2The single-track system is also known as the ideal division of professions. In addition to the division between the medical and pharmaceutical professions, the industries must also divide substantively. The property rights of the practice between the physician and the pharmacist must be independent, and there should be no overlap or confict of practice interests. That is, pharmacists cannot be employed in pharmacies funded by physicians or in joint ventures between physicians and pharmacists.

3The payment for each prescription is different by 51 RVUs in a clinic or a pharmacy. Liberty Times, 10 January 2005.

prescription on average. But the payment incentive results in the peculiar phenomenon of "front-door pharmacy," which triggered the NHIA to monitor "unreasonable prescription release patterns from clinics": the NHIA would refuse to reimburse additional diagnosis fees for clinics that release more than 900 prescriptions or over 70% of its prescriptions to a designated pharmacy, and this pharmacy dispenses more than 70% of the prescriptions released from one clinic at the same time. However, the phenomenon of registering an individual pharmacy within the proximity of the clinics was not fully curbed until the NHIA completely canceled the payment for releasing prescriptions in July 2006 and simultaneously increased the payment for drug dispensing from 21 to 28 RVUs provided by the physician-hired pharmacist.

### *The Meaning of Separating Medicine and Pharmacy*

The purpose of separating medicine and pharmacy is not only to pursue the division of labor between physicians and pharmacists but also to realize pharmacists' role as patient-centered family pharmacists, who integrate and review prescriptions issued by physicians, dispense independently, prevent patients from duplicated medication or drug interactions, and provide medication consultation.

To ensure pharmacists' right to dispense independently, most countries4 that have implemented a medicine and pharmacy separation system restrict physicians with prescription rights from operating pharmacies. It is hoped that by structurally excluding physician's intervention, pharmacists could have independent space to practice.

One of the main arguments of the pharmacists to strive for in the independent pharmaceutical service is to follow the practices of advanced Western countries. But this argument over-simplifes the purpose of this important policy. What is the problem with not separating medicine and pharmacy? Is the separation a suitable strategy to tackle these problems? Will new problems produce the strategy? All of these questions have to be assessed objectively so that the medical profession and the pharmaceutical personnel will not fall into a dispute caused by personal feelings. Because of the space limitation, this article only discusses from the viewpoint of the NHI.

4Countries such as Germany, France, Italy, Belgium, the Netherlands, Denmark, Norway, Finland, Spain, and Sweden enforce the implementation of the separating medicine and pharmacy through legislation. Separation of medicine and pharmacy is not mandatory in countries such as Switzerland, Poland, the Czech Republic, the Philippines, Australia, and New Zealand but actually implemented.

### *The Effectiveness of Separating Medicine and Pharmacy*

The result of separating medicine and pharmacy since the implementation of Article 102 of the Pharmaceutical Affairs Act can be observed from the following data:

1. Drug fee:

Two of the reasons5 for separating medicine and pharmacy are to avoid drug abuse and reduce drug fees. However, NHI outpatient drug fees increased annually between 2010 and 2017 and the average drug fee per claim also showed a general increase6 , which did not support the assumption empirically.

2. Drug fee claimed by the pharmacies:

Among the NHI drug fees mentioned above, physician-released prescriptions claimed by the contracted pharmacies also increased annually from 2010 to 20177 . Although most hospitals had hired their own pharmacists, the number of prescriptions released from the hospitals and its proportion in the total amount of drug fees claimed by the pharmacies both increased from 2010 to 20178 . As most of the medical fow of hospital outpatient visits involves flling prescriptions at the in-hospital pharmacy after making a payment, it can be assumed that the possibility of patients voluntarily requesting the release of prescriptions increases and their autonomy is relatively improved. The number of prescriptions released

5The purposes for the separation of medicine and pharmacy are roughly as follows: (1) Safeguard people's right to know about the drugs they take. (2) Physician and pharmacist both perform their duties and cooperate together. (3) It is convenient for patients to fll prescriptions. (4) Integrates drugs to avoid drug abuse and reducing drug fees. (5) Follow the advanced countries and take back the dispensing right for pharmacists. (6) Reduce the workload of physicians. The reasons for not supporting the separation of medicine and pharmacy are roughly as follows: (1) It is inconvenient to fll prescriptions at a pharmacy after seeing the doctor. (2) The medical and pharmaceutical communities will compete with each other for their interests. (3) Physicians cannot control the quality and effcacy of medications after prescribing a prescription. (4) The society has insuffcient awareness of the separation of medicine and pharmacy. (5) People may directly buy drugs at the pharmacy when they have the same symptoms next time, which increases the risk.

6There are many reasons for the increase in the NHI drug fees, such as expenses of severe and rare diseases and the introduction of high-priced new drugs. It may not be that the separation of medicine and pharmacy has not played a role. It can only say that the specifc effects of the separation of medicine and pharmacy in reducing drug fees cannot be seen from the data.

7The number of drug fees claimed by the NHI contracted pharmacies from 2010 to 2017 were 68.153 million, 74.025 million, 76.007 million, 79.059 million, 82.552 million, 83.911 million, 88.850 million, and 91.499 million respectively. The number of RVU applications is 20.69 billion, 23.72 billion, 24.16 billion, 27.54 billion, 29.83 billion, 30.89 billion, 33.19 billion, and 35.34 billion.

8The number of pharmacies' drug fee claims whose prescriptions came from hospitals from 2010 to 2017 were 8.059 million, 9.41 million, 10.79 million, 12.552 million, 13.751 million, 15.126 million, 16.599 million, and 17.934 million. The proportion of drug fee claims whose prescriptions were released from hospitals in total pharmacy drug fee claims has gradually increased from 12% to about 20% year by year.

#### 4 Comprehensive Policies

by Western medical clinics has also grown year by year9 , which is in line with the assumption mentioned above.

3. Number of the NHI-contracted pharmacies:

In 2004, there were only 3898 NHI-contracted pharmacies, and the number grew annually to 5037 in 2011 and 6203 in 2017. The increase in hospitalreleased prescriptions expanded the drug-dispensing market for contracted pharmacies, and the number of the contracted pharmacies increased subsequently.

Available data demonstrate that although the separation of medicine and pharmacy does not have the function of regulating overall drug fees, the number of prescriptions that hospitals issue increases in contracted pharmacies. It shows that over the past 20 years, the policy has gradually affected the habits of patients, so that they are now willing to have prescriptions flled in community pharmacies.

### *Ownership of Dispensing Rights from a Legal Perspective*

Regarding whether the physician or the pharmacist is more eligible to the dispense drugs, both parties have their own legal right according to the current law:

	- A. Article 66 of the Medical Care Act: when dispensing medications to patients, a hospital or clinic shall clearly indicate the patient's name, sex, dosage, quantity, method of administration, actions or indications, warnings or side effects of the medication, the name and location of the medical institution, the name of the dispenser and the date of dispensation on the container or package.
	- B. Article 13 of the Physicians Act: when issuing prescriptions, physicians shall clearly state the following on the signed or sealed prescription slip: physician's full name, patient name, age, name of medication, dosage, amount, use and year, month and day on which the prescription was issued.
	- C. Article 14 of the Physicians Act: when delivering medicines to patients, physicians have the same obligation to include necessary information such as states in Article 66 of the Medical Care Act.
	- A. Article 37 of the Pharmaceutical Affairs Act: dispensation of drugs shall not be performed unless it follows established operational procedures; the operational guidelines shall be established by the central competent health

9The number of prescriptions released by Western primary clinics and claimed by pharmacies from 2010 to 2017 were 56.386 million, 60.727 million, 61.093 million, 62.145 million, 63.985 million, 63.846 million, 67.256 million, and 68.237 million. The proportion of drug fee claims whose prescriptions were released by Western primary clinics in total pharmacy drug fee claims has decreased from 80% to about 75% year by year.

authority. (Item 1) The aforesaid dispensation of drugs shall be performed by a pharmacist. … (Item 2) Article 102: any physician having dispensation facilities as specifed in this Act may, for the purpose of medical treatment, dispense drugs by himself/herself based on his/her own prescriptions (Item 1). After 2 years of the implementation of the National Health Insurance, the provision of the preceding Paragraph shall be enforceable only in remote areas, where practicing pharmaceutical personnel are not available as announced by the central or municipal competent health authorities or in the case of urgent need of medical treatment services (Item 2).

Judging from the Medical Care Act and the Physicians Act above, physicians have the right to issue prescriptions. Although none of the laws mentioned whether physicians have the right to dispense prescriptions, they have the obligation to deliver prescriptions. Actions including preparation, compounding, and confrmation of the drugs that must be completed before drug deliveries are defned as being within the scope of "dispensation"10. Therefore, physicians should complete a series of procedures including prescribing, preparing, compounding, and confrming drugs and delivering them to patients. Moreover, the scope of the physician's dispensation is limited to prescriptions prescribed by himself or herself. That means, even with statutory equipment, physicians are not allowed to dispense drugs for other physicians.

Of course, objections have been voiced that the Physicians Act and the Medical Care Act only regulate the delivery of drugs by physicians, which is only one part of the dispensation; therefore, physicians are not allowed to conduct other parts of the dispensation11. The pharmaceutical professionals argue that, in accordance with Article 102, Item 2 of the Pharmaceutical Affairs Act (announced on 5 February 1993), 2 years after the implementation of the NHI, physicians have no right to

10According to Article 3 of Good Dispensing Practices, Dispensation shall mean the activities performed by any pharmacist or assisting pharmacist that involve prescription verifcation, prescription registration, assessment of the appropriateness of drug administration, preparation or compounding of any drug, reverifcation, confrmation of drug delivery to any recipient, and instructions for drug administration during the period between the time when the pharmacy practitioner receives any prescription to the time when the patient acquires the drug.

11Take the Supreme Administrative Court's Judgment No. 971 in 2005 as an example.

dispensation, except for in remote areas or medical emergencies. This is the principle that the later law has priority over the earlier law [1]. However, Article 14 of the Physicians Act stated in 1967 that physicians should properly label the medication when they deliver the drugs and the revision of the Article in 2002 did not delete this regulation. Instead, to protect the patient's right to know, the scope of information that physicians should label was expanded. The same principle was applied in the amendment of Article 66 of the Medical Care Act in 2004, and the abovementioned regulation was added. If the later law has priority over the earlier law, it is hard to recognize the Pharmaceutical Affairs Act as the later one. In addition, comparing Article 102 of the Pharmaceutical Affairs Act with the relevant regulation in the Physicians Act and the Medical Care Act, it is diffcult to conclude that Article 102 of the Pharmaceutical Affairs Law is a special law that should be applied frst. There are indeed unresolved conficts regarding the ownership of the dispensation rights in the provisions of the above regulations.

The judicial community also has different opinions on whether physicians can dispense the prescription in general after the implementation of Article 102 of the Pharmacists Act. There is a case involving a clinic that did not hire pharmaceutical personnel, and the drugs were delivered by the physician in charge. The health bureau of the competent authority fned the physician for violation of the provisions of the Pharmaceutical Affairs Act. The Taichung High Administrative Court ruled that the plaintiff's physician won the case. There are three reasons:

12Article 20 of the Pharmaceutical Affairs Act Enforcement Rules was deleted on 16 February 2005, and Article 37 of the Pharmaceutical Affairs Act clearly authorized the establishment of Good Dispensing Practice, but both have the same defnition of dispensation.

as the possible risk and harm to patient's health caused by drugs dispensed by the medical layman. It is questionable whether the intention of the legislation is betrayed when the competent authority recognizes both of the situations violated in Article 37, Item 2 of the Pharmaceutical Affairs Act.

After the appeal of this case, the competent authority won a reversal. The Supreme Administrative Court's Judgment No. 971 in 2005 held that:

After the Supreme Administrative Court made the above judgment, more judgments such as the Miaoli District Court's Judgment No. 28 in 2014 and the Taipei District Court's Judgment No. 195 in 2017 refected the same opinions as those of the Supreme Administrative Court.

Although the Supreme Administrative Court agrees that Article 102 of the Pharmaceutical Affairs Act restricts the physician's right to dispense, it also pointed out that "according to the needs of patients, the preparation and delivery of drugs are necessary for medical behaviors, and they are also covered by the physician's profession. It is not unreasonable for the physician to take care of it." Therefore, it is not quite reasonable for the competent authority to equate "physician's dispensation" with "layman's dispensation."

