If you were the hospital director, what would you do?

It is heartening to see that recently all four presidential candidates have responded to the medical community's longstanding appeals, proposing to improve the medical working environment, legislate nurse-to-patient ratios, and increase the GDP proportion allocated to healthcare expenses.

Vice President Lai candidly admitted, "Since the National Health Insurance program began in 1995, it has probably reached a point where reform is unavoidable. Without new momentum, the quality of healthcare and satisfaction with the National Health Insurance could fall; he sees improving the health insurance system, providing a good medical environment, promoting public health, and ensuring the sustainability of the health insurance system as his mission, stemming from his medical background."

All the presidential candidates are well aware that for a long time, Taiwan's investment in health insurance has been severely lacking, far below the OECD average of 9.7%, not to mention that most European countries exceed 12%.

The comparison with neighboring Japan and Korea is particularly disappointing. From 2002 to 2021, Taiwan's health insurance expenses as a percentage of GDP grew from 5.5% to 6.1%, an increase of only 0.6% over 20 years. During the same period, Korea doubled its investment from 4.2% to 8.4%, a growth of 4.2%. Japan increased from 7.4% to 11.1%, a growth of 3.7%.

Over more than two decades, Korea and Japan have invested in health insurance to enhance the quality of medical care. The numbers tell us that in 1996, the average life expectancy in Taiwan was 74.95 years, higher than Korea's 74.15 years. By 2022, Taiwan's life expectancy was 79.84 years, while Korea's was 83.53 years, surpassing us by 3.69 years. Moreover, in recent years, Korea and Japan have also had lower infant mortality rates and cancer death rates than Taiwan.It is heartening to see that recently all four presidential candidates have responded to the medical community's longstanding appeals, proposing to improve the medical working environment, legislate nurse-to-patient ratios, and increase the GDP proportion allocated to healthcare expenses.

Vice President Lai candidly admitted, "Since the National Health Insurance program began in 1995, it has probably reached a point where reform is unavoidable. Without new momentum, the quality of healthcare and satisfaction with the National Health Insurance could fall; he sees improving the health insurance system, providing a good medical environment, promoting public health, and ensuring the sustainability of the health insurance system as his mission, stemming from his medical background."

All the presidential candidates are well aware that for a long time, Taiwan's investment in health insurance has been severely lacking, far below the OECD average of 9.7%, not to mention that most European countries exceed 12%.

The comparison with neighboring Japan and Korea is particularly disappointing. From 2002 to 2021, Taiwan's health insurance expenses as a percentage of GDP grew from 5.5% to 6.1%, an increase of only 0.6% over 20 years. During the same period, Korea doubled its investment from 4.2% to 8.4%, a growth of 4.2%. Japan increased from 7.4% to 11.1%, a growth of 3.7%.

Over more than two decades, Korea and Japan have invested in health insurance to enhance the quality of medical care. The numbers tell us that in 1996, the average life expectancy in Taiwan was 74.95 years, higher than Korea's 74.15 years. By 2022, Taiwan's life expectancy was 79.84 years, while Korea's was 83.53 years, surpassing us by 3.69 years. Moreover, in recent years, Korea and Japan have also had lower infant mortality rates and cancer death rates than Taiwan.

Access to a lot of medical care does not mean better health care is received.

Indeed, Taiwan's health insurance is super affordable and has a high degree of freedom. Patients can visit any hospital from south to north, with no restrictions, and the average Taiwanese visits the doctor more than 15 times a year, the highest rate in the world, with a public satisfaction rate reaching 90%. The government is also very complacent due to its popularity with the public.

However, the problem is that access to a lot of medical care does not mean that better health care is received. When the Taiwanese public faces complicated diseases or fatal acute conditions, due to the unreasonable payment system of the health insurance, departments that are not profitable, such as neurology, infectious diseases, pediatric surgery, etc., are increasingly ignored. There's also a severe shortage of nursing staff, preventing people from receiving appropriate medical care. The issue has now become extremely serious.

Additionally, due to inadequate care for chronic diseases, Taiwanese people have more than eight years of 'unhealthy' life expectancy, which has increased the burden of long-term care.

Nearly 30 years since the implementation of health insurance, because the payments severely fail to cover costs, hospitals of all sizes have started to 'chase quantity' to attract patients from the start, not only disrupting the order of 'tiered medical care' but also seriously diminishing the quality of medical care. Since then, most patients in Taiwan go directly to medical centers, causing the medical system to become distorted into an inverted heavy-headed triangle.

In addition to "chasing volume," Taiwanese medical institutions are also striving to develop self-funded items.

Taiwanese medical institutions, in addition to "chasing volume," are also actively developing self-pay items, including the use of expensive medical materials and the acquisition of costly equipment. As a result, Taiwan has witnessed a very peculiar phenomenon. Despite Taiwan's health insurance investment being far lower than that of European and American countries, the density of expensive medical equipment in Taiwan, such as particle (proton and heavy particle) therapy apparatus, is reportedly the highest in the world, over five times that of the frequently criticized US.

Investing huge sums in purchasing high-tech equipment necessitates its use to recoup costs. According to a recent report by "The News Lens," during a closed-door seminar discussing "the future of medical insurance products," one doctor mentioned that, to his knowledge, there are doctors who use the da Vinci surgical system for hernia repairs and appendectomies simply because the patient has commercial insurance, not because it is in the patient's best interest, which almost made him faint.

This doctor further stated that after purchasing a da Vinci system at a high price, whether it's used or not, the annual maintenance cost of the machine is still 10 million NT dollars. He asked, "If you were the hospital director, what would you do?" The director then allocated a budget of 5 million NT dollars to the gynecology department, 3 million to urology, and 2 million to general surgery. "What do you do as a department head? You schedule more da Vinci surgeries."

Similarly, when Taiwan has 15 particle (proton and heavy particle) devices, their cost is dozens of times higher than that of da Vinci. How will these hospitals recover the costs? This is something that Taiwanese patients should ponder deeply!

To vie for a slice of the national health insurance pie, numerous 'valueless' medical treatments have emerged.

In the nearly 30 years of competing for the national health insurance pie, chasing volume and developing self-pay items have become the norm in the management of Taiwanese hospitals. Clearly, this has resulted in numerous 'valueless' medical treatments, such as using the da Vinci surgical system for hernia repairs or appendectomies, which do not benefit the patient. Using da Vinci for fibroid removal or gynecological cancer surgeries may even lead to patients spending a lot of money to their own detriment. The U.S. FDA has even issued warnings to physicians and patients.

It was certainly welcome when all four presidential candidates promised to "invest in health insurance and improve the medical environment." I believe that as the government (including the public and employers) invests more resources in health insurance to compensate for past deficiencies, it has an even greater responsibility to establish a mechanism to eradicate the sequela of 30 years of health insurance issues. This includes using positive incentives to correct the unhealthy practices developed over the past 30 years in the Taiwanese medical community. Eliminating 'valueless' medical treatments and ensuring that medical decisions are made with the patient's interest as the 'sole' consideration is essential to the true nature of healthcare.

Author: Dr. Andrew T. Huang, President & CEO, KFSYSCC