May 25, 2014

My readings on the Taiwan Health System

Three studies I just read on Taiwan health economics:
1. The Impact of National Health Insurance on Treatment for High Blood Pressure among Older Taiwanese.  
Usually when insurance intake increases medical consultations also increase. That is what this study finds for high-blood-pressure patients in Taiwan. Taiwan reformed its health system in 1995, when the country set up a universal health care insurance. The percentage of ensured people went from around 57% to 98% after the reform. The reform reduced the gap of consultations between the ensured and previously uninsured patients. 
2. Multivariate Analyses to Assess the Effects of Surgeon and Hospital Volume on Cancer Survival Rates: A Nationwide Population-Based Study in Taiwan.
Within the universal health care system in Taiwan there is a large database where every payment at a medical center gets registered, as well as related information regarding the consultation or treatment. The database is called National Health Insurance (NHI) Research Database. Unfortunately for me, only Taiwan citizens can have access to it. This study (Multivariate Analyses . . .) uses that data base, and finds: 
After adjusting for differences in the case mix, cancer patients treated by low-volume surgeons in low-volume hospitals had poorer 5-year survival rates [compared with high-volume surgeons and hospitals]. 
That database is a gold-mine for health economists to study very specific populations, diseases, and treatments.  
3. Learning from Taiwan: Experience with Universal Health Insurance
This article describes some positive effects of the Taiwan health insurance, specifically their improvement of access and better health of people at the bottom of the income distribution. But it also explains some negative effects:
On average, patients have 14 physician visits per person per year (far more than in most industrialized countries); however, a standard visit is less than 5 minutes in length. In these brief visits, the physician’s focus is on treating symptoms and prescribing medications, not listening to patients. Patients do not have time to address their comorbid conditions and rarely undergo a careful physical examination or history.  
Inappropriate physician payment incentives by national health insurance can adversely affect the specialty choices of medical trainees, and therefore the direction of postgraduate medical education in Taiwan. Trainees tend to choose specialties that allow a simpler payment process through national health insurance (such as dermatology), or specialties not covered by national health insurance (such as cosmetic surgery) that bring in much higher, out-of-pocket payments from patients. They tend to ignore poorly paid specialties covered by national health insurance (for example, obstetrics and gynecology). These distorted payment incentives may seriously affect the match between Taiwan’s physician workforce and its health care needs. 
There are many studies on the effects of the universal health system in Taiwan. What I have seen so far, however, are studies on its effect on patients' behaviour and health. One aspect I have not seen much is how the reform affected the supply (the medical centres - note that article 3 in the list above describes a response of clinicians). 

How the system works is that the government pays the hospitals base on the services provided, and that also means that there is some degree of competition among hospitals. Patients are free to choose where to go for consultation and clinics, including private or public providers. 

Since there is no market, another area worth exploring is how government compensate hospitals, and how effective that system is.  

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