創造醫、病、健保三贏

──衛生署長邱文達專訪
:::

2012 / 9月

文‧張瓊方採訪整理 圖‧莊坤儒


「17年之疾,求3年之艾,」衛生署長邱文達指出,為了讓健保可長可久,衛生署召開十幾場會議與高峰會,廣納數百位專家學者的提議建言,歸納出12項要優先執行的策略。計畫在3年內投入300億元,將台灣醫療生態做一次徹底大翻轉。

且聽、且看,從腦神經外科轉任衛生署的邱文達,如何下刀開藥,搶救病徵已現的台灣醫療。


問:醫療院所「五大皆空」的問題,引發各界關注,衛生署有何解決之道?

答:5大科人力短缺的問題由來已久,10年前,國泰醫院院長陳楷模就語出驚人地說:「只要有手有腳、會走路就可以來外科!」可見當時外科就已開始缺人。

事實上,不只在台灣,日本、歐洲、美國,都面臨同樣的問題。今年2月,日本學者大前研一警告,日本醫師人力不足,特別是外、婦、兒科,日本的健保體系面臨崩解。

我國醫師人力雖然比不上歐洲,但在亞洲僅次於日本。

台灣每年有1,300位醫學院畢業生,加上從國外學成歸國一百多人,大約就有1,450人進入職場,理應不乏生力軍,卻仍不敵需求及工作量的增加。

國內醫院10年來增加了2萬張床位,醫護人員工作量大增,醫院評鑑也加重他們的工作負荷。再加上醫療技術進步,讓診斷治療更加複雜。以子宮頸癌為例,以前手術加上放療療程就結束了,現在走個人化醫療路線,標靶藥物,加上免疫療法,還要檢測基因、生物指標等。

健保的高效率、低費用,的確把大家累壞了。科別人力分配不均及醫師年齡老化現象,也到了必須調整的關頭。

提高5大科津貼

首先我們要做的是提升全民健保的給付,去年已投入14億元將外婦兒科門診診察費調增17%,今年又編列21億元健保預算,提高5大科重症支付標準,並且加強稽核,要醫院確實將經費用在提高醫師的待遇上。

和信治癌中心醫院黃達夫院長稱,近幾年美國5大科住院醫師費提高近一倍,但現階段我們承受不起如此大幅的調漲,於是折衷,將5大科津貼一年增加12萬元,總共花費3億多元,這筆經費直接從醫療發展基金支付。

其次,衛生署將合理調整5大科的訓練容額。台灣一年專科醫師訓練名額有2,143人,但申請人數只有1,400名,求過於供,因為大家都往「五加皮」(五官科加皮膚科)擠,未來藉由容額的限制與改變,希望能有所調整。

另一方面,我們也要積極開發輔助人力,目前輔助醫生的專科護理師已有三千多名,未來將研擬辦法,再從其他醫療領域培訓臨床助理、開刀房技術員等輔助人力。

此外,住院醫師全科訓練(PGY)也從過去的半年延長為一年,讓住院醫師多熟悉5大科的醫療技術。

降低醫療糾紛風險

問:醫療糾紛日益嚴重,衛生署是否思考過「刑責合理化」修法的可能性?

答:最近的調查顯示,醫師的抱怨,醫療糾紛已超過健保,躍居第一位。

醫療糾紛,5大科占85%,其中80%以刑事提告,從被刑事起訴的醫師人數來看,台灣每年36.7位、日本15位、美國1.2位,我們必須正視這個問題。

一位年輕醫師被起訴,意志與信心都會受到嚴重打擊,也會造成人員流失。從病人的角度來看,更不好,醫生為求自保會產生防禦性醫療,作很多無謂的檢查。

但「去刑化」或「除罪化」法務部都不同意,衛生署已經提了兩個會期,都沒能通過。未來我們希望將《醫療法》第82條第3項,修正為「醫事人員因執行業務致病人死傷者,以故意或明顯違反醫療常規且情節重大者為限,負刑事責任。」這方面仍須與各部會、立法院及民間團體、醫界、法界各方溝通。

問:有沒有立即改善醫療糾紛的措施?

