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Tsuei SHT. Reflection on 30 years of Taiwanese national health insurance: Analysis of Taiwanese health system progress, challenges, and opportunities. J Formos Med Assoc 2024:S0929-6646(24)00350-4. [PMID: 39089963 DOI: 10.1016/j.jfma.2024.07.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/21/2024] [Accepted: 07/28/2024] [Indexed: 08/04/2024] Open
Abstract
On the eve of Taiwan's National Health Insurance's 30th birthday, this study reviews the policy and performance trajectory of the Taiwanese health system. Taiwan has controlled their health spending well and grown increasingly reliant on private financing. The floating-point global budget payment preferentially rewards outpatient-based services, but this has not affected the hospital-centric market composition, which persists despite several primary-care friendly developments. The outcomes suggest improving health care workforce and resource availability, good patient-centredness, respectable technical efficiency, and impressive patient care satisfaction. However, there are worrisome trends for financial barriers to access and allocative efficiency. Evidence on clinical quality suggests that hospitals are performing well though the primary care setting might not be. Overall, the public remains satisfied despite signs of lagging improvement in health outcomes, worsening maternal mortality rate, and persistently incomplete financial risk protection. Identifying what drives the worsening financial barriers of access and persistent financial risk is necessary for further discussions on potential financing adjustments. Improving allocative efficiency could draw on a combination of supporting the functions and quality of primary care alongside patient-oriented education and incentives. Further data on causes of slow health status improvement and rebounding maternal mortality rate is necessary.
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Affiliation(s)
- Sian Hsiang-Te Tsuei
- Faculty of Medicine, University of British Columbia, Canada; Faculty of Health Sciences, Simon Fraser University, Canada.
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Xie W, Liu J, Huang Y, Xi X. Capturing What Matters with Patients' Bypass Behavior? Evidence from a Cross-Sectional Study in China. Patient Prefer Adherence 2023; 17:591-604. [PMID: 36919186 PMCID: PMC10008354 DOI: 10.2147/ppa.s395928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/18/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND In China, bypassing is becoming increasingly prevalent. Such behavior, as going directly to upper-level health-care facilities without a primary care provider (PCP) referral when facing non-critical diseases, contrasts to "expanding the role of PCPs as the first-contact of care", may cause unneglectable damage to the healthcare system and people's physical health. OBJECTIVE To examine the relationship between patient experience in primary health-care clinics (PHCs) and their bypass behavior. METHODS A cross-sectional study was designed for data collection. From July 2021 to August 2021, we conducted a questionnaire survey nationally. Fifty-three investigators were dispatched to 212 pre-chosen PHCs, around which 1060 interviewees were selected to gather information, using a convenience sampling. The primary independent variable was scores measured by Chinese Primary Care Assessment Tool (PCAT-C) to quantify patients' experience at PHCs. The dependent variable was a binary variable measured by a self-developed instrument to identify whether participants actually practiced bypassing. Covariates were well-screened determinants of patients' bypass behavior including socio-demographic factors, policy factors, and health-care suppliers. Binary logistic regression analysis was employed to evaluate the association of patients' experience with their bypass behavior. FINDINGS A total of 928 qualified questionnaires were obtained. The first contact dimension (OR 0.961 [95% CI 0.934 to 0.988], P = 0.005) and continuity dimension (OR 1.034 [95% CI 1.000 to 1.068], P = 0.047) of patients' experience were significantly associated with patients' bypass behavior (P < 0.05). In addition, age (OR 1.072, [95% CI 1.015-1.132], P = 0.013) and gender (OR 2.044, [95% CI 1.139-3.670], P = 0.017) also made a statistically significant difference. CONCLUSION Enhancement in patient experience at PHCs may help reduce their bypass behavior. Specifically, efforts are needed to improve primary care accessibility and utilization. The positive correlation between bypassing rates and continuity scores may require more attention on strengthening PCPs' technical quality besides the quality of interpersonal interactions.