### *The Person in Charge of Medical Services in the National Health Insurance System*

Physicians and pharmacists are professional and technical personnel, and they must pass exams in order to practice. The state requests that certain jobs must be performed by individuals with qualifcations because of the content and nature of the work involving important public welfare and a high level of profciency; thus, the corresponding performer must possess professional knowledge and experience. At the same time, in order to protect the public welfare and the rights and interests of the professional personnel, the state will also impose penalties on those without qualifcation and execute the scope of practice.

The right to dispense was regarded as the core practice of pharmacists at the beginning of the legislation of the Pharmacists Act. Judging those who have pharmaceutical expertise from their professional competence and scope of professional practice, pharmacists are most qualifed and authorized to determine the best medication and usage for patients and take responsibility. Those who advocate for the separation of medicine and pharmacy assert that pharmacists can confrm and supervise the prescriptions from physicians; however, this confict is within the scope of practice and responsibilities of physicians.

The healthcare service in our country is characterized by the strong bond between patients and physicians, and patients are highly dependent on physicians. Therefore, there is no doubt that physicians bear the ultimate and almost full responsibility for the treatment of patients. Once the health outcome is not satisfactory, the physicians are always the subject of prosecution13. When managing contracted medical institutions, the NHIA also holds medical personnel who are in charge of the institution accountable. Exceptions occur when there are medical personnel who are responsible for specifc violations; then, the punishment will be imposed simultaneously. Except for the contracted pharmacies, the person in charge of the contracted medical institution is always a physician.

After diagnosing and issuing a prescription, the physician still has to track and adjust the prescription according to the effect of treatment and medication. If the prescription has been integrated, replaced, increased, or decreased by pharmacists, obstacles and blind spots will inevitably arise. When the physician follows up on the condition of the disease and adjusts treatment methods accordingly, the risk of medical disputes and legal liabilities thereby increases. Therefore, the NHIA established the NHI MediCloud System to share pharmacists' responsibility of integrating

13According to the medical personnel involved in the statistics of medical disputes in E-Da Hospital from 2001 to 2003, Western physicians accounted for 82%, nursing staff accounted for 6%, dentists accounted for 2%, traditional Chinese medicine physicians accounted for 2%, pharmacists accounted for 4%, examiners 1.8%, and others 2.2%. Physicians account for the absolute majority of the subjects to prosecution from patients and their families. In addition, refer to the "Medical Appraisal Medical Litigation," the Joint Commission of Taiwan, December 2013, even if the case involved disputes the appropriateness of medication, physicians and hospitals were mostly the subjects of prosecution.

medicines and avoiding duplication by checking patient's medication records from different medical facilities in the past few months. The system automatically alters the physicians if the drugs they are going to prescribe duplicate or interact with the patient's current medicine to effectively reduce the probability of such problems.

Article 17 of the Pharmaceutical Affairs Act stipulates that the pharmacist should dispense the drugs according to the prescription. If the medicine is not available or is lacking, the pharmacist should inform the physician who prescribed the medicine regarding a replacement instead of omitting or substituting medicines arbitrarily. The clause echoes the physician's right to prescribe and the fact that the physician is responsible for the medical process. If the pharmacist has to follow the physician's prescription completely, according to the above provisions, the pharmacist can only discuss and give opinions to the physician at most. The physician still has the right to decide whether to change the prescription or not. Then, in a system in which drug prescribing and dispensing are separate, the "review, supervision, check and balance" function of a pharmacist when they are "evaluating the physician's diagnosis, verifying whether duplication exists, interaction, individual contraindications, potential side effects, and rationality of medications, and others" is very limited. Besides the pharmacists, other medical personnel also have to "follow the physician's orders" when providing medical services at all times, so there is limited room for independent business execution.

Besides physicians and pharmacists, other professionals have an overlapping scope of practice. For example, bookkeepers and accountants have their own scope of practice, but both can execute tax business14.

One of the purposes of separating medicine and pharmacy is to promote the pharmacists' independent practice and to serve patients better. However, under the current conditions, physicians are the leaders of planning medical services and almost the only people who are responsible. Therefore, the failure to achieve the goal of separating medicine and pharmacy in one step is a reality that requires understanding.

### *The Strategy to Promote Separation of Medicine and Pharmacy—Discussion and Conclusions*

Before the implementation of the separation of medicine and pharmacy, these two parts of the services were intertwined in the Western medical healthcare process in Taiwan [3]. The scope of practice of physicians includes diagnosis, treatment, prescriptions, and dispensation, covering most of the medical services. In addition, medical economic research also pointed out that medical service is obviously characterized by monopolistic competition and information asymmetry, leading to

14Refer to Article 13 of the Certifed Public Bookkeepers Act and Article 39 of the Certifed Public Accountant Act.

patients' limited ability in seeking alternative services. Consequently, the bonding between patients and physicians continuously strengthens throughout the medical process, and the relationship between patients, nurses, pharmacists, medical technologists, and other medical personnel remains relatively weak. If the physicians do not actively release the prescriptions, patients usually will not request this; most people's decision-making process for choosing pharmacies is directed by the physician's instructions [2]. This is also the reason why the front-door pharmacies were so popular when the policy was just implemented.

Therefore, considering the historical factors, research results, and empirical situation of medicine and pharmacy development, society highly relies on physicians in the whole medical process, and it is not easy to change the habits of the whole of society simply by separating medicine and pharmacy. The pharmaceutical professionals actively advocate the single-track separation of medicine and pharmacy and appeal to impose legal enforcement. Embedding important policy into law is certainly one of the more feasible methods. However, concerning the habituation of society, and the separation of medicine and pharmacy, specifc arguments coupled with positive policy incentives can gradually cultivate a social environment conducive to the implementation of the policy. The proliferation of front-door pharmacies that has been attributed to the increasing RVUs of prescription releases highlights that such results may be diffcult to achieve with regulations alone. Only legal systems constructed under a mature social environment, which can promote policies, act as a stitch in time saves nine.

Sociologists point out that in addition to the economic benefts it brings, workload division also meets the needs of society. Besides establishing the relationship between different professions, we also have to invigorate individual professions and the "spontaneous division of labor" can form [2] only in this way. The same goes for the separation of medicine and pharmacy. The professionals should demonstrate their specialization by increasing drug safety and additional new values to the publics. When the public recognize the value of independent pharmaceutical service, they would become active collaborators rather than passive recipients and transform the separation of medicine and pharmacy into a social demand. Demand will guide services, and differentiated medical services will follow the trend.

There is no doubt that the NHI shapes the medical environment in Taiwan. To promote the established policy of separating medicine and pharmacy, the NHI will fully utilize the system and promote the core values of pharmacists to accelerate transformation of healthcare-seeking behavior. Before the ideal single-track division is realized, pharmacists can still seize the chance to show their expertise in the current medical environment dominated by physicians. As our society ages, the demand for home and community medical care is rising and people need not only family physicians but also family pharmacists who may be closer to their lives. In addition to performing core responsibilities such as guaranteeing drug safety, pharmacists could also transform pharmacies into important bases of the care system that exert multifaceted functions, creating more value and contributions.

### **Patient-Centered Integrated Care Plans15**

Taiwan offcially became an "aged society" when the proportion of the population aged 65 and above reached 14% of the total population in March 2018. In addition, we have only 8 years left to reach the "super-aged society" (the population aged 65 and above makes up more than 20% of the total population), which further refects the severity of ageing in our country. The NHIA has planned a number of policies in recent years to prepare for the medical needs of the super-aged society that Taiwan will face in the future. The elderly often take multiple medications, have comorbidities, and exhibit characteristics of "geriatric syndrome" such as physical and mental deterioration and disability. Therefore, the NHIA proactively implements various integrated medical service plans to construct a patient-centered healthcare system.

### *National Health Insurance Big Data Refect the Ageing Population*

With an ageing population, technology advancement, and medical progress, the average life expectancy of Taiwanese people increases continuously, and the most prevalent type of disease has gradually changed from acute disease caused by bacterial and virus infection to a chronic disease caused by lifestyle. However, the treatment of chronic disease is different from that of acute disease whereas most of the time the treatments only stabilized the condition rather than curing the disease. Therefore, as the number of patients with chronic diseases increases, their followup medical care poses challenges to the NHI.

According to the analysis of the NHI big data, the number of patients with chronic diseases and medical expenses in Taiwan has been on the rise. In 2017, medical expenses for chronic diseases have reached New Taiwan dollars (NTD) 231.8 billion, accounting for about 30% of the total, and an increase of 23% from 2013 (Fig. 4.1). The number of chronic disease patients in 2017 has exceeded 6 million, which equates to a quarter of the total population and represents a 13% increase from 2013.

In addition, the outpatient medical expenses per person for the 65-and-older population reveals that the expenditure for chronic disease drugs is around NTD 33 billion, and the medical expenses are more than NTD 60 billion, both are much higher than the expenses for those aged between 19 and 64 years old (NTD 9.3 billion and NTD 16.5 billion respectively), the working age population. In view of this, as the working age population gradually becomes the elderly in the future, the medical expenditures of the NHI will be more substantial.

15 201903 Public Governance Quarterly.

**Fig. 4.1** Medical expenses for chronic diseases and their proportion in total medical expenses. (Source: National Health Insurance Administration)

Statistics from the NHIA show that the number of chronic disease patients is 6.29 million in 2017, among them, 3.86 million are people aged 65 and above, accounting for about 60%. When we further analyze the data by the number of chronic diseases they have, there are 2.13 million people suffering from one kind of chronic disease, accounting for about 34%, and the remaining 66% suffer from more than two kinds of chronic diseases. In addition, nearly 60% of people who are aged 65 years or older have multiple chronic diseases (Table 4.1). This shows that the number of people suffering from chronic diseases in the country is increasing year by year, and patients with chronic disease who visit doctors in different hospitals or departments are likely to have duplicate prescriptions. These duplicate prescriptions do not just waste medical resources. Medications exceeding their safe dosages or interacting with medications prescribed by other physicians pose risks to patient health.

### *The Family Doctor Integrated Care Program*

Because of the abundance of medical resources in the domestic metropolitan area and the low co-payment required in the NHI system, many people visit doctors but still fail to obtain a proper diagnosis and treatment. Therefore, The NHIA implemented the "Family Doctor Integrated Care Program" in 2003 to encourage at least fve clinics in the same area to form a "community healthcare group" with partner hospitals. It is hoped that through the implementation of the Family Doctor Integrated Care Program, people will develop correct healthcare-seeking behavior. The public will receive primary care provided by primary clinics on a regular basis and get referred to the hospital for medical treatment when further diagnosis and

**Table 4.1** Analysis of the number of patients with chronic diseases in 2017

Notes:

1. The data are from the second-generation warehouse of the NHIA

2. Defnition of chronic disease: the main diagnosis in an outpatient is one of the 100 chronic diseases announced by the NHIA, the same person has seen the doctor more than twice, and there are more than 60 annual dosing days

treatment is necessary, integrating medical resources in hospitals and primary clinics.

Under the "Family Doctor Integrated Care Program," primary clinics cooperate with contracted hospitals to provide more comprehensive health care, including the 24-h consultation hotline services for members of this plan. The aim is to reduce emergency room and unnecessary visits by providing appropriate health education and value-added services. The NHIA also established a comprehensive referral mechanism to improve the continuity and coordination of patient care by implementing the two-way referral and collaborative care. We evaluate the service provision, healthcare quality, satisfaction, preventive care, and link the performance to the NHI payment system to ensure the smooth operation of the plan.

A total of 526 community medical groups in Taiwan participated in the "Family Doctor Integrated Care Program" by the end of 2017. There were 4063 primary clinics participating, an increase of 1006 from 3057 in 2016. Approximately 2.5 million people received health care in this plan in 2015, and the number increased to 4.1 million in 2017, showing a 1.6-fold increase in 3 years. Medical expenses of 2015 and 2017 were NTD 1.2 billion and 2 billion respectively, representing a 1.7 fold increase during this period (Table 4.2).