答:現階段我們已動用醫療發展基金,先推「生育事故救濟計畫」,日前已獲得行政院通過,今年10月1日確定上路。

之所以先推生育補償,實在是生產風險太高,現在七百多家醫院診所,只有三百多家敢接生,因為平均7位婦產科醫師就有一人被告。生育事故將視事故嚴重程度給予30萬到200萬元補償,藉以減少訴訟糾紛。

生育事故試辦若成功,慢慢將擴大到整體醫事事故,像手術、麻醉、加護病房等必然有一定比例風險的醫療行為,經判定沒有違反醫療常規者,都應可適用,希望在103年也都能實施。

最終我們希望能推動「醫事爭議處理及事故補償」立法,籌設「醫事事故基金」,將目前「以刑逼民」的訴訟降低。

充實偏遠醫療服務

問:離島及偏遠地區醫師及設備不足問題,又應如何改善?

答:改善偏遠地區醫療,是我到署裡最想做的事。我們的健保是全世界數一數二的,如果「健康不平等」的問題可以解決,那就更加完善。

近年醫院越來越大型化、企業化,吸引人才往都會區集中,偏遠地區網羅人才更加不易,5大科尤其嚴重。我走遍偏遠、資源不足地區,深知他們最重視的是急救和重症,因為疾病發作時往往轉診不及。

我們已選定偏遠地區78家醫院,參與提升計畫,挹注6.7億元,做到起碼有內外婦兒的急診或門診。每家醫院有2個科以上就補貼700萬元,4個科以上就補貼900~1500萬元。

前年,全國尚有8個縣市沒有婦兒科的急診,去年底台灣本島全已完備,僅剩離島尚無法達成。

最近我們將醫學中心認養偏遠醫院納入評鑑指標,像澎湖就有三總、奇美、高雄長庚去支援。台北榮總、林口長庚則去了金門縣。軍方撤出連江縣後,亞東醫院和萬芳醫院也前往支援。

培育公費醫師也能發揮調節功能。「山地離島在地養成公費生」,目前仍有150人在學,101~105年還會再培育88位,這些5大科與家醫科學生,畢業後要服務7年。另外,103年會重新啟動一般公費生(2009年停辦),成為「重點培育科別公費醫師制度」,完成訓練者需服務6年。

最後,為了延攬旅外醫師回台服務,我們也提出鮭魚返鄉計畫,鼓勵歐、美、加、日、紐、澳地區華裔醫師回來。過去卡在專科醫師執照認證上,現正研擬:只要回台在指定的偏遠地區服務滿3年,就發給專科證書。

解決急診壅塞刻不容緩

問:急診是醫療的「重鎮」,但大醫院急診塞爆、醫護人員被不理性民眾暴力對待,已成為急診室的夢魘,如何改善?

答:急診壅塞的情況多發生在大醫院,24小時滯留超過5%的有16家醫院;留觀48小時達5人以上有12家,可見轉診制度及院內控床機制不甚理想。

2011年,健保病床的占床率,醫學中心為82%、區域醫院68%、地區醫院53%,相較之下區域及地區醫院仍有空間。我們已經委託急診醫學會辦理急重症雙向轉診獎勵計畫,希望獎勵醫院垂直整合。

民眾的就醫觀念也需要改變,我們的急診分1到5級,4、5級其實到門診就醫即可,無須浪費急診資源。

急診暴力問題值得重視,我們已提出5項防暴安全措施,包括:警民連線、24小時配置保全、空間區隔、張貼海報、加強門禁管制,目前醫院完成度達98%,應具有震撼效果。

對於施暴者,過去屬告訴乃論的傷害罪,但當事人往往不敢告,我們研擬修法將其納入「公共危險罪」,在尚未修法前,會請地方衛生單位針對急診室的暴力事件積極查處。

問:醫療生態改革計畫的資金來源為何?3年可以改善到什麼程度?

