By National Health Insurance Administration Director General Lee Po-chang
The National Health Insurance Administration (NHIA) recently published the financial statements of 223 hospitals that have made National Health Insurance (NHI) reimbursement claims in excess of NT$200 million during 2019. As Director General of the NHIA, it is my duty to outline the current financial condition and the government’s planned structural reform of the NHI system.
In 2020, the amount of medical points claimed was 766.4 billion points, which compared to the global budget of NT$701.2 billion set by the National Development Council, tallies to a difference of 65.2 billion points when valuing 1 medical point at NT$1. The NHIA’s local offices have set up a mechanism to manage reimbursement claims on expenditure and approved in total 713.6 billion points in order to bring expenditures closer to the budget limit. As a result, the valuation of medical points was adjusted from NT$0.915 per medical point to NT$0.983. Many hospitals have incurred losses from absorbing the expenditure of medical services rendered, drawing criticisms from the medical community. As medical practitioners strive to provide the best drugs and diagnostic tests, the real challenges of managing the NHI system is to do so while controlling and containing the sources of expenditures.
One method has been to set quotas on medical points that may be claimed, in order to encourage hospitals to keep claims below their quotas to avoid adjustment to the valuation of medical points. For health care service providers that exceed their quotas, the amount of medical points claimed in excess is rejected. Another method comes into play when the targeted point value cannot be reached; excluding earmarks such as rare disease treatments, the authorities will calculate the amount of medical points that need to be rejected in order to reach the targeted point value, apportioning the cost collectively among all hospital. Despite these methods, in reality, hospitals often provide more services than the amount of medical points allotted.
A closer look at the breakdown of hospital expenditures reveals that in 2019, drug expenditure accounted for 208.3 billion points, representing 27.2 percent of the global budget, while diagnostic tests accounted for 95.5 billion points, representing 12.5 percent of the global budget. Reimbursement for services provided by clinical staff including surgery and anesthesia fell from 44 percent of the global budget in 1998 to 36 percent in 2019, with diagnostic fees falling from 23.5 percent to 17.7 percent. As the annual global budget is fixed, under the strain of competing reimbursement items, medical professionals have long been denied fair compensation, exacerbating the field’s poor working conditions.
In addition, resources allocated to outpatient and inpatient care have become increasingly deviated. Outpatient care in 2009 accounted for 67.4 percent of medical points and rose to 69.4 percent in 2020. Medical points allocated for the inpatient care of patients with sudden, catastrophic or rare conditions have declined from 32.6 percent in 2009 to 30.6 percent in 2020. Due to differences in resource allocation among hospitals, it has been difficult to raise reimbursement towards inpatient care in recent years, during which hospitals have been opting to prescribe more diagnostic tests. If this trend is allowed to continue, it would be more difficult to provide fair compensation for clinical staff who perform complex surgery and diagnostics and could bring deep ramifications to the development of Taiwan’s medical talent pool.
Changes to the NHI system under the “user pays” principle have been geared toward small increases in co-payments, better implementation of the referral system, and increasing the separation of prescribing and dispensing, while placing caps on co-payments in consideration of the financial burden on patients, in the hope that through copayments, the public will take greater caution against obtaining unnecessary drug prescriptions and diagnostic tests. Physicians should also inform patients about the necessity of diagnostic tests and raise awareness of using medical resources responsibly.
[2021-3-31/Liberty Times]