**Table 4.2** Number of cases and medical utilization of the "Family Doctor Integrated Care Program" from 2015 to 2017

Source: NHIA

*RVU* relative value unit, *NTD* New Taiwan dollar

### *Providing a New Model of Integration and Interdisciplinary Services*

The NHIA provides integrated medical services for patients with multiple chronic diseases, hoping that the comprehensive, coordinated, and continuous medical care helps to improve safety and avoid duplication as well as improper medication and treatment. In addition, the NHIA offers additional integrated medical services in different levels of medical institutions to cater to the healthcare-seeking behavior of the public. If patients are accustomed to visiting hospitals, they can participate in the "Patient-Centered Integrated Outpatient Care Program in Hospitals"; if patients are used to seeking treatment in the clinics, they can join the "Family Doctor Integrated Care Program." Patients with impaired mobility for whom it is not convenient to obtain medical treatment in hospitals or clinics can participate in the "Integrated Home Health Care Program."

Since 2009, the NHIA has implemented the "Patient-Centered Integrated Outpatient Care Program in Hospitals" to foster proper integration of various specialties in the hospital and encourage hospitals not only to think about treatment strategies from the scope of a single medical department, but to provide integrated outpatient care services. The hospitals integrate medical teams by providing medical services from multiple specialized physicians. Each consultation accounts for at least 3 h, or by providing a one-stop consultation service for patients with dementia, major injuries or rare diseases, multiple chronic conditions of the elderly, chronic conditions (such as high blood pressure, high blood lipids, and high blood glucose), and other diseases. In addition to the general consultation fee for each visit, an additional outpatient integration fee will be awarded. As for an integrated outpatient clinic that is provided by multidisciplinary doctors, an additional fee will be awarded; for patients with dementia, 300–500 RVUs are paid for family consultation. Through economic incentives, The NHIA provides integrated care service to patients with multiple chronic conditions, hoping to improve the quality of care, so that the public can feel more at ease while seeing a doctor when the quality of healthcare is guaranteed.

**Table 4.3** Number of cases and medical utilization of the "Patient-Centered Integrated Outpatient Care Program in Hospitals" from 2015 to 2017

Source: NHIA

*RVU* relative value units, *NTD* New Taiwan dollars

According to the statistics, 189 hospitals participated in the "Patient-Centered Integrated Outpatient Care Program in Hospitals" in 2017. The number of cases increased from 360,000 to 520,000 from 2015 to 2017, and the number has increased by 1.4 times in 3 years. Medical expenses increased from about NTD 110 million in 2015 to about NTD 230 million in 2017, and the cost has doubled (Table 4.3).

### *Incorporating the Labor Power of Home Care into Integrated Care*

To further serve patients with impaired mobility, the NHIA has been seeking funding to promote the "Integrated Home Health Care Program" since 2016. For elderly and disabled persons with impaired mobility, the care team in community evaluates and integrates care resources before long-term care staff provide life care services, and medical personnel can provide home medical care for them. The service extends to home hospice and palliative care as the patients' conditions shift, to care for them at the end of life in a patient-centered manner.

The "Integrated Home Health Care Program" comprises general home care, home respiratory care, home hospice care, and the home medical care plan that was trialed in 2015. Through the cooperation of care teams and the case management mechanism, the NHIA provides patients with complete medical services. The continuity of home medical care is therefore enhanced when patients do not have to change the care team when their health conditions change.

A total of 195 teams and 2024 hospitals participated in 2017, covering all 50 medical sub-regions, and more than 90% were primary clinics and home care, which can provide care nearby. The cumulative number of participants in 2017 was 32,759. Among them, 85.4% are over 65 years old, and this is 4.3 times higher than the 7675 people receiving service between March and December in 2016. Medical expenses have increased by seven times, from NTD 60 million in 2016 to NTD 470 million in 2017 (Table 4.4).

Starting from 2019, the "Integrated Home Health Care Program" has expanded its scope and started to include services provided by dentists, Chinese medicine physicians, and pharmacists. At the same time, the responsibility of home care

**Table 4.4** Number of cases and medical utilization of the "Integrated Home Health Care Program" from 2016 to 2017

Source: NHIA

*RVU* relative value unit, *NTD* New Taiwan dollars

doctors has been further emphasized. The home care doctor is responsible for evaluating a patient's overall needs for home care, and requesting services provided by other medical personnel, such as dentists, Chinese medicine physicians, nurses, and respiratory therapists, when necessary. Patients are required to cooperate with home care doctors in medication reconciliation and comprehensive home care. If the patient cannot cooperate with the doctor, he or she shall return to receive medicine during outpatient sessions, so that the limited number of home care service providers can take care of physically impaired patients with actual needs.

### *Promoting the Vertical Integration of Hospitals and Clinics*

The implementation of the "Family Doctor Integrated Care Program," the "Patient-Centered Integrated Outpatient Care Program in Hospitals," the "Integrated Home Health Care Program," and various programs of the NHI is aimed at improving medical accessibility and quality to construct a patient-centered medical care system, by providing patients with safe, appropriate, and continuous integrated medical services according to their needs, and to reduce the waste of medical resources.

The tiered medical care system and two-way referral, which NHIA has proactively promoted since 2017, have received enthusiastic responses from the majority of medical centers and regional hospitals. They have come forward to take the leading role by forming alliances with community hospitals and clinics actively in their areas. As of mid-November 2018, there was a total of 78 "vertical integration" strategic alliance groups of institutes in Taiwan. The NHIA encourages people to seek medical care from their trusted family doctors nearby when they are not feeling well. As the primary clinics have medical centers as their medical backup, referrals can be arranged through the "Electronic Referral Platform" established by the NHIA when necessary. The division of workload and cooperation between clinics and hospitals not only provides continuous care for patients, but also reduces their cost and time spent traveling to and waiting in big hospitals.

### *Healthcare Digital Transformation Brings Win–Win–Win for Physicians, Patients, and National Health Insurance*

With limited NHI resources, the NHIA and the medical profession must reach a consensus on how to design incentives that support the integrated care services and reward systems that pay according to the service quality. Some representatives of the medical profession complained that under the current division of medical specialties, it is diffcult to provide integrated care services from physicians with different expertise. Some hospitals provide integrated care services, whereas in fact they only integrate the medical information, so patients still have to visit multiple departments. Some patients hope to maintain the freedom of choosing their medical providers. Because of the above-mentioned factors, the medical care system is still facing challenges in fragmentation.

In recent years, the NHIA has been actively integrating various sorts of medical information, such as the establishment of the "NHI PharmaCloud System" in 2016 to ensure the safety of patients' medications and avoid duplicate medications. It was upgraded to the "NHI MediCloud System" in 2017, providing additional medical information including examination and test records and results. The NHIA established the "Medical Image Sharing and Access" mechanism in 2018 to provide clinicians with real-time cross-hospital access to patients' digital medical images, and has further set up an online real-time reminder, so that the clinician can immediately review the medication and examination (test) patients received in the last 3–6 months before ordering new ones. If every physician can query the NHI MediCloud System in the clinic thoroughly to avoid duplicate examinations and medications, unnecessary medical expenses can be reduced, and patient safety can also be guaranteed.

In recent years, the NHIA has carried out various medical and expenditure reforms to distribute the medical and NHI resources more effectively, and reduced medical waste by managing its source, hoping to avoid the impact on income of medical staff caused by the RVU fuctuation attributed to the global payment system (Fig. 4.2). In addition, the NHIA improved the mobile phone authentication function of "My Health Bank" in 2018 to support people's self-health management. The public can download the National Health Insurance Mobile Easy Access mobile application (NHI Express App) to check personal insurance premium payment and medical records, health examinations, preventive health care, and other related information easily. By the end of 2021, the number of downloads had exceeded 7 million. We hope to create a win–win–win situation for physicians, patients, and the NHI so as to meet the challenges of the super-aged society.

### **Connection to Long-Term Care After Hospital Discharge**

To provide comprehensive and continuous care after hospital discharge, the NHIA continues to support contracted hospitals in improving the quality of the discharge planning service. We look forward to providing high-quality discharge planning

**Fig. 4.2** The NHIA won the 2020 National Sustainability Award with the theme of "Digitalized Health Network—the NHI MediCloud"

through cross-organization cooperation, so that inpatients who have needs for longterm care can receive necessary services in a timely manner.

### *Covering the Discharge Planning and Follow-Up Management Fee Through National Health Insurance*

The NHIA provides patients with needs assessment, health education, and interprofessional communication during their hospitalization. The services also include coordination of information as well as referral arrangement for subsequent medical follow-ups, long-term care and social resources to reduce the possibility of emergency revisit and readmission shortly after their discharge. The "Discharge Planning and Follow-up Management Fee" was added to the NHI fee schedule in April 2016, so that 1500 RVUs are paid per person per time. The NHIA stipulated the subject eligibility and established the specifcations and procedures in June 2017 as operational guides that hospitals could follow and properly connect hospital discharge with follow-up care services.

Most hospitals provide discharge planning by their in-house discharge planning team. The case managers customize discharge plans for specifc inpatients and conduct at least one interprofessional communication meeting depending on the patients' condition. Participants of the discharge planning team may include

physicians, pharmacists, nurses, dietitians, rehabilitators, respiratory therapists, social workers, etc. When necessary, family meetings that facilitate communication between family members and medical professionals will be held to assess patients' post-discharge medical care, long-term care, or other social need. The discharge planning team provides the patient and their family members with health education and related information, as well as arranging referral to follow-up care such as community healthcare groups in the NHI Family Doctor Integrated Care Program, various types of home care, the Integrated Home Health Care Program, and long-term care institutions. The service also includes more than one telephone follow-up and telephone consultation within 2 weeks after discharge.

### *Implementation of Long-Term Care 2.0*

Owing to the aging population in Taiwan and the diversifed needs for care services, the Ministry of Health and Welfare has established a community-based long-term care service system in response to the need for long-term care for the increasing proportion of the population with disability and dementia. To tackle the challenges of long-term care in our aging society, the "National Ten-Year Long-Term Care Plan 2.0" (referred to as Long-Term Care 2.0) was approved by Executive Yuan in December 2016 and put into effect in January 2017.

In addition to promotion of the Comprehensive Community Care and development of innovative services, the Long-Term Care 2.0 also focuses on the establishment of a community-based healthcare team, and connection to other services such as discharge planning and home medical service.

### *Connection Between National Health Insurance Discharge Planning and Long-Term Care 2.0*

The goal of the "Discharge Planning and Long-Term Care 2.0 Connection Friendly Hospital Reward Program" and the "2020 Discharge Planning Connect to Long-Term Care Plan" is to encourage hospitals to complete a long-term care needs assessment, and referral arrangement to the long-term care facilities before patients leave the hospitals, so that the long-term care services can kick in within 7 days after discharge to avoid care fragmentation. By doing so, we hope to reduce the long waiting time before the initiation of long-term care service caused by the traditional needs assessment process (Fig. 4.3).

From April 2017 to December 2020, there were a total of 508,534 claim cases from 361,708 patients regarding the "Discharge Planning and Follow-up Management Fee." Among them, 139,034 claim cases were eligible for the Long-Term Care 2.0 and assessed for their Long-Term Care 2.0 needs before or after being discharged from the hospital. Among them, 94,113 cases subsequently

**Fig. 4.3** Connection process between medical care and Long-Term Care 2.0

received the Long-Term Care 2.0 services, accounting for 68% of the total number assessed. The rate of subsequent transfers to long-term care services is increasing year by year (Table 4.5).

To understand if cases are connected to Long-Term Care 2.0 seamlessly, we conducted a subset analysis for 69,336 cases who received a needs assessment prior to discharge. Among them, 28,447 cases received the Long-Term Care 2.0 service within 7 days after discharge, accounting for 41% of the recipients of the Long-Term Care 2.0 needs assessment during their hospital stay and the proportion of this item is showing an increasing trend (Table 4.6).

### **Tiered Medical Care System**

In Taiwan, the comprehensive coverage provided by NHI allows residents to gain easy access to medical treatment, and can freely choose the institution for medical treatment. Therefore, people tend to swarm to big hospitals regardless of whether they have serious or mild illnesses. The overcrowded situation in big hospitals causes extreme waiting times for patients with acute, severe, and diffcult diseases with immediate needs for specialized care. On the other hand, it is diffcult for small community hospitals to sustain themselves because of the small number of patients they serve. These two extremes have caused ineffciency in the overall medical care system, and revolutionary policies are urgently needed to improve this situation.