答:3年300億的資金來源有三,一是健保總額的成長部份、二是醫療發展基金、三是公務預算。

改革內容包括4大面向、12項策略(見表),希望藉此達到3個目標:包括解決五大皆空的人力不足問題;讓年輕醫事人員重新對救治生命懷抱熱情;我們已整合各方意見,設立優先順序,聚焦解決問題,希望病人、醫院、醫事人員都能三贏。

台灣的健保制度創下許多奇蹟,但改革勢在必行。17年之疾,求3年之艾,我們會全力以赴!

衛生署「醫療生態改革計畫」內容:4大面向、12項策略

提高5大科執業意願

● 提高全民健保5大科別支付標準

● 增加5大科住院醫師津貼

● 合理調整5大科醫師訓練員額

● 充實5大科醫療輔助人力

● 強化畢業後全科及5大科訓練

降低醫療糾紛風險

● 推動生育事故救濟及籌辦醫療事故救濟制度

● 推動醫療過失刑責合理化

充實偏遠醫療服務

● 挹注5大科偏遠地區醫療資源

● 山地離島在地養成公費生制度及開辦重點培育科別公費醫師制

● 延攬旅外醫師返鄉服務

解決急診壅塞及安全

● 急診壅塞因應策略

● 強化急診室安全

相關文章

近期文章

EN

The Rescue Plan for Medical Caregivers, Patients and the NHI:An Interview with DOH Minister Chiu Wen-ta

interview by Chang Chiung-fang /photos courtesy of Chuang Kung-ju /tr. by Phil Newell

“We have a disease that has been progressing for 17 years, and we are aiming to cure it in three.” This is how Chiu Wen-ta, minister of the Department of Health (DOH), describes ongoing efforts to put the National Health Insurance (NHI) system on a sustainable footing for the long haul. To these ends, the DOH convened summit conferences, collecting opinions and advice from hundreds of scholars and experts, and produced an action plan with 12 main priority strategies. The plan, which will require an investment of NT$30 billion over three years, aims to completely transform the “medical ecosystem” of Taiwan.

It is up to Chiu, a neurosurgeon turned minister, to decide where to make the incisions and apply the palliatives necessary to treat the emerging symptoms of illness in Taiwan’s insurance system.


Q: Let’s start with a problem that is getting widespread attention, the shortage of physicians in the so-called “Big Five” specializations: internal medicine, surgery, OBGYN [obstetrics and gynecology], pediatrics, and emergency medicine. Does the DOH have a solution?

A: This has been a longstanding problem, not only in Taiwan, but also in Japan, Europe, and the US. Although we cannot compare with Europe in terms of our human resources in the medical profession, in Asia we are second only to Japan.

Each year 1300 students graduate from medical school in Taiwan, and another 100-plus return from overseas, so that makes a total of about 1450. But still the supply can’t keep up with demand and the ever-increasing volume of work.

Over the last decade hospitals in Taiwan have added 20,000 more beds, sharply increasing the workload of medical professionals. Hospital evaluations also add to their burden. And on top of that, advances in medical technology mean that diagnosis and treatment have become more complex and time-consuming.

NHI calls for high efficiency while keeping costs down, which is wearing everybody down. The problems of maldistribution among specializations and the aging of doctors are two bottlenecks we definitely have to address.

Raising incomes

The first thing we want to do is to increase payments under the NHI system. Last year we invested NT$1.4 billion to increase payments in the fields of surgery, OBGYN, and pediatrics by 17%. This year we have budgeted NT$2.1 billion to raise payment levels for all of the “Big Five.” We will also enhance our monitoring of hospitals to ensure that the additional funding is really being used to increase doctors’ income.

Right now we can’t afford a major increase. Therefore, we will provide subsidies to increase salaries for the “Big Five” by NT$120,000 per doctor per year. The total cost of doing this will come to over NT$300 million, which will come from the Medical Care Development Fund.

Secondly, the DOH will appropriately adjust the quotas for advanced training in various specializations. Right now there are 2,143 spots per year for advanced training, but only 1,400 applicants, so there just aren’t enough applicants to fill all the spots. Therefore, people are able to avoid the Big Five by crowding into the easier specialties, such as dermatology, ophthalmology, and ENT [ear, nose, and throat]. In the future, we hope to change this through changes in quotas, limiting the number of spots for the easier fields and nudging more people toward the areas where they are needed.