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Affiliation(s)
- Wenwen Xie
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Jiayuan Liu
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Yuankai Huang
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
| | - Xiaoyu Xi
- The Research Center of National Drug Policy & Ecosystem, China Pharmaceutical University, Nanjing, People’s Republic of China
- Correspondence: Xiaoyu Xi, Email
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Chang SS, Hu HY, Cheng FS, Chen YC, Yen YF, Huang N. Factors associated with nonadherence to surveillance for hepatocellular carcinoma among patients with hepatic C virus cirrhosis, 2000-2015. Medicine (Baltimore) 2022; 101:e31907. [PMID: 36451463 PMCID: PMC9704922 DOI: 10.1097/md.0000000000031907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Hepatocellular carcinoma (HCC) surveillance can detect the early stage of tumors and lead to improved survival. Adherence to guideline-concordant HCC surveillance is crucial in at-risk populations, including patients with hepatic C virus (HCV) cirrhosis. This study was conducted to identify patient and provider factors associated with nonadherence to HCC surveillance in patients with HCV cirrhosis. Data were primarily obtained from the Taiwan National Health Insurance Research Database for the 2000 to 2015 period. Adult patients newly diagnosed as having HCV cirrhosis between 2003 and 2012 were enrolled. Each patient was followed up for 3 years and until the end of 2015. Annual HCC surveillance was defined as the uptake of an abdominal ultrasound and alpha-fetoprotein (AFP) test annually during the 3-years follow-up. Nonannual surveillance was defined as the lack of an annual abdominal ultrasound and AFP test during the same 3-years period. Multinomial logistic regression models were applied to determine factors influencing adherence or nonadherence to annual HCC surveillance. We included a total of 4641 patients with HCV cirrhosis for analysis. Of these patients, only 14% adhered to annual HCC surveillance. HCC surveillance improved in later years, compared with the earlier phases of the study period. Patients with HCV cirrhosis comorbid with coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) or those with a relatively high number of comorbidities had a significantly higher likelihood of nonadherence. Patients who primarily received care from internists were significantly less likely to exhibit nonadherence to annual HCC surveillance compared with patients receiving care from physicians of other specialties. Patients who primarily received care from physicians practicing in larger hospitals were significantly less likely to exhibit nonadherence. HCC surveillance rates remain unacceptably low among high-risk patients, and our findings may be helpful in the development of effective interventions to increase HCC surveillance. The effective incorporation of HCC surveillance into routine visits for other chronic comorbidities, particularly for CAD or COPD, may be crucial for increasing HCC surveillance.
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Affiliation(s)
- Shen-Shong Chang
- Division of Gastroenterology
- Department of Internal Medicine; Taipei City Hospital Yang-Ming Branch
- Department of Medicine, School of Medicine
- Institute of Public Health and Department of Public Health
| | - Hsiao-Yun Hu
- Institute of Public Health and Department of Public Health
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
| | - Feng-Shiang Cheng
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
| | - Yu-Chin Chen
- Department of Education and Research; Taipei City Hospital
| | - Yung-Feng Yen
- Institute of Public Health and Department of Public Health
- Institute of Hospital and Health Care Administration; National Yang Ming Chiao Tung University
- Section of Infectious Diseases, Taipei City Hospital Yang-Ming Branch
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences
| | - Nicole Huang
- Department of Education and Research; Taipei City Hospital
- * Correspondence: Nicole Huang, Institute of Hospital and Health Care Administration, School of Medicine, National Yang Ming Chiao Tung University, Room 201, The Medical Building II, No. 155, Section 2, Li-Nong Street, Taipei 112, Taiwan (e-mail: )
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Chang SS, Hu HY, Chen YC, Yen YF, Huang N. Late hepatitis C virus diagnosis among patients with newly diagnosed hepatocellular carcinoma: a case–control study. BMC Gastroenterol 2022; 22:425. [PMID: 36115934 PMCID: PMC9482748 DOI: 10.1186/s12876-022-02504-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/13/2022] [Indexed: 12/09/2022] Open
Abstract
Abstract
Background
New direct-acting antiviral therapies have revolutionized hepatitis C virus (HCV) infection therapy. Nonetheless, once liver cirrhosis is established, the risk of hepatocellular carcinoma (HCC) still exists despite virus eradication. Late HCV diagnosis hinders timely access to HCV treatment. Thus, we determined trends and risk factors associated with late HCV among patients with a diagnosis of HCC in Taiwan.
Methods
We conducted a population-based unmatched case–control study. 2008–2018 Claims data were derived from the Taiwan National Health Insurance Research Database. Individuals with an initial occurrence of liver cancer between 2012 and 2018 were included. The late HCV group were referred as individuals who were diagnosed with HCC within 3 years after HCV diagnosis. The control group were referred as individuals who were diagnosed more than 3 years after the index date. We used multivariable logistic models to explore individual- and provider-level risk factors associated with a late HCV diagnosis.
Results
A decreasing trend was observed in the prevalence of late HCV-related HCC diagnosis between 2012 and 2018 in Taiwan. On an individual level, male, elderly patients, patients with diabetes mellitus (DM), and patients with alcohol-related disease had significantly higher risks of late HCV-related HCC diagnosis. On a provider level, patients who were mainly cared for by male physicians, internists and family medicine physicians had a significantly lower risk of late diagnosis.
Conclusions
Elderly and patients who have DM and alcohol related disease should receive early HCV screening. In addition to comorbidities, physician factors also matter. HCV screening strategies shall take these higher risk patients and physician factors into consideration to avoid missing opportunities for early intervention.