**Table 4.5** Situation of the cases of the National Health Insurance (NHI) "Discharge Planning and Follow-up Management Fee" receiving Long-Term Care 2.0 services

**Table 4.6** Situation of the cases of the National Health Insurance (NHI) "Discharge Planning and Follow-up Management Fee" receiving Long-Term Care 2.0 services—assessment before discharge

The goal of the tiered medical care system is to encourage the public to seek medical care in the right way by receiving healthcare from the same provider regularly. In this way, their doctors can quickly evaluate their conditions and refer patients to appropriate hospitals for further medical treatment when necessary. Of course, the change of behaviors cannot be accomplished overnight. It must be promoted over a long period and implemented with appropriate supporting measures.

### *Current Distribution of Hospital Levels*

The number of hospitals has shown a decreasing trend in the past 5 years. For example, in 2020, there were 25 medical centers, 82 regional hospitals, and 368 district hospitals. Compared with 2016, the most signifcant change was that the number of district hospitals decreased by 6. However, the number of wards increased at all hospital levels. The total number of wards increased from about 130,000 to 134,000 over the 5 years (Tables 4.7 and 4.8).

In terms of medical expenses, the total medical expenses claimed by medical centers and regional hospitals are both around 200 billion RVUs each year, whereas that of district hospitals has grown gradually to approximately 100 billion RVUs, and medical expenses of district hospitals have also slightly increased from 16.7% in 2016 to 18.7% in 2020 (Table 4.9). This may be attributed to the downgrading of the two regional hospitals to district hospitals in 2019.

**Table 4.7** Statistics of the number of facilities at each hospital level in the past 5 years

**Table 4.8** Statistics on the number of wards at each hospital level in the past 5 years

**Table 4.9** Statistics on the number of medical expenses claimed by each hospital level in the past 5 years

*RVU* relative value unit

### *Encouraging Big Hospitals to Treat Acute, Severe, and Diffcult Diseases*

The hospitals are divided into three levels in the NHI: medical center, regional hospital, and district hospital. Medical centers and regional hospitals, commonly known as "big hospitals," are staffed not only by various specialists but even by subspecialists. Besides that, they have a wide range of examination and test equipment and advanced instruments. Big hospitals are able to provide high-quality medical services for inpatients and patients with acute, severe, and diffcult diseases with the highly specialized human resources and equipment they possess. Therefore, the NHI, with a strong backing for big hospitals, is obligated to provide big hospitals with strong support in term of reimbursement.

Because of the diffculty of treatment for acute, severe, and diffcult diseases, the big hospitals demand more security in their human resources. Therefore, the NHIA strives to utilize the limited NHI resources to not only increase the reimbursement of diagnosis, treatment, and surgery related to acute, severe, and diffcult diseases continuously, but also secure the value of the RVU. Starting from 2021, the NHIA planned to frst adopt a fxed RVU value to guarantee the inpatient examination fee, nursing fee, and ward fee of the intensive care ward, and then obtains a budget in the following years to gradually expand the scope of coverage.

### *Small Hospitals Are the Leaders of Community Medical Care*

The most fundamental level of the pyramid of the tiered medical care system is the primary health care from community medical institutions. Community medical care is provided by all primary clinics and small hospitals in the community. Based on 368 million outpatient visits in 2019, about 71 million medical visits were made in big hospitals (medical centers and regional hospitals), which means that 297 million medical visits accounting for 80% of total outpatient visits, occurred in community medical institutes.

To promote the "good doctors in the community" policy, district hospitals, as the big brothers of community medical care, not only cooperate with the promotion of "Holiday Clinics in District Hospital" to share the congestion in emergency departments of big hospitals but also continuously improve the lineup of their doctors. In addition to inviting doctors from big hospitals to support outpatient clinics, the district hospitals also actively join the medical alliance led by big hospitals to fully accomplish the assignment of connecting the services between community medical care and big hospitals.

Supporting policies should also be in place. As for the global budget of 2021, the NHIA planned to use a fxed amount of 500 million NTD to guarantee that holiday and night outpatient visits in district hospitals are reimbursed at a fxed RVU value. The NHIA also explores the possibility of enhancing the capacity of district hospital

services by providing measures such as: evaluating the upper limit for the number of support visits in district hospitals made by physicians from medical centers, regional hospitals and primary clinics, and encouraging the establishment of telemedicine models among hospitals of different levels, to strengthen people's confdence in community medical care.

### *Consolidate Small Hospitals in Remote Areas to Continuously Protect the Health of Residents*

The main purpose of the implementation of NHI is to reduce the barriers to medical care for the disadvantaged; therefore, the NHIA especially focuses on those who reside in remote areas with scarce medical resources. And this is how the policy can intervene to assist hospitals that have established their foothold in remote areas to provide services continuously.

For hospitals established in mountainous areas, offshore islands, and areas with insuffcient medical resources, or hospitals that are located in neighboring towns of the aforementioned areas, as long as they meet the requirements of the "Medical Service Improvement Plan for Areas with Insuffcient Medical Resources" of the NHI, and provide 24-h emergency and outpatient services in Internal Medicine, Surgery, Obstetrics & Gynecology, and Pediatrics Departments, subsidies up to NTD 15 million each year would be granted to help these hospitals to have better medical delivery capabilities.

### **Co-Payment Adjustment**

The spirit of the co-payment adjustment is not only to raise the public's cost awareness and let people cherish medical resources but also to further guide the correct medical behaviors of the insured, implement the tiered medical care system, and promote the separation of medicine and pharmacy. When unnecessary medical treatment is reduced, patients with minor illnesses and stable chronic diseases go to community institutions for medical treatment, and patients with acute and severe illnesses are referred to hospitals for treatment according to medical professions. The total amount of medical services will decrease, and the value of the RVUs will increase. The doctors have more time to take care of patients, and the quality of medical care will naturally improve, creating a win–win medical environment for patients and medical personnel. It promotes the effciency of medical services, maximizes the benefts of health insurance, and achieves the goal of improving effciency and quality through doctor–patient communication.

The NHIA refers to the opinions of all parties, analyzes the overall trend of the co-payment and the medical use situation, and proposes the following planning and

thinking for reference and discussion. It is hoped that after the advice is widely accepted into the policy, a consensus can be gradually built, so that the public and medical service providers can accept and beneft.

### *Current Situation Analysis*

There are two types of drug prescriptions: general drug prescriptions and continuous prescriptions for chronic diseases. According to the current collection analysis of the co-payments for drugs and examinations (tests), the average drug cost is NTD 381, but 70% of prescribed drugs are less than NTD 100, where the public does not have to bear the co-payments. Taking 2019 as an example, the NHI paid a total of NTD 80.6 billion for continuous prescriptions for chronic diseases, an average drug cost of NTD 985, but the public did not pay for any of them.

For examinations and tests, the average examination (test) cost per item is 1169 RVUs (1719 RVUs for medical centers, 1466 RVUs for regional hospitals, 1184 RVUs for district hospitals, and 435 RVUs for clinics). However, according to the current regulations, the co-payments of the examinations (tests) are not charged.

### *The Planning, Thinking, and Direction of Outpatient Co-Payments*

With aging of the population, and the development of medical technology and new drugs, it is an indisputable fact that medical expenses have increased year by year. The number of RVUs claimed is much higher than the number approved, with the budgets falling into a vicious circle of doing more and getting less, making Taiwan known as a "sweat hospital." Further analysis shows that among the overall medical expenses, the annual increase in the cost of drugs and the examinations (tests) are the most obvious. Taking drugs as an example, there is no need to pay the copayments for drugs under NTD 100 currently, and the maximum charges only NTD 200 for the drugs above NTD 1001. Some people took drugs home, but did not take them on time, causing a waste of resources. Furthermore, people do not need to pay extra costs for examinations or tests in hospitals, resulting in a small number of people who may ask doctors for additional examinations or tests.

The NHIA analyzed the suggestions of all parties comprehensively, planned adjustment measures for the co-payments, and focused on increasing the copayments slightly, implementation of the tiered medical care system, and enhancement of the separation of medicine and pharmacy. The NHIA adopts a fxed-rate system to collect the costs that the people should bear in accordance with the NHIA, and also considers people's affordability and sets a ceiling price. It is hoped that with the paying part of the medical expenses, the people will think about whether to take more unnecessary drugs and do unnecessary tests, and the doctors should also

carry out their responsibilities to inform patients about the necessity of the tests. It is hoped that the cost awareness of the people can be raised, the medical resources can be used appropriately, the insured can be further guided toward the correct behavior for medical care, and the tiered medical care system can be promoted continuously. The planning direction is divided into three parts: drugs, examination (tests), and emergency treatment.

	- A. The NHIA plans to charge co-payments for outpatient drugs at a statutory rate and set a ceiling price. The plan to collect the co-payment of drugs for continuous prescriptions for chronic diseases is expected to improve the perception that patients with continuous prescriptions for chronic diseases do not cherish drugs because they do not have to bear the co-payment of drugs. However, it is still considered that patients with chronic diseases need longterm regular drugs, and there are concerns about the fnancial burden. Considering the amount that chronic patients need to bear, the co-payment at different levels of medical institutions and community pharmacies needs to be moderately adjusted.
	- B. The NHIA will also plan to encourage people to go to district hospitals and clinics for medical treatment, and obtain drugs from community pharmacies, so as to implement the tiered medical care system and the separation of medicine and pharmacy.
	- A. The NHIA plans to charge the co-payments for examinations (tests) at a statutory rate. Considering that the issuance of examinations (tests) involves medical professional judgments, and the additional collecting of the copayments will cause shocks in all walks of society and be more controversial. Therefore, people who cooperate with the tiered medical care system will be referred by a doctor after diagnosis and charged at a lower rate to the plan. After analysis, the average cost of each examination (test) at each level of medical institution is different, so different ceiling prices will be set according to the level and with or without referral.
	- B. In addition, the NHIA will plan the co-payment mechanism for examinations (tests) toward the direction of encouraging people to go to district hospitals and clinics for medical care. If there are further medical needs, the primary doctors will refer patients to hospitals above the regional levels according to professional recommendations.

When adjusting the co-payments of drugs and examinations (tests), the copayments at the hospital level will approach or even exceed the quota for emergency care. It may cause people transfer to the emergency department for medical treatment. After investigation, the current emergency department does not collect the co-payments for drugs and examinations (tests), so the co-payments for the emergency department will be fne-tuned in coordination with the overall plan. We hope to advance the emergency medical resources of large hospitals to the tasks and roles of emergency and critical care, prevent mild cases from going to the emergency department of medical centers, and guide people toward behaving correctly in seeking medical care.

### **Conclusion**

Providing a comprehensive and continuous service for people in Taiwan is always the aim of the NHI. With the ageing of the population and the development of medical care, medical expenses have increased year by year. To protect patients' medical rights with limited resources, expenditure reduction by inhibiting inappropriate use of medical resources is an answer to reduce the pressure of premium increases.

The high or low co-payments affect the rights and interests of most of those insured, because of Taiwan's medical convenience and the people's freedom of medical treatment. Our goal is to control the balance of interest conficts and account for the rights of the insured and basic justice. The NHIA explains the concept and direction of the plans for everyone with reference and discussion. It is hoped that after the advice is widely accepted into the policy, a consensus can be gradually built, so that the public can accept and beneft.

### **References**

**Open Access** This chapter is licensed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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### **Chapter 5 Pursuing Health Equity**

**Po-Chang Lee, Yu-Chuan Liu, Yu-Hsuan Chang, Joyce Tsung-Hsi Wang, Shu-Ching Chiang, and Hsueh-Yung Mary Tai**

### **Introduction**

The purpose of Taiwan National Health Insurance (NHI) is to improve the health and secure the fairness of the medical rights of all citizens. To safeguard the health of the disadvantaged, the National Health Insurance Administration (NHIA) announced a full-scale unlocking of the NHI card to realize the universal right to equal medical care. In addition, the NHIA conducted various programs that encourage providers to supply rural medical services, hoping to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. As for patients with rare diseases, the Legislative Yuan passed "The Rare Disease and Orphan Drug Act" to offer more comprehensive care, making Taiwan the ffth country in the world to protect the medical rights of patients with rare diseases through legislation.