Furthermore, we also have to be more proactive about training manpower to assist physicians. There are currently more than 3000 specialist nurses, and in the future we will be looking for ways to train more clinical assistants and surgical technicians from other medical fields, to provide more support to specialist doctors.

We will also extend the post-graduate-year (PGY) system, which gives all residents basic training in all fields of medicine, from six months to one full year, so as to give residents more exposure to the Big Five.

Reducing risk from medical disputes

Q: The problem of medical disputes seems to be getting more serious by the day. Has the DOH considered the possibility of amending the law in the direction of decriminalization?

A: Of all medical disputes, the Big Five account for 85%, and of these 80% involve criminal prosecutions. An average of 36.7 people are prosecuted per year in Taiwan under criminal law for medical disputes, compared to 15 in Japan and 1.2 in the US.

When a young doctor is indicted, it often takes as long as five years, and sometimes even longer, to resolve the case. These indictments are also a severe blow to the doctor’s morale and self-confidence—some doctors even leave their specialized fields as a result. Yet patients don’t really benefit from this system very much, because doctors end up doing a lot of unnecessary tests just to protect themselves.

But the Ministry of Justice is opposed to decriminalization, and though the DOH has proposed this for two legislative terms in a row, it has not been passed. In the future, we want to change Paragraph 3 of Article 82 of the Medical Care Act to read something like, “Medical personnel shall bear criminal responsibility in cases where their actions in the exercise of their profession lead to the death or injury of the patient, but only in such cases where the death or injury has been inflicted deliberately or as the result of failure to follow normal and routine medical procedures, and only where the negligence has been very serious.” To achieve this we will have to coordinate views with other ministries, the Executive Yuan, non-governmental groups, and the medical and legal communities.

Q: Are there any measures that can immediately alleviate the problem of medical disputes?

A: For the moment, we have decided to give priority to providing compensation in disputes that arise in cases of childbirth, and for this we are drawing on the Medical Care Development Fund. These regulations were passed by the Legislative Yuan recently, and will come into effect on October 1.

The reason we are starting with maternity cases is that there are such high stakes in pregnancies. Right now, only 300 or so of the country’s more than 700 hospitals and clinics handle childbirth, because they are afraid: one out of every seven OBGYN doctors has been subjected to legal action. Compensation for incidents connected to childbirth will range from NT$300,000 to NT$2 million depending upon the severity of the case, and we expect that this will reduce lawsuits.

If this provisional compensation plan works out, we will gradually extend it to cover all medical disputes. For example, there is always a certain level of risk with any medical procedures involving surgery, anesthesia, or intensive care, and the compensation fund will be used in all cases in which there has not been “failure to follow normal and routine medical procedures.” We hope to see complete implementation by 2014.

Ultimately we hope to see the passage of a new law to set procedures for handling medical disputes and for compensation. We are already planning the creation of a compensation fund, in hopes of providing an alternative that will reduce the resort to criminal law when the real goal is simply compensation.

Medical care in remote areas

Q: There is a shortage of doctors and facilities on offshore islands and in remote areas. What can be done to improve the situation?

A: Our health insurance is one of the best in the world, but we can make it even better if we can eliminate inequalities in access to health care.

In recent years, medical care has moved in the direction of bigger and bigger institutions and more corporatization, which attracts talented people to concentrate in the cities. It is harder than ever for remote locations to attract doctors, especially in the Big Five fields. I have travelled to every remote location and every place where medical resources are inadequate, and I have learned that what the residents most want is better emergency care and help with serious ailments, because when serious illness strikes sometimes there’s not enough time for patients to be transferred to bigger hospitals.

We have already organized 78 clinics in remote areas into an upgrading program. We have invested NT$670 million to encourage them to offer either emergency care or at least routine care in the fields of internal medicine, surgery, OBGYN, and pediatrics. Clinics with at least two specializations get NT$7 million in subsidies; those with at least four get between NT$9 and 15 million.

The year before last, there were still eight counties and cities without any emergency room services for OBGYN or pediatrics, but by the end of last year there were none. The only places we have not yet reached are the offshore islands.