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Lu S, Li Y, Gao H, Zhang Y. Difference in bypass for inpatient care and its determinants between rural and urban residents in China. Int J Equity Health 2022; 21:132. [PMID: 36100917 PMCID: PMC9469557 DOI: 10.1186/s12939-022-01734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 08/25/2022] [Indexed: 11/05/2022] Open
Abstract
Abstract
Background
Bypass for inpatient care is an event of excessive demand. Though primary care facilities provide inpatient care in China, local residents may choose more distant higher-level hospital for inpatient care services. Given the differences in accessibility of hospitals and socioeconomic development between urban and rural areas, this study aims to estimate the rate of bypass for inpatient care and explore the factors predictive of bypass among rural and urban residents in China.
Methods
The rates of bypass for inpatient care were estimated using data from 1352 hospitalized patients, obtained from the 2018 Sixth National Health Service Survey of Hubei, China. Bypass for inpatient care was identified if the patient was hospitalized in a hospital for a certain disease that should be treated at primary care facilities in accordance with government requirement. Anderson’s Behavioral Model of Health Services Use was used as a theoretical framework for determining the factors of bypass. Logistic regression was used to identify the relationship between bypass for inpatient care and predisposing, enabling, and need characteristics for urban and rural residents.
Results
The rate of bypass for inpatient care was 73.8%. This rate for inpatient care (91.3%) in cities is higher than that in rural areas (56.2%). Age were associated with bypass for both rural (OR, 0.982; 95% CI, 0.969–0.995) and urban (OR, 0.947; 95% CI, 0.919–0.976) patients. The patients whose closest healthcare facility was hospitals were more likely to have bypass behavior in rural (OR, 26.091; 95% CI, 7.867–86.537) and urban (OR, 8.323; 95% CI, 2.936–23.591) areas than those living closest to township/community health centers. Signing a family doctor was not helpful for retaining patients at primary care facility. Among rural patients, those with circulatory (OR, 2.378; 95% CI, 1.328–4.258), digestive (OR, 2.317; 95% CI, 1.280–4.192), or skin and bone (OR, 1.758; 95% CI, 1.088–2.840) system diseases were more likely to show bypass behavior than those with respiratory diseases.
Conclusions
Bypass for inpatient care is sizable, and urban residents have a higher bypass rate for inpatient care than rural residents in China. More actionable measures in strengthening and leading patients to primary care are needed. Gradual establishment of a referral system is recommended. Inpatient care for circulatory, digestive, or skin and bone system diseases may be prioritized to be improved at primary care facilities in rural China.
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Lee JJ, Hu HY, Lin SY, Huang CM, Huang SJ, Huang N. Factors Associated with Having Home Care Physicians as an Integrated Source of Medications for Chronic Conditions Among Homebound Patients. Int J Qual Health Care 2022; 34:6617285. [PMID: 35748484 DOI: 10.1093/intqhc/mzac055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/30/2022] [Accepted: 06/24/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Inappropriate management of medications is a major threat to homebound patients with chronic conditions. Despite many efforts in improving medication reconciliation in ambulatory and inpatient settings, little research has focused on home care settings. In 2016, Taiwan initiated the Integrated Home Health Care programme, which was intended to reduce potentially inappropriate medication management and risks of uncontrolled polypharmacy through the integration of different medication sources for chronic conditions among homebound patients. This study investigated factors associated with having home care physicians as an integrated source of medications for chronic conditions among homebound patients. METHODS This retrospective cohort study enrolled 3,142 community-dwelling homebound patients from Taipei City Hospital. Homebound patients' adherence to using home care physicians as an integrated source of chronic condition medications was defined as having all prescriptions for their chronic conditions prescribed by a single home care physician for at least six months. Both patient and home care physician characteristics were analysed. Multivariable logistic regression was applied. RESULTS Of the 3,142 patients with chronic conditions, 1,002 (31.9%) had consistently obtained all medications for their chronic illnesses from their home care physicians for 6 months and 2,140 (68.1%) had not. The most common chronic diseases among homebound patients were hypertension, diabetes mellitus, dementia, cerebrovascular disease, and constipation. Oldest-old patients with poor functional status, fewer daily medications, no co-payment exemption, and no recent inpatient experience were more likely to adhere to this medication integration system. In addition, patients whose outpatient physicians were also their home care physicians were more likely to adhere to the system. CONCLUSION The finding suggests that building trust and enhancing communication among homebound patients, caregivers, and home care physicians are critical. Patient and provider variations highlight the need for further improvement and policy modification for medication reconciliation and management in home care settings. The improvement in medication management and care integration in home care settings may reduce misuse and polypharmacy and improve homebound patients' safety.