In addition to medical care for the disadvantaged, the health literacy of the public is also the top priority of the NHIA. My Health Bank system enables users to query their real-time medical and health information, which encourages self-health management and also improves the safety and quality of the medical care that they receive. The NHI is introduced in elementary school textbooks to familiarize the younger generation with its concept and create a more profound infuence.

P.-C. Lee (\*) · Y.-C. Liu · J. T.-H. Wang · S.-C. Chiang · H.-Y. M. Tai

National Health Insurance Administration, Ministry of Health and Welfare, Taiwan, Taipei, Taiwan

Y.-H. Chang Ministry of Health and Welfare, Taiwan, Taipei, Taiwan e-mail<EMAIL_ADDRESS>
e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS><EMAIL_ADDRESS><EMAIL_ADDRESS><EMAIL_ADDRESS>
### **Removing Barriers to Health Care to Protect the Disadvantaged**

With the spirit of improving the health and safeguarding the fairness of medical rights of all citizens, the NHIA not only implements measures to assist the disadvantaged in paying the premium of the NHI but also gradually decouples the payment of premiums from the right to receive medical care for the disadvantaged (hereinafter referred to as unlocking of the NHI card) (Fig. 5.1). The number of people whose NHI card was locked owing to overdue NHI premiums dropped from 693,000 in 2007 to approximately 42,000 in April 2016. Furthermore, the NHIA announced a full-scale unlocking of the NHI card in June 2016 to realize the universal right to equal medical care, and to build a comprehensive umbrella to safeguard the health of the disadvantaged.

### *Decoupling of the Payment of Premiums from the Right to Receive Medical Care*

To ensure the fair burden and the sustainability of the NHI, the public bear the responsibility of paying the premiums while enjoying the right to medical care. Therefore, the NHIA has a statutory disgorgement mechanism for those who owe

**Fig. 5.1** Since June 2016, the policy of a full unlocking of the NHI card has been implemented

insurance premiums. The implementation of a full-scale unlocking of the NHI card means that no fnancially disadvantaged citizens will experience a delay in medical treatment because of their overdue premiums.

The NHIA combines the efforts from different sectors of the society and governmental agencies to assist the disadvantaged with premium payment and remove their psychological barriers when seeking medical treatment. Measures to provide those who are in need fnancially and care for the weakest in the society include (Fig. 5.2):

**Fig. 5.2** Assistance for the disadvantaged

payment in up to 48 installments if the total annual individual income does not exceed personal exemption, standard deductions, and special deductions of income from salaries or wages for the most recent year.

### *The National Health Insurance Premium Deferment Paying Measures of the COVID-19 Epidemic*

Considering that the global outbreak of COVID-19 may impact people's fnance and livelihoods and hamper their ability to pay the NHI premiums on time, the NHIA allowed insured units and individuals affected by the pandemic to apply for deferment of their premium payments of February to July 2020 and April to September 2021. The overdue charges, payment reminder, and transfer for compulsory enforcement are exempted during the deferred period, so as to tide citizens over any diffculties. The total amount of the application is about New Taiwan dollars (NTD) 2.6 billion in 2020 and NTD 4.7 billion in 2021.

By the full-scale unlocking of the NHI card and all the assistance measures, the disadvantaged are no longer afraid of being unable to receive necessary medical care owing to overdue premiums. The move not only relieves their fnancial pressure and paves the last mile toward comprehensive protection to medical rights, but also helps to improve the health of all citizens and stabilize society. As for those who have the ability to repay, the NHIA continues to collect the arrears effectively and transfer them to compulsory enforcement, in order to avoid deliberate arrears and ensure that the full-scale unlocking of the NHI card does not impact the fnance and operations of the NHI.

### **Medical Services on Remote and Offshore Islands**

The NHI is committed to improving the accessibility and comprehensiveness of medical care for residents living on remote and offshore islands. With this goal in mind, the NHIA has carried out various initiatives since 1999 to encourage providers to invest in rural medical services, including the "Integrated Delivery System (IDS)," "Improvement Plan for Medically Underserved Areas," and "Upgrading Medical Services in Underserved Areas" plans, and others (Fig. 5.3). These initiatives are designed to incentivize more medical institutions and professionals to offer timely and affordable health care to under-resourced communities, with the full backing of the NHI system.

### *The Integrated Delivery System*

The IDS coordinates and optimizes local medical resources, and provides diversifed care appropriate to local conditions, including resident outpatient clinics, 24-h emergency services, night-time outpatient clinics, standby clinics for evenings and

**Fig. 5.3** The history of the National Health Insurance medical services promotion on remote and offshore islands

holidays, specialized medical care, specialized medical care bolstered by relevant medical staff, mobile clinic services, on-call medical services in the event of natural disasters, chronic disease management and prevention services, comprehensive home health care, and other medical services constituting a comprehensive network of care. Each IDS is unique to local conditions, implemented according to the distinctive needs of the community it services. Currently, there are 50 IDSs in full operation across Taiwan, buttressed by 26 large hospitals working in concert with local providers. In 2019 alone, the NHIA invested in a sum of NTD 5.04 billion in remote rural areas, of which IDS operations commanded NTD 1.17 billion. A total of 2012 specialist consultations were provided each month, serving more than 470,000 patients. From mountainous village clinics to offshore medical stations, IDS medical staff travel to wherever they are needed to provide high-quality, comprehensive health care to Taiwan's residents in remote areas.

In 2019, average visits per person in remote areas were 14.9 and 16.4 visits on offshore islands and mountain areas respectively. Notably, these averages were higher than that of the entire population (13.1 visits/person), of which a majority live on the main island, particularly in urban areas. Personal medical expenses in IDS areas were also comparable with those of the entire population (Tables 5.1 and 5.2). Since the program's inception in 1999, the IDS has attained a public satisfaction rate of more than 90%. The statistics above refect gradually disappearing inequities in healthcare access and quality between highly populated urban areas and remote communities, as the NHIA looks beyond solely using IDS support to truly close the distance.

### *Improvement Plan for Medically Underserved Areas*

Beyond deploying highly effective IDS networks across Taiwan, in order to mitigate inconvenience experienced seeking care in medically under-served areas, the NHIA has devised specialized initiatives to encourage medical professionals across the spectrum—traditional Chinese medicine doctors, Western medicine physicians, and dentists—to establish resident and mobile practices in areas still lacking adequate medical infrastructure. The Improvement Plan for Medically Underserved Areas was implemented in a total of 374 villages and towns in 2019 (Table 5.3), enabling an impressive 40,357 specialized consultations serving 710,144 patients.

**Table 5.1** The average number of Western medicine outpatient visits per person per year

90

**Table 5.2** The average relative value units (RVUs) of Western medicine outpatient visits per person per year

Unit: RVUs

Source: The NHIA Data Warehouse system. People registered on the mountain areas and offshore islands and are insured, adjusted for age and gender

NHI = National Health Insurance

**Table 5.3** Outcome of the Improvement Plan for Medically Underserved Areas for Western medicine, Traditional Chinese medicine, and dental in 2019

### *Upgrading Medical Services in Underserved Areas*

To further enhance local healthcare services for residents in mountainous towns, offshore islands, and areas with insuffcient medical resources, the "Upgrading Medical Services in Underserved Areas" initiative was implemented in 2012 to establish comprehensive health coverage in these communities, such as 24-h emergency services, inpatient services, as well as care spanning the disciplines of Internal Medicine, Surgery, Obstetrics and Gynecology, and Pediatrics. In total, 92 hospitals participated in providing needed care to underserved communities in 2019.

### *National Health Insurance Strives to Remove Barriers to Medical Treatment*

The Kinmen IDS network implemented by the Taipei Division of the NHIA exemplifes the innovative work the NHIA has undertaken to remove all barriers to medical treatment, be them fnancial, economic, or geographical. The Taipei Veterans General Hospital (TVGH), as the pillar of the Kinmen IDS, deploys specialists to enhance the capabilities of Kinmen Hospital, so that major operations, such as craniotomy and cardiac catheterization, can now be performed in Kinmen. Patients suffering an ischemic stroke can receive thrombolytic therapy, and cancer patients can receive chemotherapy right on Kinmen Island—they and other Kinmen residents can rely on timely, potentially life-saving treatment without needing to travel to Taiwan's main island by boat.

Ms. Zhang, a Taiwanese citizen living abroad, was rescued from the grips of death by the IDS Kinmen team, an experience she shared on 17 December 2020, at a NHIA press conference reporting on the results of the Kinmen and Matsu IDS programs. Driving on a visit to Kinmen in July 2020, she encountered a serious car accident, which dealt her a traumatic intestinal injury, sternum fracture, chest contusion, blunt head injury, and severe laceration. Fortunately, the IDS medical team of Taipei Veterans General Hospital stationed at Kinmen Hospital, was available to give Ms. Zhang emergency life-saving treatment, afterward sending her to the TVGH main campus in Taipei for follow-up treatment. Ms. Zhang's full recovery from this otherwise fatal accident is one of many incredible testimonies to the importance of establishing equitable, comprehensive health care in remote and offshore areas.

### *Prospects*

Beyond implementing an array of targeted, localized plans to improve the accessibility of no-compromise, high-quality medical services in remote and offshore areas, the NHIA ultimately aims to cultivate self-sustaining healthcare ecosystems in these areas. To this end, the NHIA leads efforts to recruit talents from a variety of specializations to provide resident services locally. A "National Physician Manpower Demand for Rural Areas Platform," featured on the homepage of the NHIA's offcial website, has been established to match physicians with fully reimbursed service opportunities in mountainous and offshore communities across the country. This platform is expected to foster a dynamic forum for mutual mentorship and progress, in which resident and visiting physicians learn from each other's experiences, in turn deepening the quality and longevity of health care in remote, under-resourced areas. At the same time, to avoid improper use of precious resources of the National Health Insurance and ensure the quality of medical services in underserved communities, the NHIA continues to monitor the service capacities and perform on-site visits to assess the quality of the on-the-ground services delivered by both resident clinics and mobile stations alike, and regulates hospitals that deviate from the central goal of serving still under-resourced communities, e.g., by fraudulently claiming compensation.

### **National Health Insurance Stands by Patients with Rare Diseases**

To care for patients with rare diseases more comprehensively, the Legislative Yuan passed "The Rare Disease and Orphan Drug Act" in 2000. In the past two decades, the NHI has served as the patients' strongest support. As of 2019, there are 9600 rare-disease patients receiving drugs covered by the NHI.

Rare diseases are uncommon diseases with a low prevalence rate, and according to "The Rare Disease and Orphan Drug Act" the defnition of "rare disease" is "diseases with prevalence lower than the standard announced by the central competent authority (1 in 10,000)." Under special circumstances, a disease could be recognized as a rare disease through review by the Review Committee for Rare Diseases and Orphan Drugs (hereafter referred to as the Review Committee) and designated and publicly announced by the central competent authority. Orphan drugs are used to prevent, diagnose, and treat rare diseases, under the premise of being recognized through review by the Review Committee and announced by the central competent authority. The same Act also stipulates that after obtaining designation or special approval from the central competent authority, orphan drugs can be submitted for listing in the National Health Insurance Pharmaceutical Benefts and Reimbursement Scheme. As of the end of December 2020, the NHI covered 207 drug items that had either been announced by the competent authority as drugs eligible for special importation (manufacture) or those qualifed for orphan drug licenses under the Rare Disease and Orphan Drug Act.

### *Rare Diseases Are Categorized as Catastrophic Illnesses to Waive Patient Co-Payments*

Given that patients with rare disease are uncommon, they have higher and more urgent medical needs owing to the severity of their health conditions, the NHIA has classifed all individuals with rare diseases as having catastrophic illness. In this way, their co-payments for medical care could be waived, reducing the heavy fnancial burden of families with a member who has a rare disease. As of the end of May 2020, the Ministry of Health and Welfare has announced a total of 223 categories of rare diseases. According to the statistics in 2019, the largest number of patients with rare diseases who applied for a catastrophic illness certifcate comprises multiple sclerosis patients with brain or nervous system lesions, a total of 1445 patients (Table 5.4).

