Health Care Policy in East Asia: A World Scientific Reference

The following sections are included:

• Foreword
• Preface
• About the Editor-in-Chief
• About the Editors
• Acknowledgments
• Contents

“Striving for universal health coverage is an admirable goal everywhere!” (WHO, 2010). The United Kingdom launched the National Health Service (NHS) in 1948, and since then, many developed countries except the United States of America have developed their NHS or national health insurance (NHI) schemes (Terris, 1978). Following the footsteps of developed countries, Taiwan launched its NHI scheme in 1995 (Chiang, 1997). In a broad sense, Taiwan’s NHI shares three objectives of health care reforms identified in the 1990s in OECD countries: (1) to provide equal access to adequate health care for all citizens in order to improve the health of the people; (2) to control health care costs at a socially affordable level and (3) to promote efficient use of health care resources (OECD, 1995). To date, Taiwan’s NHI has been well established and progressive though there are challenges ahead.

What lessons can be learned from the story of Taiwan's NHI? It was in the beginning of the 21st century when I heard for the first time the concept of "Triangle that moves the Mountain" in a Dragon Net meeting in Thailand (Hasegawa, 2009). The Mountain means a big and very difficult problem, usually unmovable, such as health care reforms. The Triangle consists of: (1) creation of relevant knowledge through research, (2) social movement or social learning and (3) political involvement (Wasi, 2000). At once, I realized how critical the role of knowledge is in the development of Taiwan's NHI since its conception. To share with the world, this book documents how Taiwan's NHI has been planned, implemented and reformed in the past decades, with an emphasis on the use of health research.

This chapter aims to provide background information for our readers and consists of three parts. Firstly, it presents an overview of Taiwan; secondly, it briefly describes Taiwan's health care system and finally, highlights the content of the book.

Health care reform is in progress throughout the world (OECD, 1995; WHO, 1993), and Taiwan is not an exception. On March 1, 1995, the Taiwan government after a six-year planning inaugurated a national health insurance (NHI) scheme. The goal of Taiwan’s reform was to establish an effective and socially affordable universal health insurance. In a broad sense, it was very similar to the goal of reforms in OECD countries (OECD, 1995). However, the situation of Taiwan was very different. Before the introduction of the NHI scheme, about half of the population in Taiwan did not have any health insurance coverage (Peabody et al., 1995). Thus it was a greater challenge for Taiwan to achieve a dramatic expansion of insurance coverage and to contain the rapidly rising health care costs at the same time. Under considerable domestic political pressure, the Taiwan government had to fully implement the NHI scheme at once. Within a year of its inauguration, the NHI scheme covered 92% of the population and did not run into deficits.

This chapter analyzes Taiwan's experience in health care reform and discusses the lessons for other nations. In specific, I will address the following questions: (1) What factors led the Taiwan government to establish a compulsory universal health insurance scheme? (2) What are the objectives and major strategies in Taiwan's health care reform? and (3) What remains to be done in light of how the system has evolved to date in response to the reform?

The following sections are included:

• Introduction
• Pressures Prompting NHI Reform
• Planning Process for the Second-Generation NHI
• Focuses of Task Force Recommendations
• Amendments to National Health Insurance Act
• Conclusion
• References

In September 2015, the United Nations adopted Universal Health Coverage (UHC) as one of the 17 Sustainable Development Goals to be achieved by 2030 (United Nations, 2015). However, implementing UHC is a contentious issue (Reich et al., 2016; Schmidt et al., 2015; Boerma et al., 2014). Effective coverage means that there is adequate supply of health services to meet the demand. Furthermore, this supply must also be equitably distributed across communities and socioeconomic strata…

Before the initiation of the National Health Insurance (NHI) scheme in the year 1995, one of the five purposes of the Medical Care Act of 1986 was to improve quality of care. Just like the iron triangle of most health care systems, access to care and equity became one of the major concerns in the very beginning of NHI. To cover those 41% of uninsured beneficiaries, aged under 14 and over 65, the NHI’s single- payer system was setup achieving almost universal coverage in Taiwan. Cost containment and financial sustainability were achieved hand in hand by the NHI administration. Multiple reimbursement methods from fee-for-service to case-based payment, global budget, fee-for-outcome (pay-for-performance, P4P), diagnosis- related group (DRG), etc. were launched across the years. It was not until the planning of the Second-Generation of NHI that the concept of accountability or quality of care became the focus or vision of NHI. The establishment of Quality of Care Committee under the NHI provided good evidence. In the meantime, Department of Health (now the Ministry of Health and Welfare, MOHW) passed through several phases of establishing an advisory committee for quality policy recommendations, including Quality of Care Committee, Patient Safety Committee, Quality of Care & Patient Safety Committee and Policy Consultation Committee for Quality of Care. Quality of care under the NHI obtained increasing importance which matched well with the evolving trend of medical quality (Relman, 1988)…