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Affiliation(s)
- Jason Jiunshiou Lee
- Department of Family Medicine, Taipei City Hospital, Yangming Branch, No. 105, Yusheng Street, Shilin District, Taipei 111, Taiwan.,Institute of Public Health, National Yang Ming Chiao Tung University, No. 155, Sec.2, Linong Street, Taipei 112, Taiwan.,Department of Health and Welfare, University of Taipei, No. 101, Section 2, Zhongcheng Rd, Shilin District, Taipei 111, Taiwan.,Department of Education and Research, Taipei City Hospital, No. 10, Section 4, Ren'ai Rd, Da'an District, Taipei 106, Taiwan
| | - Hsiao-Yun Hu
- Institute of Public Health, National Yang Ming Chiao Tung University, No. 155, Sec.2, Linong Street, Taipei 112, Taiwan.,Department of Health and Welfare, University of Taipei, No. 101, Section 2, Zhongcheng Rd, Shilin District, Taipei 111, Taiwan.,Department of Education and Research, Taipei City Hospital, No. 10, Section 4, Ren'ai Rd, Da'an District, Taipei 106, Taiwan
| | - Shu-Yi Lin
- Department of Education and Research, Taipei City Hospital, No. 10, Section 4, Ren'ai Rd, Da'an District, Taipei 106, Taiwan
| | - Chao-Ming Huang
- Data Office, Superintendent Office, Taipei City Hospital, No. 145, Zhengzhou Rd, Datong District, Taipei 103, Taiwan
| | - Sheng-Jean Huang
- Superintendent Office, Taipei City Hospital, No. 145, Zhengzhou Rd, Datong District, Taipei 103, Taiwan.,Department of Surgery, College of Medicine, National Taiwan University, No. 7, Zhongshan S Rd, Zhongzheng District, Taipei 100, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No.155, Sec.2, Linong Street, Taipei 112, Taiwan
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Detecting Undifferentiation of Tertiary and County Hospitals in China in Adoption of DRG Instrument. Healthcare (Basel) 2021; 9:healthcare9080922. [PMID: 34442059 PMCID: PMC8393376 DOI: 10.3390/healthcare9080922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Undifferentiated function for medical institutes in different levels had been a barrier to China’s healthcare reform. Thus, this study aimed to detect medical services that were capable offered both in tertiary and county hospitals in China and discuss the process of detection. (2) Method: Data of 2 tertiary hospitals that were city level and 12 county-level hospitals from one city in China were collected and grouped into diagnosis-related groups (DRGs). A strategy with four steps was devised by considering the aspects of service volume, in-hospital mortality rate, in-hospital adverse events rate, and inpatient cost. Additionally, a comparison of each indicator was made between city- versus county-level hospitals. (3) Results: There were no differences in service quality between the two levels of hospitals while county hospitals had lower average inpatient costs in 129 DRGs that covered 39.5% of all cases. About CNY 0.26 billion would be saved if certain cases were paid at county-level prices. (4) Conclusion: The study proposed a strategy with four steps that could help in locating the range of diseases in which patients’ admission suffered from the problem of undifferentiation between hospitals’ functions to reduce the irrational growth of healthcare expenditure.
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Li X, Zhang L, Li Z, Tang W. Patient Choice and Willingness Toward Gatekeepers as First-Contact Medical Institutions in Chinese Tiered Healthcare Delivery System: A Cross-Sectional Study. Front Public Health 2021; 9:665282. [PMID: 34249837 PMCID: PMC8261039 DOI: 10.3389/fpubh.2021.665282] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/24/2021] [Indexed: 12/31/2022] Open
Abstract
Introduction: Gatekeeping mechanism of primary care institutions (PCIs) is essential in promoting tiered healthcare delivery system in China. However, patients seeking for higher-level institutions instead of gatekeepers as their first contact has persisted in the past decade. This study aims to explain patients' choice and willingness and to provide potential solutions. Methods: A survey was conducted among residents who had received medical care within the previous 14 days. Patients' choice and willingness of PCIs for first contact together with influencing factors were analyzed using binary logistic regression. Results: Of 728 sampled patients in Hubei, 55.22% chose PCIs for first contact. Patients who are older, less educated, with lower family income, not living near non-PCIs, with better self-perceived health status, only buying medicines, and living in rural instead of urban area had significantly higher probability of choosing PCIs. As of willingness, over 90% of the patients inclined to have the same choice for their first contact under similar health conditions. Service capability was the primary reason limiting patients' choice of PCIs. Conclusions: The gatekeeper system did not achieve its goal which was 70% of PCIs among all kinds of institutions for first contact. Future measures should aim to improve gate-keepers' capability.
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Affiliation(s)
- Xia Li
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.,Research Center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, China
| | - Zhong Li
- School of Medicine and Health Management, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China.,Research Center for Rural Health Services, Hubei Province Key Research Institute of Humanities and Social Sciences, Wuhan, China
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China.,Center for Pharmacoeconomics and Outcomes Research of China Pharmaceutical University, Nanjing, China
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