Recently we have added a new category to our system for evaluating medical centers: how much they support remote clinics. For example, three major medical centers now provide support to clinics on the ­Penghu Islands, while two others give aid to clinics on Kin­men Island. When the military fully withdraws from Ma­tsu Island, two other hospitals will step forward to provide support.

There are also things we can do by training doctors at state expense. We have a program in place where medical students from remote areas can have the state pay for their entire medical education if they promise to return to their place of origin and serve for seven years. There are currently 150 students still in school who are in this program, and an additional 88 will be in it from the 2012–2013 through 2016–2017 academic years. These spots are limited only to the Big Five fields or family medicine.

Which reminds me: going back for a moment to the issue of the shortage of doctors in the Big Five fields, in 2014 we will revive the system of providing state funding for students and transform the system into a training ground for the Big Five major specialties. These state-funded students will have to serve six years in those specialties after completing their advanced training.

Getting back to the problem of staffing remote areas, there is one further point I want to make. A lot of doctors who went to medical school and got licenses to practice in Taiwan have moved abroad, and become specialists in their new countries of residence, so we also have a program to attract these people back to Taiwan from Europe, the US, Canada, Japan, Australia, or New Zealand. The main obstacle in the past was getting a local license to practice their specialty, but we are currently studying a proposal to give doctors a license to practice their specialty if they return to Taiwan and serve in a designated remote location for three years.

Emergency care for emergency care

Q: Emergency care is the “front line” of medicine. But emergency rooms in big hospitals are already overwhelmed, and violence or abuse of ER personnel has become a nightmare. What is to be done?

A: Overcrowding of ERs is mainly a problem at big hospitals. Right now there are 16 hospitals where more than 5% of patients are stuck in the ER for over 24 hours, and 12 where an average of five or more patients are in the ER for observation for 48 hours. Obviously the system for transferring patients out of the ER into clinical care and getting them beds in the main hospital wards is not functioning as well as it should.

In 2011, there was an occupancy rate of 82% of NHI beds at medical centers [the highest level of hospital in the NHI system, with the most comprehensive and advanced facilities], 68% at regional hospitals, and 53% at local hospitals. So there is still room at regional and local hospitals. We have commissioned the Taiwan Society of Emergency Medicine to come up with an incentive program for a more efficient transfer system for patients who come to the ER, so that only the most serious cases take up hospital beds in medical centers. We want to encourage more vertical integration among hospitals.

We also have to change popular attitudes toward medical treatment. ER cases are divided into five levels, but in fact level four and five cases could just come to see the doctor during normal clinic hours, thus sparing ER resources.

The problem of violence or abuse in ERs needs to be taken very seriously. We have proposed five measures to improve security including better cooperation with the police, 24-hour on-site security, creating greater separation for the areas where doctors and nurses work, putting up warning posters, and improved security at the hospital doors. The implementation rate of these measures is 98%, and they should have a deterrent effect.

Under current law, the people who do the violence can only be charged with assault if the victim files charges and brings adequate evidence for the police to begin an investigation, but often victims are too frightened to file charges. We want the law to be changed so that these offenses fall under “crimes against public order.” Until the law is changed, we will ask local health authorities to be more proactive about investigating and dealing with cases of violence against ER personnel.

Q: Where will the money come from for the three-year, NT$30 billion plan to transform the “medical ecosystem”? And how much do you expect to achieve in three years?

A: There are three sources of funding. One is the increase in the general NHI fund, the second is the Medical Care Development Fund, and the third is the central government budget.

There are four main elements to this reform, divided into 12 strategies, with which we aim to achieve three main goals. These include solving the problem of inadequate staffing in the Big Five fields and inspiring young medical professionals to regain their passion for saving lives. We will collate opinions from all interested parties, establish a list of priorities, and attack the problems. We are aiming for solutions that will benefit patients, hospitals, and medical personnel all at the same time.

Taiwan’s NHI system has been in many respects a miraculous achievement, but reform is now essential. We have given ourselves three years to cure problems that have been developing for 17, and we are determined to succeed.

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