Friday, April 8, 2011

Improving Taiwanese Health Care: Some Suggestions

As most Taiwanese and expats in Taiwan are aware, our fair country boasts one of the best healthcare and health insurance systems in the world. We have care that is comparable to that in a Western country - I've never felt as though the care I received in Taiwan was substandard or not as good as what I'd get back home. We also have a government-sponsored insurance program that, while expensive for the government, is not nearly as expensive as for the Canadian and British governments, who control care as well as payment - or for the USA, where we bear the cost of a broken insurance system and astronomically priced care later on, in the wasted money of inefficient and unproductive workers who can't perform better because they can't afford treatment for what ails them. It may cost Taiwan a lot of money to run its program, but it's still a step ahead of the USA where even greater costs are invisible (or at least we'd like to pretend they are).

It was wise for Taiwan to have a public insurance plan but allow for private care clinics that do accept insurance, alternative plans and non-insured clinics to exist. It takes the burden of paying to build the infrastructure off the government and allows basic supply and demand to determine the availability of care. As such it's less expensive and there are more care options without long waiting periods.

I'd like to see the USA adopt a system similar to Taiwan's, which does mean that everyone would be obligated to have insurance, just as everyone pays taxes to fund education and then has access to that educational system. Generally, we have a great system in Taiwan that deserves accolades, study and emulation globally.

There is definitely room for improvement, though. There are a few aspects of the system that I would like to see Here are my thoughts:

- Women's health: cover more reproductive health options and preventive osteoporosis testing.

In terms of women's health in Taiwan, there is a striking dichotomy. On one hand, pelvic exams for women over 30 are covered at a rate of one per year. OB/GYN services are covered, birth in a hospital costs a bit more but does receive coverage, prenatal care (I believe) is covered, mammograms and other women's health issues are covered and there is excellent coverage for treatment of illnesses that affect women.

On the other, birth control is not covered. This is ridiculous, seeing as it's a $450-$600/month proposition, or more - that's more than you'd pay for a weeklong hospital stay if you have a shared room! Granted it's still only US$20 a month, but it should still be covered. I've heard two reasons as to why it's not: the first is that contraception is "elective" (excuse me?!) - you don't "need" birth control, apparently (yeah, you don't "need" it according to people who are deeply out of touch with modern society). The second is more sadly pragmatic: the government wants to increase the birth rate - something I personally don't think they should be encouraging, in fact, I think it's short-sighted and idiotic - so they are happy to push women to become mothers in any way they can.

This second reason is downright sexist: if a woman is sexually active, as most adult women are, she has to bear the full price of contraception. For me, NT$600 is not a lot of money but for a college student who doesn't feel she can talk to her parents about the issue? A new graduate in her first job earning NT $25,000/month? A working-class woman, whether foreign (such as a domestic care worker) or Taiwanese who may earn far less? A foreign bride who can't or doesn't want to communicate with her husband on the issue? NT$600 is a bigger burden for them, and yet the government doesn't seem to care. Considering the general attitude towards condoms in Taiwan, that's hardly a solution.

It also pushes women who can't afford the pills to risk pregnancy when they are not necessarily in a position to become mothers.

Abortions are only covered in certain circumstances (in the case of rape, incest, a health threat or "seduction" - whatever that means - I believe it does receive coverage, but if you claim "psychological duress" it's not, as far as my research showed). They should receive coverage regardless.

Osteoporosis preventive testing is only covered after a fracture, and you are only covered at a rate of 2 or 3 for life. It's not an expensive exam, and should be covered for women over a certain age.

Also, cover iron supplements (NT$800 per bottle, generally) for menstruating women and calcium supplements for women at risk of osteoporosis. This is an important component of good female health. Many women suffer from anemia during certain points of their cycle and this is a simple way to boost overall health and as a result, productivity (a woman who is not anemic is going to be more attentive, alert and efficient at work than a woman who can't think straight and feels dizzy, as I used to before I realized that it was caused by cyclic anemia).

- Have a payment plan offering so that those who need an emergency procedure but don't have the money can pay it off gradually.

Right now, if you need a procedure you're expected to pay for it more or less immediately. If you can't pay, in theory you can't get the procedure. For those who need immediate care and have no money, there are charities that can help pay or defray the cost. Generally if you have family they will also step in to help if you don't have the money. This is insufficient, however, and not always available to foreigners. A system in which, if you require expensive treatment (or inexpensive treatment but you happen to be below the poverty line), you can get it and pay it off in regular monthly installments would be a great improvement in terms of health care availability for the poor, working class and struggling.

- Pay for the most effective procedure or medication, not the cheapest

Also not necessarily the newest, most expensive or most advanced: do more objective research into the most effective procedures and cover those, even if they are not the cheapest option. This will save money down the road, as people who receive more effective care generally need less care later. This includes procedures or medications with the least side effects or recovery time.