The NHIA has always been very concerned about the medical rights of patients with rare diseases. Since 2005, it has strived for a dedicated budget for orphan drugs to avoid rare-disease cases from being squeezed out by the Global Budget owing to the high medical expenses. Expenditures for orphan drugs increased from 1.738 billion RVUs in 2010 to 6.167 billion RVUs in 2019, and the average growth rate of

**Table 5.4** Number of patients with rare diseases applying for the ten most common catastrophic illness certifcates

annual cost in the past 5 years is about 11.2%. We further analyzed the medical resource utilization of various rare diseases. Taking 2019 as an example, patients who contributed the highest average drug costs are those with mucopolysaccharidoses (9.938 million RVUs per patient), followed by Gaucher's disease and Fabry's disease (9.832 million RVUs per patient and 7.753 million RVUs per patient respectively).

Because of the scarcity of patients with rare diseases, the pharmaceutical companies are often unwilling to invest in the development of drugs for rare diseases owing to the economic scale. As a consequence, production costs and unit prices for rare-disease drugs are extremely high. Without alternative treatments on the market, the drugs for rare diseases are also called "orphan drugs." In response to patients' demand, the NHIA proactively includes orphan drugs in its beneft package. For example, Spinraza, a drug for the treatment of spinal muscular atrophy (SMA), has been covered by the NHI since 1 July 2020. This not only brings good news to patients, but also starts a new page for NHI's coverage for SMA treatments.

### *Strengthening Control Measures for Orphan Drugs*

However, considering that the medical expenses of rare diseases have increased year by year recently, the NHIA has begun to strengthen control over orphan drugs. Starting from 1 September 2019, only patients with rare diseases recognized by the Health Promotion Administration are eligible for orphan drugs. It is hoped that with assistance from medical institutions, patients with rare diseases could obtain their catastrophic illness certifcates promptly. By doing so, their fnancial burden could be reduced or eliminated, and they could qualify for using orphan drugs and be treated properly.

#### 5 Pursuing Health Equity

Another control measure is the routine review for the prices of orphan drugs. According to Article 24 of the Regulations on Drug Price Adjustment of the NHI, the payment for orphan drugs should be reviewed and adjusted every 2 years. In addition, Article 35, Item 2 of the "National Health Insurance Pharmaceutical Beneft and Reimbursement Scheme" also stipulates: "Orphan drugs included in this scheme without drug license must acquire drug license or documents certifying their safety and effcacy from the competent authority within 3 years, or they will be subject to delisting. However, drugs that have obtained the US or EU market approval are exempt from this requirement, and their prices may be reduced by 5% annually." The NHIA will continue to collect opinions from experts and scholars and revise the orphan drug payment regulations according to clinical evidence. For example, the review of the orphan drugs payment for mucopolysaccharidoses and Fabry's disease was carried out and implemented in December 2018 and September 2019 respectively. In addition to the abovementioned policies, we will evaluate the effcacy of high-priced orphan drugs constantly in the future to ensure the rational allocation of NHI resources.

Changes in health status are often unpredictable. The offspring of healthy persons may also be at risk of suffering from rare diseases. Therefore, the NHIA always treats patients and their families with empathy. Life is valuable for everyone to pursue their own opportunities. Even though the medical expenses of patients with rare diseases are high, we uphold the spirit of caring for the disadvantaged and allocate limited resources fairly. In consideration of medical rights, fairness and justice, and social ethics, we frmly support patients with rare diseases by fulflling medical needs that their lives depend on. We call on everyone to cherish medical resources together, so that every dollar of the premium of the NHI contributed by each citizen can beneft more insured people in need of medical care.

### **My Health Bank—Promoting Self-Health Management**

### *My Health Bank Guards Our Health*

To realize "people-centered health care," the NHIA applied the concept of My Data to establish "My Health Bank" in 2014. People can browse their medical and health information of the past 3 years on their mobile devices, including outpatient records, inpatient records, surgical data, medication records, allergy data, examination and test results, imaging and pathological examination, test reports, hospital discharge summaries, willingness for organ donation, hospital palliative care, adult preventive care, vaccination records, physiological measurement, hepatoma risk prediction, evaluation of end-stage renal disease and other information. Possessing personal health records not only encourages their self-health management but helps them to communicate with medical providers, and thereby improves the safety and quality of the medical care they receive.

### *Rapid Cell Phone-Based Certifcation Allows Users to Manage Their Medical Information Easily*

The NHIA integrated personal health information of "My Health Bank" into "National Health Insurance Mobile Easy Access" mobile application (NHI Express app). The function of rapid cell phone-based certifcation for users' identity was further added in May 2018 under the premise of information security. The rapid cell phone-based certifcation function of the NHI Express app makes it the frst application that government agencies use on a large scale for identity certifcation through cell phones because of its safety and convenience.

To allow people to search information related to the National Health Insurance quickly in a more intuitive and user-friendly way, the NHIA continues to optimize the operation surface and the service process of the NHI Express app. A modifed vision was introduced in March 2021, aiming to enhance the quality and effciency of these convenience services.

### *Family Member Management Function Added to Safeguard Family Health*

The family member management function was added to the My Health Bank system in May 2019. For the elderly and children under 15 who are less familiar with electronic products, a designated person can access the My Health Bank system for the elderly and children on his or her own cell phone through the family member management function to assist their health management (Fig. 5.4).

### *Software Development Kit Connects Health Services Better*

To further apply the use of the My Health Bank system to more diversifed settings, the NHIA developed the Software Development Kit (SDK) of the My Health Bank system in May 2019, so that third-party apps can connect with the My Health Bank system through the SDK. After authorization, users can select personal medical treatment, medication, test results and other information within a specifc period in the My Health Bank system freely, download and store it on mobile devices and bridge it to trusted third-party apps. The third-party apps can combine their original functions with medical information so that the user can receive more value-added healthcare services, such as online medical consultation, chronic disease management, while using the apps they are already accustomed to. The data from the My Health Bank system integrated to the third-party app enhances the completeness and value of health information, and therefore makes it easier for its user to manage their health.

**Fig. 5.4** Family member management function safeguards our family's health

As of 9 November 2021, a total of 130 manufacturers (306 apps) have applied, 23 of which (47 apps) have been offcially launched. Among them, 11 are health information management software companies, 9 are medical institutions, 2 are medicine and medical device manufacturers, and 1 is a government agency.

### *Supporting Name-Based Mask Distribution System to Assist the Country in Epidemic Prevention*

The global pandemic of COVID-19 continued to heat up in 2020. The name-based mask distribution system was implemented in February 2020 to ensure a stable supply of anti-epidemic masks, granting people equal opportunities to purchase masks, and the NHI card was used as the ID for purchasing masks at pharmacies. The name-based mask distribution system 2.0 was implemented in March of the same year and the NHI Express app is utilized for mask preorder processing, and a review of purchase history. In this way, purchasing masks is much easier for populations such as offce workers and students so that they no longer have to wait in a long queue at pharmacies.

The function of the My Health Bank system also continues to increase. The total number of medical visits and a detailed history of medical visits were added to the system (Fig. 5.5). By displaying the total number of medical visits in each of the past 3 years, as well as the number of RVUs claimed by medical institutions and co-payments paid, we look forward to helping the public to understand and cherish the resources of the NHI overall (Fig. 5.6).

**Fig. 5.5** My Health Bank—overview function of medical visits

**Fig. 5.6** In September 2020, the National Health Insurance Administration (NHIA) celebrated the 25th anniversary of the National Health Insurance and over 5 million logins to My Health Bank. Premier Su Tseng-Chang, Health Minister Chen Shih-Chung, and NHIA Director General Lee declared the opening of the ceremony together. (From Executive Yuan. https://www.ey.gov.tw/ Page/AF73D471993DF350/a3b1039f-ad86-4571-a713-f2cb7eb986cb)

### **The Signifcance of Including National Health Insurance in Elementary School Teaching Materials**

It has been 27 years since the inception of the NHI in 1995. If we personify the life course of the NHI, it is already a college graduate who has entered the workforce. However, even though many people rely on the NHI, their understanding of it is still at the "kindergarten" level. Some people think the NHI is just like private medical insurance, life insurance, and accident insurance; some people think that because they pay the NHI premium every month, it is a waste not to use it and even want to earn their money back; some people think that the NHI will take care of them when they are sick anyway, so they neglect their obligation to take care of their own health. Therefore, we hope that pupils can understand the meaning and value of the NHI through the articles and lectures in the elementary school Chinese curriculum to cultivate the concept of cherishing the NHI resources in the younger generation.

When organ donation was actively promoted at National Cheng Kung University Hospital, an organ recipient Mr. Chao-jung Huang wrote about his life experience in an article "Love Doesn't Die." After being rewritten by the National Institute for Compilation and Translation and Hanlin Publishing Company, the article was included in the ffth-grade textbook. When promoting a concept with activities such as feld trips or speeches, the audience reached is limited because of time and space constraints. However, by integrating the concept into textbooks that are read by tens of thousands of students every year, the idea takes root from generation to generation, creating a more profound infuence.

The establishment of the concept of the NHI must start at an early age. By incorporating it into elementary school textbooks, the concept can be conveyed from teachers to students, from students to their families, and then spread from close family members to other relatives and neighboring communities. The NHIA has always emphasized and promoted the value of "cherishing the resources of the NHI." Offcials of the NHIA visited the Ministry of Education to explain this idea in person. The Minister of Education, Wen-chung Pan, also recognized further incorporating the concept of the NHI into education (Fig. 5.7). Both disciplines of Health and Physical Education and Society in the 9th year and the 12th year include related topics such as understanding of the NHI and medical system and avoiding resource abuse.

By introducing and discussing the social phenomena presented in the texts, teachers can gradually foster students' sense of citizenship. Although the two subjects of Health and Physical Education and Society touch upon the concept of the NHI, the Chinese course, for 5 h per week, allows children to have more time for reading and thinking. Therefore, the ultimate goal is to include the NHI in a Chinese subject textbook.

The NHIA has visited several publishers to discuss these ideas. As Hanlin Publishing Company has adapted the article describing the experience of organ donation, "Love Doesn't Die," it highly recognizes the educational concept of the

**Fig. 5.7** On 15 December 2017, Director Po-Chang Lee visited with Minister of Education Wen-chung Pan

NHIA, and strongly supports including it in Chinese subject textbooks. After many discussions, Hanlin assisted in the drafting of "The Most Admired Health Care System in Asia" and included it in the "Reading Paradise" unit of the ffth-grade Chinese subject textbook. In addition, Nani Publishing also promised to include two articles about the NHI in the Chinese subject workbook of the ffth grade in elementary school, so that children can also be exposed to the concept of the NHI when practicing new words learned in the class (Table 5.5).

In these textbook articles, Ms. Shu-chu Chen's childhood experience is used to illuminate that because of the medical care provided by the NHI, no Taiwanese are unable to seek medical treatment owing to economic barriers. We also mention the current development of information technology and provide students with a preliminary understanding of the convenience brought about by the "National Health Insurance MediCloud System (NHI MediCloud System)," so that they can have more confdence in tiered medical care. The functions and advantages of "My Health Bank" are introduced to strengthen the ability of self-care. The most precious thing is using this opportunity to explain the spirit of "mutual assistance" of the NHI with easy-to-understand wording and inspire both older and younger readers to internalize the concept of cherishing the resources of the NHI.

**Table 5.5** The topic of National Health Insurance is included in Chinese elementary school textbooks

The incorporation of the concept of the NHI into Chinese subject textbooks was carried out in 2020. We believe that the goal of cultivating the concept of cherishing the NHI resources in the general public will be achieved step by step from now on (Table 5.6).

**Table 5.6** The content of the elementary Chinese subject textbook about Taiwan's National Health Insurance published by Hanlin Publishing Company (From Hanlin Publishing Company. https:// www.hle.com.tw/index.html)

#### **The Most Admired Health Care System in Asia** Author: Su-Ling Chen

A vegetable vendor in Taitung, Ms. Shu-Chu Chen, was ranked as the eighth place among the top 100 infuential people in the world by American Time Magazine in 2010, as her selfessness moved people all over the world. She has been hardworking and thrifty all her life, but generously donated to those in need. However, there are several sad stories behind her kindness.

