Deadly contrast
To patients, medical services are an "intermediate product" rather than their ultimate objective. They naturally continue to seek medical care until they achieve that objective: a return to good health.
Recognizing the power of patients' desires for good health, medical institutions have not only been pursuing a large piece of the NHI pie, but also encouraging patients to spend money out of pocket to receive "even better" care. As a result, the ratio of out-of-pocket expenses to covered expenses has been rising steadily in recent years.
In early October, the THRF published a survey showing that more than 46% of the public paid medical fees over and above their copayments and coinsurance costs.
According to the BNHI website, medical centers most frequently ask patients to pay out of pocket for IV drips. Other common items include disposable medical products (e.g. single-use ear-temperature-gun sheaths, enema syringes, catheters, and drainage bags), patient-controlled administration of analgesics, hyperbaric oxygen therapy, and PET scans.
Close scrutiny shows most out-of-pocket expenses to be superfluous, though they can, in a few limited circumstances, be crucial.
The contrast agents used with some imaging technologies offer an excellent example.
In recent years, PET scans have vaulted to the top of the BNHI's top 10 examination procedures. The scans, which are touted for their ability to "see through the whole body," require the injection of a contrast agent. Generally speaking, NHI will pay for the use of the traditional ionic contrast agent, but this agent can cause nausea, vomiting, and even allergic reactions (at a 4-12% rate). To protect high-risk groups, BNHI will pay for the use of a non-ionic contrast agent for patients who meet any one of nine criteria, including impaired kidney function and major organ failure. But there's a catch: until recently the exception applied to a maximum of only 10% of examinations. Hospitals used this ceiling as an excuse to demand that patients themselves pay NT$1500 for the injection of the non-ionic contrast agent, thereby fattening their bottom lines.
In one case, a Mr. Lin, an 80-year-old man with poor kidney function, was asked to pay for the non-ionic injection. Lacking the money to pay the extra fee, he took a chance on the traditional ionic contrast agent, had an allergic reaction to it, and died.
In the wake of his unfortunate death, the Department of Health last year announced that it would eliminate the 10% cap and would pay for the use of the non-ionic agent for any patient that met one of the nine criteria. It also forbade hospitals from deceiving or rejecting patients.
Other dilemmas
Expensive new anticancer drugs similarly fall into the out-of-pocket category. Should you take them or not? Are they worth a roll of the dice? Such questions place patients and their families squarely on the horns of a dilemma.
Sheen Mao-ting, director of BNHI's Medical Review and Pharmaceutical Benefits Division, says cancer treatment is rife with out-of-pocket expenses, especially when you get into the realm of tailor-made targeted drugs. Trastuzumab, used to treat certain varieties of breast cancer, is a case in point. A year's supply of the medication costs an average of NT$700-800,000. At present, these kinds of incredibly expensive experimental drugs can only delay death; they don't cure the cancer. From the BNHI's standpoint, their costs outweigh their benefits, and it won't pay for them. This leaves patients and their families to decide for themselves whether to use (and shoulder the costs of) such treatments.
Out-of-pocket expenses also include "off-label" uses of medications. For example, there are currently no drugs specifically aimed at the treatment of colorectal cancer, and doctors frequently administer breast-cancer drugs to patients. The effectiveness of off-label uses is largely a matter of luck, so NHI won't pay for them, leaving patients to pay their entire cost themselves.
Sometimes out-of-pocket expenses aren't a matter of life and death, but simply of how much a patient can bear. Pain medications are a case in point.
Everyone who has had surgery knows that post-surgical pain from the wound can be hard to bear. Now that we have patient-controlled administration of pain medications, patients are able to press a button to administer analgesics any time they feel pain. Though this is great for patients, its costs them NT$3,000-7,000 out of pocket depending on their course of treatment.
But patient-controlled administration of analgesics isn't the only way to go. NHI pays for both the oral administration and the injection of painkillers, but hospitals are reluctant to provide adequate doses of the drugs in this manner.
Medical pillage?
In addition to encouraging patients to pay out of pocket for "better" care than NHI provides, some medical facilities simply invent their own out-of-pocket expenses. As a result, the public at large is coming to view hospitals as money pits and the economically disadvantaged are becoming even less willing to visit them unless they absolutely must.
A THRF survey of Taiwan's 25 counties and metropolises shows that "medical looting" makes "products" of services that had previously been free of charge and invents "special perks" that are easily tiered by price. For example, medical facilities now charge NT$100 to check medical records, NT$250-1000 to make an appointment with a specific outpatient clinician, NT$10-30,000 to get a specific surgeon for an operation, NT$200 to request to be squeezed into the schedule of a doctor who has already seen his or her allotted number of patients for the day, and NT$500 if a consultation goes beyond 15 minutes. In addition, hospitals are now charging NT$300-1,000 to change beds (e.g. from a non-NHI bed to an NHI bed), NT$150 to jump the queue to see a doctor early, and NT$100 to grind up medications. According to the THRF's study, the last three charges have long been explicitly banned by the health bureaus of each of Taiwan's counties and municipalities.
Some of these items are more than a little arbitrary and even dodgy in their implementation. For example, creating a disk backup of medical records costs NT$200 at some hospitals and NT$1,000 at others, a difference of 500%. Charging a fee to check medical records is banned in 18 counties and municipalities and "recommend against" in a further four. Charging a fee to see a specific doctor is likewise banned in 17 counties and municipalities, but permitted in five others.
Patients are already frightened by their illnesses. Arbitrary billing standards make matters worse, and leave patients feeling that going to the hospital means getting fleeced.
The limits of care
In the commoditized healthcare market, there's a constant parade of new products. This confuses people, who don't know what to choose. Given that there are limits to medical care, it's worth considering whether the "good, or better?" direction in which the medical system is so vigorously moving is correct.
Chiang says that over the last 100 years, the average life expectancy of Taiwanese has grown by 50 years. It's an amazing achievement, on a par with our economic miracle. But in recent years, there has been a sharp decline in marginal improvements. Most of the 120,000 people who die every year have simply reached the end of their days. Fewer than 20% could have been saved by better, more extreme medical procedures.
In other words, medical care can improve the quality of life, but has reached the limits of its ability to extend life.
Given that the use by patients at the top of the socioeconomic pyramid of every available treatment will do little to extend their lives, Chiang sincerely urges that we utilize more of our resources to shrink the health disparities between rich and poor, and strengthen programs to encourage people to lose weight, stop smoking and quit drinking. Health programs such as anti-drug advocacy and the construction of public health information networks are, in his view, the only way to reduce pervasive health disparities and maximize the effectiveness of modern health care.
"Taiwan spends NT$800 billion on healthcare every year, but 92% of that amount is on treatment. Preventive care accounts for only 3% of spending," says Chen, who strongly urges that we turn those numbers around.
It seems that if we are to end wealth-related health disparities and create genuine health equality, we need to put the brakes on the commodification of healthcare and rethink our allocation of healthcare resources. Instead of putting all our resources into saving those who are drowning, we need to keep people from falling into the river in the first place. This is the principle we should be applying to resolving the wealth gap in medical care and our health inequalities.
