledge management in Taiwan

• Development of e-health in Taiwan began under the
  National Information Infrastructure (NII)
• Major progress in NII development
• Distance education
• Teleconsultation
• Video-on-demand
• Electronic library

56
Knowledge management in Taiwan

Video-conferencing Case library

E-journal Video On Demand (VOD)
57
Knowledge management in Taiwan

• Videoconferencing provides face to face teaching
  and learning in real time between teacher and
  students
• Case library application of telecommunication
  technique to ? clinicians effort and time in
  continuing medical education
• E-journal Chinese full-text journal
• Video on demand (VOD) virtual classroom
  providing web-based distance learning course with
  teaching materials

58
Standardization of clinical protocol

• Prevent the abuse use of medical services as well
  as misuse of budget, BMHI specify a list of
  treatment for different kinds of illness
• Treatment not listed must be
  approved by BNHI.
• Ensure that the patient
  obtained same treatment no
  matter which hospital they go.

59
Further Coverage
60
Further coverage in Taiwan

• Catastrophic coverage
• NHI has covered over 96 of population in Taiwan,
  so the private insurance is said to be
  insignificant.
• Well cover In 921 earthquake, all patients would
  be waived of co-payment.
• still purchase personal health insurance.
• Fear that the national health insurance policy do
  not cover all kinds of catastrophic illness.
• Conditions qualifying as catastrophic illness
  under NHI (www.cens.com.tw)
• Cancer, congenital abnormality of coagulation
  factors, severe anemia, chronic uremia,
  generalized autoimmune syndrome requiring
  lifelong treatment, chronic psychiatric disorder
  .

61
Further coverage in Taiwan

• Foreign insurance companies in Taiwan
• Currently, there are 14 U.S. insurance companies
  in Taiwan insurance market.
• They put more effort on educating clients about
  their coverage and meet the particular needs of
  their client.
• Catastrophic disease insurance programs are
  expected to be more popular in future. (Chou,
  1999)

62
Questions Answers
63
Reference

• Website
• www.gio.gov.tw
• www.dgbas.gov.tw
• www.doh.gov.tw
• www.nhi.gov.tw
• Public Health in Taiwan R.O.C., Department of
  Health, Republic of China, August 1997