While the Planning Task Force for National Health Insurance (NHI) was developing the NHI, they found that those who already enrolled in “labor insurance”, “farmer insurance” or “civil servant insurance” systems had higher health care utilization than the non-insured and the number of outpatient visits was 1.2–1.9 times higher than the uninsured (Shih et al., 1994; Wu, 1989; Shih and Chen, 1980). In order to prevent the health care utilization from increasing dramatically after the implementation of NHI, the Planning Task Force decided to design the cost sharing system in the NHI based on the study evidence provided by RAND HIE study. The RAND HIE study demonstrated that cost sharing had a material impact on lowering utilization without significant negative health consequences (Newhouse et al., 1981; Manning et al., 1987). It is clear that for the higher charge rate, the health care utilization rate is relatively low (Lu and Hsieh, 2000)…

The following sections are included:

• Introduction
• Design of GBPS Reform Plan
• GBPS Planning and Implementation
• Evaluation of the Global Budget Payment System
• Conclusion and Implications
• References

The following sections are included:

• Introduction
• Inpatient Payment Schemes
• Research Evidence from Taiwan
• Conclusions
• References

The payment scheme is one of the most important elements in a health insurance program. This chapter introduces the pay-for-performance (P4P) payment design, which has been adopted in many health systems around the globe. This chapter includes three sections: the development and effects of P4P programs worldwide, the development and effects of P4P programs in Taiwan’s National Health Insurance (NHI) scheme and the lessons learned from Taiwan.

Since Taiwan implemented National Health Insurance (NHI) in 1995, the National Health Insurance Administration (NHIA) has adopted several strategies to control the fast growth of pharmaceutical expenditures. This chapter describes the features of pharmaceutical market in Taiwan, analyzes the design of price adjustment on pharmaceuticals, and highlights issues related to the policy of price adjustment on pharmaceuticals.

Information technology is critical to universal health coverage. During its preparatory period, Taiwan’s National Health Insurance (NHI) already listed information systems as key infrastructure. The digitalization of the medical field was promoted gradually, including the issue of NHI IC cards. Over the past 20 years, information technology has become an important pillar in Taiwan’s NHI operations.

The information technology field has what is known as Moore's Law. This states that the computing power of integrated circuits doubles approximately once every 18 months, whereas the price simultaneously shrinks by 50%. When Taiwan's implemented its NHI scheme over 20 years ago, the hardware of information systems was limited in performance and extremely expensive in comparison to today's. Because the directions taken by the planners were correct and thanks to the continued promotion of executives, Taiwan has become an excellent example internationally for the use of health IT to support universal health coverage.

The following sections are included:

• Introduction
• Access to Care
• Quality of Care
• System Responsiveness and Satisfaction
• Health Care Spending, Affordable Costs and Sustainable Financing
• Increasing Value for Money in Health Care System: Quest for Efficiency
• Conclusion
• References

The 1995 health care reform (HCR) in Taiwan has been highly regarded as a successful one (PBS 2008; Krugman et al., 2005; Reinhart et al., 2008). The main purpose of HCR is to achieve universal health. Universal health coverage (UHC) is just the means, the real goal is universal health or health for all, but there are many factors that influence universal health other than UHC. This concluding chapter reviews the background and reasons of the successful reform in Taiwan’s health care system and provides lessons for the other countries in their efforts to reform their own health care systems.

When Taiwan was planning for UHC, it specifically emphasized providing universal, comprehensive and continuous health care (1990 Planning Report) within the scope of society's resources. This policy implied, "For everyone, but not for everything", so it coincided with the WHO Year 2000 Report.

Similar to the UHC implemented in any other country, this is not something that can be perfected all at once. It needs to go through a reform process in accordance with each country's politics, economy, social and cultural evolution and history development. Therefore, even though the principles and processes of how each country achieves UHC may be similar, each country is unique in itself.

UHC must exhaust many resources in society (financial, human, social and political resources) in order to establish the foundation. Politically, it must have good governance and policies. The government should serve as a steward to collect financial resources and cultivate human and facility resources under good governance in order to form an efficient system that provides health care.

The following section is included:

• Index