Here's a real life example: when I first came to Taiwan, I ended up with a severe herniated disc in my lower back - so severe that it required surgery. There are two surgical options: a multi-hour ordeal with a full opening of the back and two-month recovery period, and microsurgery, which takes an hour, has a one-week recovery and is easier on everyone from doctor to patient to employer. NHI only covers the first option, which seems downright medieval when better technology exists. The second option is out-of-pocket and costs NT$80,000. Still cheap by American standards (that's what it would cost in the USA with many insurance plans) but still a few thousand US dollars.

I had the microsurgery. Rather than keep someone out of work for over a month and have the doctor do an operation that takes up half a day when he or she could be seeing other patients, I truly do not understand why they don't just cover microsurgery. In terms of economic productivity, someone who can be back to work in a week and a doctor who can see more patients is better in the long run, even if microsurgery is more immediately expensive.

The same is true for medication: for septic shock, the most effective medication costs NT$300,000 a dose (I believe it works in one to three doses) - NHI doesn't cover it unless the patient has suffered two organ failures. If they covered it before the organ failure(s) though still as a second-string option, sure it'd cost a lot up-front but in the long run, you'd have two less organ failure treatments to deal with - and those can get expensive.

Along these lines, cover procedures that greatly increase patient comfort, even if they cost more. Obviously some are more effective than others, but occasionally a slightly more expensive procedure can drastically improve patient comfort, especially for the elderly. A more comfortable citizen is a more productive citizen.

- Cover preventive care.

A popular new benefit offered by Taiwanese companies is an annual check-up. As a foreigner, I have to get a check-up on my own dime every year to renew my work permit. I don't mind this, as physical exams are good to have regardless, and by American standards it's not that expensive (NT$800-$1600 depending on the hospital). Preventive care for Taiwanese should be covered - one inexpensive check-up per year could save thousands, if not millions, of NT dollars per patient down the road. I'm happy that many people have this option through work, but many don't, and most don't want to pay out of pocket so they simply forgo preventive care. This really ought to be addressed.

- Cover better dental care.

Cleanings and fillings are covered, but root canals and crowns are not. Why? How is that "elective" in any way? If your tooth is abscessed or infected and you need a root canal and crown, how can you not get it? As someone with three crowns (I blame the water in China), I can say that you really can't eat or do much of anything without one, if you've undergone a root canal.

Why on earth is this not covered?

At least vision care receives pretty good coverage.

- Consider not covering certain elective Chinese medical practices.

I don't mean "stop covering Chinese medicine" because, while I do believe it's a good holistic method of preventive care and yet not good for acute treatment, it is a part of local culture and as such deserves respect and coverage for people more comfortable with that option. Chinese herbal medicine should definitely be covered (especially for preventive care). Things like suction, acupuncture etc. have not been proven to work, however, and don't deserve coverage while other important things, such as more effective procedures, women's reproductive health and preventive care are neglected.


Holly said...

I'm with you on the women's health issues. I was shocked when a health problem arose my first year here and I was asked to pay out-of-pocket for a routine pap smear because I was under 30.

Inefficiency is another huge issue. I think, on the whole, Taiwan is more efficient - no need for appointments, usually, and seeing a specialist is easy peasy. Sometimes, though, the insurance requirements just completely defy logic. When I went for a mammogram a couple of years ago, it was required that I come in for the results. I took the morning off work, had a friend come with me (my Chinese wasn't very good then), waited an hour, and was with the doctor for roughly 2 minutes for him to look at my chart and tell me nothing was wrong. This could have been done over the phone and saved a lot of time for everyone. When I went again a year later, and they asked me to schedule the appointment for results, I told them I wanted the results over the phone, and they said insurance requirements meant I had to come in, and my results would not be released if I didn't make the appointment!

Another thing that drove me crazy was required hospitalization the night *before* wisdom teeth surgery. I had general anesthesia and was getting all 4 teeth out, and was told it required a 2-night hospital stay: 1 night to make sure you don't eat anything before the surgery, and 1 night for recovery. When I asked if I could just promise not to eat anything and sleep in my own bed at home, they said if I didn't stay in the hospital (this was NTU Hospital), insurance would not cover the anesthesia.

And are you sure about the root canals? Unless there has been some change, they should be covered, though the crowns are not. I had to get a lot of dental work a few years ago, and the root canals (x3) only cost the basic fee for each appointment, which was $150 per visit for that doctor. The crowns came out to something like $10,000-15,000 each, out of pocket.

I'm still grateful to live under Taiwan's healthcare system, though. One of the reasons my teeth ever got so bad in the first place was that I simply couldn't afford to fix them. For what I paid here for 3 crowns, 3 root canals, and lots of filling replacements (swapping out old metal fillings from childhood), I might have afforded maybe one root canal/crown in the US. And with as many broken bones, food poisonings, and other trips to the hospital as I've made here, I'm sure I've saved thousands.

(By the way, nice reading your blog lately - really good topics!)

