By Teng Xi-Hua/ Spokesperson of the NHI Supervision Alliance, Secretary General of Taiwan Association for Psychosocial Rehabilitation and President of the Taipei Association of the Licensed Social Workers
In September 2013, there was a news report about the lack of drug in Taiwan to treat a boy with Atypical Hemolytic Uremic Syndrome (aHUS). Another case was reported in May 2014. This time, the life-saving drug is available. The problem was that it cost NT$210,000 per dose and the drug was not reimbursed by the NHI. Despite the huge treatment expense paid out by the family, the little girl only lived for 28 days. After the incident, the Taiwan Foundation for Rare Disorders raised a question: How long will the NHI keep patients waiting for NHI-funded orphan drugs? Taking the drug for treating PNH for example, it took two whole years. So far, the NHI has not yet included the drug for aHUS into the benefit scheme.
Do those stories make you worry about the high treatment costs or a long wait for the access to new treatment?
As the NHI celebrated its 20th anniversary this year, the Global Budget for 2015 reached NT$600 billion. Among them, drug fees account for 25%. This means that the NHI is to spend NT$150 billion on drugs. Then, why are there still patients waiting anxiously for the access for drugs? How does the NHI decide which drugs to be reimbursed and which ones to be left out? Are the drugs reimbursed by the NHI any good? How fast is the decision making process?
No Money, No Treatment
The NHI was implemented on March 1, 1995, to provide the public an easy and fair access to healthcare services. However, the data on National Health Expenditure (NHE) showed that the percentage of expenses paid out of patients’ own pockets has exceeded 36% since 2010. The DGBAS’s data revealed that the poorest 20% households in Taiwan have been in negative savings for 7 years in a row (people in this group are usually older, hence in need of higher health spending). The data also suggests a negative growth in real-term wage, indicating that the purchasing power is declining. On the other hand, the percentage of self-payment treatments is increasing. The contrast raises the alarm. In the future, the access to medical treatment will be beyond the reach of the poor.
A long ait for NHI-reimbursed new drugs
Drug reimbursement has long been a complicated issue. We could start the discussion from the NHI drug reimbursement procedure.
According to the data from Chen Chao-Tzu, a senior member of the Expert Meeting and the Director of the Pharmacy Department of KFSYSCC, after the introduction of the “NHI Drug Dispensing Items and Fee Schedule Joint Establishment Meeting”, it takes an average of 415 days for the authority to review and approve a new drug application case (from case submission to approval), and about 934 days for a new cancer drug.
Among all new drug application cases, about 73% of them will pass the Expert Meeting, 65% will be forwarded to the “NHI Drug Dispensing Items and Fee Schedule Joint Establishment Meeting” for discussion. Despite the fact that the pass rate in the Joint Establishment Meeting is 62%, only 37% of all applications can successfully apply for NHI payment prices. For new cancer drugs, the pass rates are even lower, about 53% for the Expert Meeting, 42% for the Joint Establishment Meeting and 26% for NHI payment prices.
As for applications of new indications, only about 50% of them will be included in the NHI, and only half of them will receive effective payment prices. On average, the whole process takes 320 days (381 days in the worst case). Considering that the introduction of a targeted treatment in Taiwan is about 2-3 years later than its first launch, patients in Taiwan may have to wait a total of 5-6 years for the access of a new targeted treatment.
NHI Drug Dispensing Items and Fee Schedule Joint Establishment Meeting
The drug review procedure is not only time consuming, but also affected by structural factors. In the Joint Establishment Meeting, over half of the members are representatives of hospitals and medical associations. Hospital representatives are very concerned about the financial impact. On the contrary, the representatives of the insured and employers are comparatively lack of related experiences and training. A representative of the insured even blamed parents for rare diseases, and mentioned that target treatments have no actual benefit as they are just to prolong patients’ life for a few months. Irrational discussion and poor efficiency have crippled the progress of the meetings.
In reply to the criticism, the NHIA recruited 4 doctors into the Joint Establishment Meeting in 2014. As they join the meeting as individual professionals rather than as representatives of medical associations, their performances and functions are yet to be observed.
Furthermore, the Joint Establishment Meeting has a serious defect: the lack of a consensus-based drug reimbursement principle. For example, there are no ground rules for the standard for financial impact, the time period for the evaluation of the economic benefits of a drug, the savings from reducing complications, the survival rate of targeted treatments, drugs on priority list, the criteria for assessing the impact on patients, and the collection of comments from the public and patients, etc. These critical issues have already been incorporated in the models implemented in many countries, such as the UK, Australia and Canada. Taiwan is still on ground zero. Representatives in the Joint Establishment Meeting require intensive training and need to build up consensuses.
30 people decide the treatments for 23m people
NHI-reimbursed drugs surely are not bad. Drugs for the self-payment market may not be more effective. In the Joint Establishment Meeting, a group of 30 people decide the treatments available for the 23 million people. Though the meeting minutes and records are open to the public’s access, the public’ involvement should be increased. If the authority is not able to establish the principles for reimbursement, at least it can make the discussion process open and transparent. It is time to request the NHIA to broadcast the discussion meetings live to viewers and allow the media to observe meetings.
This issue concerns everyone, because we all get ill sometimes.
【2015-01-26/ United Daily News】