2012 / 9月
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.