#### **Reading Paradise 2**

Try to answer the question before you start reading. Please describe what items are needed when you visit a clinic or hospital by yourselves or accompanied by your family members.

### 5 Pursuing Health Equity

**Table 5.6** (continued)

Ms. Shu-Chu Chen's family was poor. When she was 13 years old her mother died in childbirth because her family couldn't make up the NTD 5000 deposit for the hospital. Later on, her third brother suddenly had an unknown disease. Her family missed the best time to rescue him and lost him because they couldn't make up the medical expenses immediately. Even after many years, Ms. Chen Shu-Chu couldn't help but fll her eyes whenever she recalled these memories: "Because we were too poor. If we had money, our family member would not have left us. It was because we could not come up with money for medical expenses..." This is the true story from Ms. Chen Shu-Chu's miserable and helpless family. It is also a portrait of many poor families in the era when there was no health insurance system—they did not have savings or the means to pay for the medical care they needed.

### **Table 5.6** (continued)

Only those who have suffered understand the taste of bitterness. Therefore, Ms. Shu-Chu Chen is willing to endorse the NHI for free. In the short flm "It's nice to have the National Health Insurance," she said with sentiment: "When there was no National Health Insurance you had to borrow money from others when you get sick, …… you won't understand the hardships of no money for saving lives until you encounter it." Indeed, if you haven't experienced the hardships, it is diffcult to truly understand. We Taiwanese enjoying the comprehensive health insurance system now should know more about and support the National Health Insurance.

#### **Logo of the National Health Insurance**

You can fnd a circular logo on the top of the NHI card. There are two "little green persons" in the middle of the logo. It is not the little green man traffc sign that helps us to cross the road, but a logo of the NHI! Take a closer look, the logo shows a man and a woman shaking hands, which means:

### 5 Pursuing Health Equity

### **Table 5.6** (continued)

"Help each other and take care of each other, and then everyone will be healthy." Let's further imagine, which English letter does this male and female shaking hands pattern look like? Yes, it's the English letter "H"! Do you know? This "H" implies three special meanings, which are "Help" each other, "Health," and "Happy." It means that: "If everyone helps each other, everyone can be healthy and happy!" Isn't this sign very interesting and meaningful?

### **Table 5.6** (continued)

#### **Features of National Health Insurance**

#### **Help each other and care for the disadvantaged**

Let's start form the meaning of "Help." The National Health Insurance is a compulsory program. Since its inception in 1995, the insurance has been fnanced mainly by the premium contribution of the public, employers, and the government. It is worth mentioning that the NHIA has allowed people who owe premiums to seek medical treatment in time when necessary, since June 2016. The purpose is to prevent life-long regrets just like Ms. Chen Shu-Chu's relatives, who were unable to go to the doctor owing to fnancial diffculties.

### 5 Pursuing Health Equity

### **Table 5.6** (continued)

At the same time, it also allows better-off people to contribute more to maintain the sustainability of the National Health Insurance and benefts everyone continuously.

### **Technology integration safeguards**

### **our health**

The NHIA has built the National Health Insurance MediCloud System to provide physicians with patients' medical information and access to more sophisticated medical examination images. This is also a major prerequisite and guarantee for the implementation of the "tiered medical care system"—if the patient needs to be referred, the medical history information can be exchanged smoothly. Everyone can also obtain his or her medical and medication records within the past 3 years by checking their "My Health Bank" online, and fully understand their personal health status. It is a good aid to self management of health!

### Tips

In the "tiered medical care system," treatment of minor illnesses such as colds and minor injuries are taken care of in clinics; large hospitals focus on treating severe illnesses and contributing to medical research.

### **Table 5.6** (continued)

#### **All people are satisfed, feeling happy inside out**

Taiwan's National Health Insurance system is based on the concept of goodness: "care for each other and help each other." It aggregates the power of everyone to realize the goal of providing equal rights to medical care. In recent years, more than 80% of people surveyed are satisfed with the service of the National Health Insurance. The comprehensive and continuous medical care provided by the National Health Insurance contributes to healthy bodies, and further brings physical and mental wellness.

#### **Taiwan is widely recognized by the world for its National Health Insurance**

In 2008, the US Public Broadcasting Service produced a special report that compared the health insurance systems of fve countries, including the United Kingdom, Taiwan, Germany, Switzerland, and Japan. The report praised Taiwan's healthcare services, smart NHI cards, and low medical costs, which are less than half of those in the United States. These strengths have all become the focus of discussion.

### **Table 5.6** (continued)

for the National Health Insurance, what will your elements be? In what way will it be presented? Please draw the pattern and explain it.

Insurance system has also become the model for countries around the world because of its high satisfaction rate. Various reports from international media and journals brought Taiwan more attention and affrmation from people around the world.

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# **Chapter 6 Infrastructure of the Medical Information System**

**Hsueh-Yung (Mary) Tai and Shwu-Huey Wu**

### **Introduction**

Since the launch of the National Health Insurance (NHI) in 1995, people in Taiwan can receive healthcare properly and conveniently without barriers, and their medical rights are also protected. People only need to afford the registration fee and a small amount of co-payment to seek medical care. In 2019, the total number of outpatient visits was 367.61 million, which was equivalent to 1 million visits per day, and the average number of outpatient visits per person per year is much higher than that of Organization for Economic Cooperation and Development member countries.

To process medical claims submitted by NHI-contracted medical institutions, the NHIA established medical information systems. Coupled with the NHI IC card launched in 2004, the National Health Insurance entered a new era of comprehensive informatization. The application of the NHI virtual private network (VPN) and centralized information system enables contracted medical institutions to fully digitalize claims. Platforms such as the National Health Insurance MediCloud System (NHI MediCloud System) were constructed to encourage medical providers to share medical examination reports, test reports, and images promptly.

H.-Y. (Mary) Tai (\*) · S.-H. Wu

National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan e-mail<EMAIL_ADDRESS><EMAIL_ADDRESS>
### **Cornerstone of the National Health Insurance Database— Introduction to the NHI Medical Information System**

The NHIA medical information system is constructed mainly for internal and external medical business services. The NHI Intranet, which enables offcers of the NHIA to execute various healthcare affairs of the NHI, applies a multi-tier architecture and the actual information data center are located in Taipei and Taichung to back each other up. Externally, the medical information system provides the NHI applications system (including VPN and Internet) for medical institutions, pharmaceutical companies, special medical device suppliers, and the general public to carry out relevant healthcare services. The overall operating environment runs on a well-protected network of the NHI and the relevant system architecture diagram is shown Fig. 6.1.

### *Highly Automated Process of Medical Claims*

The medical information system mainly processes the claim submission, acceptance, and data verifcation of the medical claims. Administrative review is a series of automated reviews conducted by computers, followed by sampling and professional peer review, and then an accounting and approval procedure. Except for professional peer review, the main medical claim process has been highly automated to improve the effciency of the operation and the consistency of claim data verifcation, so that the medical reimbursement can be fnalized within 60 days after acceptance.

**Fig. 6.1** Medical information system architecture diagram

In addition to the basic medical claim data, the system also collects relevant data that formulate through medical pilot projects by the NHIA and daily uploading NHI IC card medical information from contracted medical institutions to conduct various service-related inspections. The NHIA also undertakes commissioned business from other government agencies. For example, the Health Promotion Administration (HPA) entrusts the NHIA with paying medical expenses for various preventive health care, and the Bureau of Labor Insurance entrusts the payment of medical expenses for occupational injuries. Owing to the condition of the entrusted businesses, the system, structures, and requirements of information for data editing, accounting, and payment approval procedures are different.

The medical information system mainly functions as an operational environment for internal medical claims and reviews and it also provides an external web service platform for contracted medical institutions, pharmaceutical companies, and special medical device suppliers to submit and obtain the results of claims data. The medically related data are uploaded into the NHI Data Warehouse information system regularly for subsequent statistical analysis and decision-making assistance applications. The main process of the medical system is shown in Fig. 6.2.

In response to the increasing number of claims that required professional peer review, and to provide a timely and remote cross-regional review function, the NHIA has constructed and upgraded related equipment to establish a centralized medical images system, the Picture Archiving and Communication System, hoping to lay a solid foundation for precise reviews.

**Fig. 6.2** The main process of the medical information system

### *Establishing National Health Insurance MediCloud System to Implement a Tiered Medical Care System*

In recent years, the NHIA has been actively constructing the NHI MediCloud System to encourage medical institutions to upload medical examination reports and images promptly and expand the scope of digital review. At the same time, the NHIA also incentivizes medical institutions to establish a two-way referral mechanism under the tiered medical care system through various programs. Meanwhile, the NHIA strengthens the integration function of the "Intelligent Peer Review System." This effort included the establishment of automatic links to health insurance payment regulations, review guidelines, patient's electronic medical records, reviews of focal point information, reminder mechanisms and individualized settings in helping medical reviewers to perform their work accurately and effciently. The NHIA further integrates the artifcial intelligence (AI) analysis module of the Data Warehouse system and give feedback to doctors as a reference, so as to improve the accuracy of professional review and the effciency of the peer review process.

The NHIA has carried out a number of medical policy reforms according to important national healthcare guidelines, and the implementation of these policies requires a powerful information system as its foundation. With rapid changes and developments in different stages of the medical policy, the NHIA needs to modify relevant medical information systems to keep up with the changes accordingly to accommodate rapid developments of information technology and guarantee operation effciency and information security simultaneously. To enhance medical services of the NHI, the Information Management Division of the NHIA endeavors to maintain smooth operation of the medical information system, to provide highquality information services, and to accomplish missions assigned.

### **The National Health Insurance MediCloud System**

Many people are used to seeking medical care in different hospitals or visiting different doctors owing to different illnesses, so their personal medical records and medication history are scattered in different medical institutions. When doctors can hardly view patients' previous medical records from other medical institutions promptly, then duplicated medications can be provided and examinations or tests can be conducted easily. Drug–drug interactions caused by duplicated medication may affect medication safety for patients, and also may result in the waste of medical resources.

### *Building Patient-Centered "NHI PharmaCloud System"*

The NHIA built a patient-centered "NHI PharmaCloud System" by using computing technology in July 2013. This system provided assembled patients' recent medication records by consolidating medical claims data from medical institutions and data uploaded via the NHI IC card. To avoid duplicated medications and enhance drug safety for patients, this system allows doctors and pharmacists to view patients' medication records.

### *Upgrading of the "NHI MediCloud System"*

The NHIA upgraded the "NHI PharmaCloud System" into the "NHI MediCloud System" in 2015. When doctors are providing clinical treatments and/or prescriptions or pharmacists are dispensing medicines and/or providing medical consultations, they can access the NHI MediCloud System to query 12 categories of patient medical records, such as western and traditional Chinese medication records, examination records and results, surgery records, dental care records, drug allergy records, specifc medication records of controlled drugs and coagulation factors, rehabilitation records, discharge summary and vaccination records from the Centers of Disease Control (CDC) (Fig. 6.3).

In 2018, medical images such as computed tomography (CT), magnetic resonance imaging (MRI), X-ray, ultrasound, gastroscopy, and colonoscopy can be uploaded and shared in the NHI MediCloud System (Fig. 6.4), thus allowing doctors to obtain patients' medical information in real time in different medical institutions.

In May 2018, the NHIA expanded the one-way provision of patients' medical information to a two-way information exchange model, so that medical professionals can report "drug therapeutic inequivalence," "questionable quality of uploaded medical images," and "drug allergy" to the NHI MediCloud System to improve the effciency of information sharing and the quality of medical services.

### *Design of Active Reminders in the NHI MediCloud System*

To increase effciency and effort in browsing plenty of information and enhancing safety, "active reminder for duplicated orders" and "active reminder for drug interactions and/or allergies" have been provided since September 2018. By instant comparison with the NHI database, these functions remind doctors if there are duplicated orders, drug–drug interactions upon patients' remaining medicine, or drug allergies when medicine or treatment codes are entered into the Hospital Information System (HIS) from prescriptions.

**Fig. 6.3** Functions of the NHI MediCloud System

**Fig. 6.4** Development of medical images uploading and sharing

### *Personal Privacy Protection and Information Security Management*

Because medical information is highly private and sensitive, since the initiation of the NHI PharmaCloud System, the NHIA has gathered professionals from relevant felds such as information, medical quality management, and law to jointly discuss system settings, regulations on the use of medical institutions, etc.