Catherine Shu said...

Another great post! I agree with Holly -- you have covered some great topics recently.
I totally agree about the patchy dental coverage and I've noticed the same thing with physical therapy, now that I am going regularly. My appt. with the doctor (3-5 minutes) and basic pain relief procedures (electrodes and ultrasound therapies) are all covered, but manual therapy is out of pocket for NT$500 per session. That's where a physical therapist spends about 20 minutes manipulating my muscles and tendons, massaging them and checking their movement. It's been the most beneficial in terms of improving my RSI and diagnosing exactly what is messed up. I would like to do it twice a week, but I can't really afford to. The thing is, I think that if NHI covered even a couple of manual therapy sessions per person once a year, I'm sure it would reduce the amount of times they have to go in to the PT clinic for pain relief (before I got manual therapy, I was in there daily… now I only go once or twice per week).

By the way, I got my wisdom teeth pulled last year and it was an outpatient procedure (I was in and out in 30 minutes). Then again, I only had to get two removed and both of them had erupted fully… maybe it's different for surgical extractions.

Jenna Lynn Cody said...

You're right, Holly - my mistake. The root canal is covered but the crown is not. I guess the crown was so surprisingly expensive (but still cheaper than the USA) that I thought it included a root canal fee.

I think that the illogical bits of the rules on what's covered come from a.) political maneuvering - a lot of times government regulations that make NO real-world sense exist because two parties reached a weird hodgepodge compromise that doesn't actually address the problem, because they can't agree on how to do that; and b.) political arguments and lobbying regarding what to cut to save costs: when lobbies and political interests are involved, things get cut that should be covered because they are politically "safe" and things that are covered but could get cut remain because they are more volatile.

I'd say that's one argument in favor of not having government insurance plans, but it's really not. It's a problem, for sure, but compared to the mess in the USA it's not the worst problem to have.

"But the system is losing money!" one friend said last night. True - but it's not losing nearly as much money as the broken pile of crap in the USA is costing the American economy, and I honestly don't think health insurance can ever be both profitable and affordable/useful. It does require that money go into it. Like education, it's not a natural profit generator and as such shouldn't be privatized. So yeah, the system is losing money but I don't think that's as huge a problem as some people say. (A lot of Americans will point to that and go "ah hah!" as though they've discovered some great flaw in the Taiwanese system - err, only if you ignore how much more the American system is bleeding).

陳慧芳 said...

Hi, I occasionally read your blog and enjoy your posts. You cover a lot of ground and are thoughtful.

In this post, you make a lot of great points, however it must be said that your Western perspective (bias) carries through rather strongly. This comes forth most clearly in your last point:

"Things like suction, acupuncture etc. have not been proven to work..."

I was just reading an article today in the WSJ about acupuncture that states it is beneficial (measured scientifically), but Western doctors can't pinpoint exactly why. Just because you can't scientifically explain something, doesn't mean it becomes null and void. Why are you rejecting Chinese medicinal treatments when they don't fit the neat scientific categories that Westerners have? Just because you don't understand it, doesn't mean it's not valid or any less real.

I agree that you - as a guest in this society - can voice your opinions (as I too believe in Western 'democracy'), but please don't denigrate this society when you don't understand it completely.

(Here is the article:

Jenna Lynn Cody said...

I'm glad you like the blog, and sorry that you interpreted my small bit about Chinese medicine at the bottom that way. If you read the entire paragraph you'll see that I do think it is useful for holistic treatment, that the herbal medicines, at least in a more preventative/holistic way, do have a medical use and that as a part of local culture, Chinese medicine should be given respect.

So I am not sure where you are getting the idea that I am denigrating it - I respect it greatly. I use a lot of Chinese herbal remedies myself (clove as an oral anasthetic, ginger to calm the stomach, the various oils and balms such as camphor, white flower, green oil and hinoki). I find they are great for reducing itching, pain, motion sickness, nausea, tiredness and even insomnia. I take the 'eight immortals' cough medicine (the brown chunky stuff) and drink the kumquat cough syrup when sick. I do believe this stuff works because it works for me and others I know.

I just feel that birth control, quality-of-life procedures such as better surgery options and better dental care are more important things to be spending money on. "Can't pinpoint why it has an effect" is simply not good enough when birth control, which is an important part of respect for women's health, is not covered.

In fact, the WSJ doesn't have the whole story on acupuncture: recent studies show that it does reduce pain as damaging the cells with hot needles releases a natural painkiller through the nerves not unlike popping some ibuprofen. It has not, however, been proven to work for anything else that is claimed of it.

I have actually tried acupuncture and the skin-scraping procedure and found them to not work. Acupuncture did nothing to lessen my back pain when what I really needed was surgery - surgery not covered under national health insurance!

So if I have a bias, it's from personal experience with Chinese medicine not working while procedures that did work were not covered, it's not because I'm a Westerner.