UHC Forward: Towards Universal Health Coverage

Taiwan has a market-driven health care delivery system with a mix of publicly and privately owned hospitals. The National Health Insurance (NHI) program provides medical services to the insured population through contracts between the Bureau of National Health Insurance (BNHI) and providers, including hospitals, clinics, pharmacies, medical laboratories, and home nursing care. For hospitals and dental clinics, the contracted rate is 98% of all health facilities in Taiwan, suggesting that the contract serves as a comprehensive and inclusive network for consumers to access providers’ services. The contracted rate of clinics for both Western medicine and Chinese medicine are in the range of 84 to 90%. The broad and inclusive range of institutions that contract with NHI allows patients to see almost any doctor within the country.

Most health providers operate in the private sector and form a competitive market. Citizens have almost complete freedom of choice among providers and therapies. There is no rationing of care, no referral system, and patients are also allowed to seek out care at tertiary institutions regardless of the severity or nature of their illness. This has allowed patients large degrees of freedom in provider choice. However, doctors who practice in private clinics do not have hospital admitting privileges, thus hospitals have developed large outpatient departments and affiliated clinics for primary care, to maintain inpatient flows. Many private clinics also maintain about a dozen beds for their patients. One criticism of this system is that its delivery system is somewhat fragmented, because private physicians can practice, but have no hospital admitting privileges. This occasionally results in duplicative facilities and equipment, and can disrupt continuity of care.

Table 1: Health Service Delivery System in Taiwan, 2004

Source: Health Statistics (2006)

In total, there are about 5.7 beds per thousand people, 35% of which are public and 65% are private. In 2000, about 86% of hospitals were privately owned. Doctors in Taiwan are either salaried staff physicians in the hospitals or self-employed owners of clinics. A majority of clinics, about 97%, are privately owned. About 63% of physicians are employed by hospitals and paid on a salaried basis and the remaining 36% of doctors are private practitioners.

Since the NHI’s inception in 1995, the capacity and use of Taiwan’s health care system has expanded. While Taiwan’s population grew by 5.2% between 1994 and 2000, the supply of health professionals overall increased by 39.6%, and the number of physicians increased by 33.5%. Over the same period the number of hospital beds increased by 32.3%. While Taiwan’s population grew 5.2% between 1994 and 2000, the volume of hospital outpatient visits increased by 16.6%, emergency room visits by 42.2%, outpatient surgery by 56.4%, and inpatient hospitalization by 18%. With the exception of certain costly high-tech treatments which require prior authorization from BNHI, there are effectively no ceilings on utilization, which has resulted in high health care usage rates, especially for outpatient care.

The use of services has expanded unevenly across hospital types and locations. Services in low income and remote areas are not well-distributed and offer varying degrees of service. While the overall ratio of physicians per 1,000 people in 2001 was 1.37, it was only 0.33 among Taiwan’s aboriginal people and 0.8 in the mountainous areas and offshore islands. BNHI has since introduced incentives for providers to practice in remote areas and has exempted cost sharing for the poor and for those who live in remote areas.

The Aarogyasri network includes 244 private and 98 public hospitals, all of which must meet specific structural, procedural and pricing requirements. Individuals seeking care approach their nearest in-network health facility, where Aarogya Mithras guide them through the system. If a patient needs further care, they will be given a referral card to the appropriate network hospital(s). Beneficiaries may also seek care and receive referrals at health camps held by in-network hospitals.

As of January 2010, there were a total of 342 hospitals in the network. The principal reason Aarogyasri Trust decided to work with private providers was the lack of resources in the public system. The government has been unable to attract the needed specialists to public facilities, while the private sector has rapidly expanded high quality healthcare services.

A hospital or nursing home in Andhra Pradesh is eligible to be a part of the Aarogyasri network of care, established for indoor medical care and treatment of disease and injuries. The hospital should comply with the following minimum criteria:

• Have at least 50 inpatient medical beds
• Be fully equipped and engaged in providing in-patient medical and surgical facilities along with diagnostic facilities (e.g., pathological tests and X-rays, E.C.G. etc.) for the care and treatment of injured or sick persons
• Have at least one operation theater of its own where surgical operations are carried out
• Have fully qualified nursing staff under its employment 24 hours a day
• Have fully qualified specialist doctor(s) on premises 24 hours a day
• Maintain complete records as required by Aarogyasri on a daily basis and able to provide necessary insured patients’ records to the insurer or his representative as and when required
• Have sufficient experience in the specific identified field
• Agree to deliver the package of services at the rate specified for each identified intervention/surgery as approved by the Trust. The package includes consultation, medicine, diagnostics, implants, food, cost of transportation, and hospital charges, etc. The package price should cover the entire cost of treatment of the patient from date of reporting to discharge from hospital, as well as 10 days after discharge and any complications while in hospital, making the transaction truly cashless to the patient.
• Include the services of a Radiation Oncologist and Medical Oncologist if it desires to be empaneled for Chemo- and Radio-therapies
• Include services of trained ENT Surgeon(s) and Auditory Verbal Therapist(s) if it desires to be empanelled for Cochlear Implant Surgery

All hospitals that qualify to be in-network must sign a memorandum of understanding with the insurance company. This Memorandum is subject to the approval of the Trust. A provision is made in the Memorandum for non-compliance/default; all such matters are looked into by the Trust.

From the perspective of beneficiaries, the path to seeking care is made as simple as possible, as indicated in Figure 1.

• Beneficiaries approach nearby health facility (either public health clinic or area hospital) where an Aarogya Mithra is placed to help beneficiary navigate the health system. Alternatively, the beneficiary can utilize the Aarogyasri 24x7 customer care toll free number (by dialing 1800-474-7788), state’s emergency medical service (by dialing 108), or telemedicine service (by dialing 104) to reach a network hospital. Follow the links for more information on the state’s emergency medical and telemedicine services.
• Beneficiary is seen and diagnosed by a doctor with the support of an Aarogya Mithra to ensure proper care is delivered.
• If beneficiary needs to seek care elsewhere, he/she will be given a referral card to the appropriate network hospital(s)—the beneficiary can select which network hospital they would like to visit for the next step of care.
• Beneficiaries may also attend the Health Camps being conducted by a network hospital in a village and can get the referral card based on the diagnosis done at the Health Camp.