1. Establishing the Authentication Mechanism and Management for Data Acquisition

The system is built in a closed VPN, in which only when three necessary cards, i.e., the medical institution secure access module card, physician card (or pharmacist card), and the patients' NHI IC card, are verifed during the visit can healthcare providers obtain patients' medical history. All query history is documented for the NHIA's subsequent management purposes. When doctors or hospitals have to download patients' data to integrate it into HIS, they must obtain the patient's written consent before doing so. In addition, the NHIA has established relevant information security management measures to conduct information security inspections on medical institutions that download in batches from time to time.

2. Password Protection

To further protect personal privacy, doctors and pharmacists will be restricted from querying patients' medical records if those insured set passwords for their NHI IC cards. Setting a password does not affect patients' rights and interests in receiving health care, and medical professionals should provide health care according to the needs of their patients.

### *Cloud-Based Healthcare Technology Is a Future Trend*

Uploading medical information to the NHI MediCloud System enables medical information to be accessed and shared across medical institutions and assists clinical medical professionals in diagnosis and planning patients' follow-up healthcare. Therefore, the concept of "good hospitals in the community; nice doctors in the neighborhood" in the hierarchically integrated medical system policy can be frmed up, and patients' medical care quality and convenience can be improved. Furthermore, the problem of overcrowding in hospitals and overwork of medical professionals can be reduced.

### **Continuously Upgrading the NHI MediCloud System**

The NHI strongly supports and guarantees the social stability and health security of Taiwan. Its wide coverage, easy access, and high quality of care are well-known worldwide. Because of people's expectations of the NHI, the NHIA has innovated and made breakthroughs continuously since its establishment in 1995. The NHI IC card was launched in 2004; in the meantime, the NHI entered a new era of comprehensive informatization. The application of the NHI VPN and centralized information system has enabled contracted medical institutions to fully digitalize claims. With a 93% contracting rate of medical institutions, the National Health Insurance database contains health information of almost all residents in Taiwan, making it a unique national treasure house.

It is convenient for Taiwanese people to seek medical treatment in different hospitals with their NHI IC cards. To allow doctors to review the medications, examinations, and tests uploaded by different medical institutions, the NHIA has established a patient-centered "NHI MediCloud System" for medical institutions to query patients' recent medical records and/or medical images. In addition to linking to websites directly, methods such as batch download and the Application Programming Interface (API) connection have also been launched in response to information development, so that medical institutions can use the in-house information system for data innovation and value-added applications. The achievements were shared in the "Benchmarking Sharing Session on the NHI MediCloud System" on the annual demonstration of this successful public–private partnership. The infrastructure works in line with national policies (so was quickly employed in COVID-19 epidemic prevention in 2020) and establishes a solid foundation on the development of AI.

### *Applying the Technology to Provide Reminders Proactively*

The NHI MediCloud System collects 12 categories of medical information, which is quite diverse and rich. However, medical professionals usually have to make decisions in a split second. By combining information system that provides medical professionals with "information" for clinical practice reference speedily via the HIS, which the medical staff are familiar with, the NHI MediCloud System maximizes the benefts and demonstrates the true value of cloud systems.

Previously, owing to the lack of information circulation, seeking health care in different hospitals often led to duplicated prescriptions or drug interactions, which adversely impacted people's health and caused a waste of resources of the NHI. In addition to providing suffcient information, the NHI MediCloud System shoulders the responsibility of reminding physicians in a more active way to ensure patient safety. Therefore, the NHIA promoted an "Active reminder for duplicated orders" in September 2018 and launched an "Active reminder for drug–drug interactions and/

or allergies" and an "Active reminder of traditional Chinese and Western medicine interaction" in 2019 and 2020 respectively. Innovative technologies were applied to calculate and analyze data actively, and then remind physicians immediately.

The so-called active reminder refers to the quick and instant data exchange between the NHI MediCloud System and the HIS of the medical institutions through the API connection. Before a physician issues a prescription, the information of the prescription is sent to the NHIA through the API, compared with the NHIA big data in real time, and then the physician immediately receives feedback on whether there is a duplication for the current prescription, any interactions with the remaining medicine, or any medicine that patient is allergic to (Fig. 6.5). The connection between the NHI MediCloud System, and the hospital HIS that physicians are accustomed to can be completed within 1–3 s in the same window, which saves physicians time and effort spent on browsing a large quantity of information, as well as enhancing patient safety and medical effciency.

In addition, medical costs related to kidney disease have remained high in recent years. Kidney function impairment causes patients to enter a course of dialysis, which severely impacts on patients' quality of life. To avoid nonsteroidal antiinfammatory drugs (NSAIDs), contrast media, and other nephrotoxic drugs from causing further kidney damage to patients with renal dysfunction, the NHIA added "Renal Dysfunction Reminders" in the summary area of the NHI MediCloud System in 2019, and an "Active reminder for NSAID drug usage" in 2020 to remind physicians to review and pay attention to drug prescriptions for specifc risk groups.

**Fig. 6.5** The active reminder function of the NHI MediCloud system

### *Image Upload, Retrieval, and Sharing*

The NHIA started the promotion of medical image-sharing mechanism in 2018 to prevent radiation exposure caused by unnecessary examinations and reduce the waste of medical resources. This mechanism breaks through the limitations of the image retrieval system, formats, and storage space. The NHIA encourages medical institutions to upload imaging data of the patient to the NHI database, so that the doctors from other hospitals can access the images in the NHI MediCloud System through medical image sharing. It reduces patients' cost of transportation, time, and money when applying for video disks from the hospital to seek a second opinion or follow-up care from other hospitals. It also reduces the radiation exposure hazards that the patient may be exposed to when repeatedly undergoing imaging examinations. It is estimated that by sharing CT images and MRI, approximately New Taiwan dollars (NTD) 5.98 million in image reproduction fees and travel time costs were saved every month for the society as a whole.

Medical imaging is an important tool for assisting physicians in diagnosis and disease treatment. In recent years, high-tech imaging examinations such as CT and MRI have been widely used, and their related expenses have always ranked in the top few in the proportions of medical expenses of the NHI. However, repeated medical imaging has the same problem as repeated medications. Physicians may order the examinations owing to professional considerations such as the necessity to check different parts, changes in condition, but it is likely that some examinations are truly unnecessary. It is hoped that through information sharing and decisions made jointly by physicians and patients, in addition to medical necessity, patients must understand the risks of repeated examinations, and cherish medical resources by avoiding unnecessary imaging examinations to achieve the goal of multiparty win-win.

### *Importing ISO Certifcation to Protect Personal Information*

Medical records are classifed as sensitive data with a high degree of privacy in the Personal Data Protection Act. Considering that medical information is helpful for the safety and quality of care when people receive medical care in different hospitals and promotes holistic care, the NHIA not only provides real-time data queries online but also allows the contracted medical institutions to batch download the medical records of the registered patients. The medication, examination, and test are batch downloaded to the HIS system for data integration and value-added applications, such as automatic drug-dosage decisions, and preoperative bleeding risk checks. However, the contracted medical institutions must comply with the Personal Data Protection Act and related regulations and obtain patients' written consent. Before the NHIA provides the active reminder function, some medical institutions have already downloaded patient medical information in batches to build a pop-up

reminder in the HIS system to alert doctors. It is especially effective in medication integration, reduction of repeated medications, examinations, and tests of outpatients in hospitals, as well as the prevention of drug interactions.

To ensure that the medical information of the public is fully protected and preserved, the NHIA has set up the "Principles of Batch Download Operation of the NHI MediCloud System for the Contracted Medical Institution" to standardize the implementation of batch download. The institutions should delete the relevant information immediately after completing the consultation (if preservation is necessary, the medical record preservation regulations must be followed). In addition, selfassessment must be conducted every year according to the checklist established by the operation principles. The NHIA will conduct on-site inspections to ensure that the institutes implement the personal data and information security protection.

The Cyber Security Management Act was announced in 2018 and the Regulations on the Classifcation of Cyber Security Responsibility Levels was amended in 2019 to effectively formulate the cyber security management policies and construct a secure cyber communication environment through the hierarchical management. Taking the agencies with level A cyber security responsibility (such as medical centers) as an example, their core cyber security system should integrate the Chinese National Standards (CNS) 27001/International Organization for Standardization (ISO) 27001 and other Information Security Management System (ISMS) and should be verifed by a fair third party. In line with the previous acts and regulations, the NHIA encourages institutions that implement batch downloads to include the NHI MediCloud System batch download operation into the scope of hospital CNS 27001/ISO 27001 certifcation to standardize management procedures, simplify the trial of batch download, and further ensure the information security protection when utilizing the NHI MediCloud System.

### *Integrating Information Across Organizations to Safeguard the Health of All Residents*

To provide doctors with reference for holistic care, the NHIA not only improves the NHI data integration, but also focuses on cross-organizational information integration. For example, the link to the homepage of the medical institution Electronic Medical Record Exchange Center was added to the examination and test results tab of the NHI MediCloud System in 2017; the NHIA cooperated with the Food and Drug Administration, Ministry of Health and Welfare (MOHW) to promote the report function of the "Drug Therapeutic Inequivalence Reporting System" and establish a drug quality protection mechanism in 2018; the "CDC Vaccinations" tab was added on the NHI MediCloud System at the end of 2018 to provide linkage to the "National Immunization Information System (NIIS)" of the Centers for Disease Control, MOHW; the NHI MediCloud System connects the data of the Taiwan Organ Registry and Sharing Center to provide the function of "comprehensive reporting for overseas organ transplantation" in 2019. The NHIA cooperated with the HPA to import records of adult preventive health care and offer screening results for four major cancers, as well as hepatitis B and hepatitis C, in 2021 to further provide patient-centered diagnosis and treatment.

At the beginning of 2020, the COVID-19 epidemic gradually spread in various countries around the world. The NHIA cooperated with the Central Epidemic Command Center (CECC) to take advantage of the wide use of NHI VPN and the NHI MediCloud System in various medical institutions and quickly integrate the reminder function for travel history of Wuhan and the contact history with confrmed cases provided by the CDC in the NHI MediCloud System. As soon as the patient's NHI IC card is inserted, the system will immediately display a pop-up window to remind the medical institution to pay attention to the patient's condition. Based on the overall epidemic prevention measures, the reminders have been expanded to travel history in various countries, specifc high-risk occupations and cluster, referral for further COVID-19 examinations, and whether patients were prescribed with infuenza antiviral drugs within 10 days. Through integrating information from the MOHW, National Immigration Agency of the Ministry of the Interior (MOI), the Civil Aeronautics Administration of the Ministry of Transportation and Communications, and the Veterans Affairs Council (Fig. 6.6), the NHI MediCloud System provides medical institutions at all levels (including contracted and noncontracted medical institutions), long-term care institutions, and administrative

**Fig. 6.6** The integrated interministerial information safeguards the national epidemic prevention. SFTP = secure fle transfer protocol

agencies (the National Fire Agency of the MOI, the Agency of Corrections of the Ministry of Justice, and the local public prosecutor offce) with multiple queries such as online queries (with/without the NHI card), batch download, or API connect, to access epidemic prevention information such as travel history, occupation, contact history, and cluster (TOCC) of incoming and outgoing personnel (Fig. 6.7). The abovementioned information was used to reduce the risk of nosocomial infection and the infection spreading in clusters and communities, reduce internal pressure and infection risks of medical staff and executives, effectively control the spread of diseases, and comprehensively prevent cluster infections. According to statistics, the total number of TOCC inquiries reached nearly 1.18 billion persontimes from February 2020 to September 2021.

The fexible data connection, real-time query, and convenience of the NHI MediCloud System enables it to exert its powerful additional value at this time, so that medical staff can feel more at ease and avoid exposing themselves to danger. Although it is unexpected, the NHI MediCloud System plays an important role in epidemic prevention.

**Fig. 6.7** The epidemic prevention information reminder window such as travel history, occupation, contact history, and cluster of the Continuous National Health Insurance MediCloud System upgrade enables smart medical care

### *Continuous NHI MediCloud System Upgrade Enables Smart Medical Care*