Front Matter
- Title Page
- Foreword
- Preface
- Acknowledgments
- About the book
- Table of Contents
- List of Contributors
- List of Figures and Tables
Chapter 1: Introduction of Taiwans National Health Insurance
This chapter provides the overview of Taiwans National Health Insurance (NHI) System. In 1995, major social insurance programs, such as Labor Insurance, Government Employee Health Insurance and Farmers Insurance were merged and enlarged as the NHI to deliver universal health coverage. The payment system of the NHI is based on fee-for-service method since its inception. Besides, most of the health care is provided by private sectors, and there are no restrictions on patients seeking medical care. Though premium rate adjustment is stipulated in the National Health Insurance Act, it is not carried out as suggested because of political concern. As a consequence of the high medical accessibility, the volume of outpatient services is high and the NHIA has to develop various measures to maintain its financial balance. Assorted strategies were implemented by the NHIA for health equity, and the National Health Insurance MediCloud System, the NHI card, and My Health Bank were provided in order to ensure patient safety and enhance healthcare quality.
Chapter 2: Income of the National Health Insurance
The NHI is a compulsory national health insurance that provides universal coverage to all citizens of Taiwan and those who have had a registered domicile in the Taiwan area for six months. The insureds right to access medical care is protected whether they suffer from illness, injury or require reproductive care. The first chapter introduces the financial structure of National Health Insurance, enrollment eligibility and how the premium and premium rate was calculated for different insured groups and their insured units. The collection of supplementary premiums, which correlate additional premium contribution to non-salary-based income, is explained as well. In order to maintain the financial independence and the liability system of the NHI, the premium rate, by law, is reviewed actuarially annually.
Chapter 3: Payment System of the NHI
The payment system has a great impact on the overall growth of medical expenses, the distribution of medical resources, and medical efficiency and quality. For quickly integrating the existing civil service, labor, and farmers insurance system, the fee-for-service approach was adopted as the primary NHI payment system at the beginning of the establishment. The second section elaborates the concept and operation mechanism of Global budget payment system and various supplemental payment methods in the NHI, such as case payment, per diem payment, pay-for-performance, Taiwan Diagnosis Related Groups (Tw-DRGs). The dilemma of securing RVUs or RVU Value to foster specific health care services was discussed in this chapter. The NHIA continues to revise the Fee Schedule to reflect technological progress, real clinical needs and reasonable rewards for health professionals. Here we introduce the Fee Schedule revision process and integration of HTA in the decision making. To close the inevitable budget gap, self-management of the global budget for each NHI district and payment department was designed to further contain medical costs.
Chapter 4: Comprehensive Policies on the National Health Insurance
With the sharply escalating medical expenses, The National Health Insurance Administration has implemented a number of programs to contain expenditure, deliver patient-centered health care, and meet the medical needs of the super-aged society that Taiwan will face in the future.
Taiwan followed the steps of many advanced countries to separate medicine and pharmacy to promote medication safety. Here we describe various obstacles and contingent approaches NHIA took to implement a policy which is quite against the social norm. Analysis of the outcome was done to evaluate the effect of this controversial policy. To guarantee smooth connection between hospital discharge and long-term care, discharge planning and follow-up management fees are covered by the NHI. The National Health Insurance Administration has also endeavored to encourage two-way referrals in the tiered medical care structure since 2017, hoping to improve the efficiency of the overall healthcare system by redistribution of workload and continuity of health care. Therefore, in addition to reimbursement increase for hospitalization and emergency treatment, differences in copayment for referral visit from different level of hospital was applied to encourage better healthcare-seeking behavior. We also discuss the decision-making process of the ongoing copayment adjustment at the end of the chapter.
Chapter 5: Pursuing Health Equity on the National Health Insurance
This chapter explained why NHIA decoupled the premium payment and right to health care to safeguard the medical right of the financially disadvantaged. Furthermore, various programs were carried out to improve the accessibility and comprehensiveness of medical care for residents of remote and offshore islands. NHI also progressively covers orphan drugs to fulfill medical needs for patients with rare diseases.
In addition to eliminating geographic and economic health disparity, NHIA strives to improve health literacy and knowledge of the health insurance system of the public. My Health Bank was launched to enable its users to query personal medical and health information in real-time, hoping to encourage self-health management, enhance safety and quality of medical care. The NHI was introduced to the elementary school pupils, so as to acquaint the younger generation with its concept and generate more profound influence.
Chapter 6: Infrastructure of the National Health Insurance Healthcare Information System
This chapter explicates how Taiwan exerts its strong ICT industry to construct the NHI medical information system and the solid information security management and data protection mechanism behind it. The NHI Medical Information System was even constructed to enable digital claim for providers and automated claim review for NHIA. Then it introduced the revolutionary centralization of medical records to the NHI MediCloud System, which collects 12 categories of medical information. It allows medical providers to query patients' medical records and share medical images in real time, which significantly improves efficiency and prevent unnecessary examination or test. Additionally, it further protects patient safety by reminding physicians drug duplication or interaction actively. Also, application Programming Interface (API) connection have also been launched so that medical institutions can use the in-house information system for data innovation and value-added applications.
The latest part of the chapter is about how Taiwan integrated information across different government agencies to notify the providers if patients are at high risk of COVID-19 infection, prevent the spread of COVID-19 and safeguard the health of all citizens.
Chapter 7: Innovative Applications of the National Health Insurance Information System
The National Health Administration began a pilot telemedicine program for people in remote areas after the Ministry of Health and Welfare expanded the eligibility of telemedicine. The impact of COVID-19 on health care system also accelerated the inclusion of telemedicine in the coverage. This chapter then talks about how 5G facilitates telemedicine and services such as virtual NHI card could bring comprehensive medical service to more settings such as home care by virtualizing the identification process.
The NHI played a pivotal role in Taiwans battle against COVID-19. Besides providing TOCC to medical providers on electronic medical records systems, the NHI VPN system was used to distribute mask through the contracted pharmacies in the early stage of the epidemic, and the NHIA further pull in data including vaccination history, PCR test results from NHI database to the National Health Insurance Mobile Easy Access mobile application (NHI Express APP) so the public can manage their health promptly. The last part of the chapter talks about Taiwans successful story of opening data to the private sector to carry out the name-based mask distribution system.
The issue of secondary use of data collected by NHI is discussed in detail.
Chapter 8: Drug and Medical Devices Reimbursement
Chapter 7 talks about factors the NHIA considers when including drugs and medical devices to benefit packages and explains how their price and category are determined. Strategies such as annual drug price adjustment according to market price, Drug Expenditure Target (DET), prevention of prescription duplication etc. are applied to contain total drug expenditure while improving beneficiaries access to new drugs.
The last part of this chapter thoroughly explains the Managed Entry Agreement (MEA) NIH applies to pay for new drugs, especially cancer treatments that have not been proven effective clinically. By signing such agreements with pharmaceutical companies, NIH is able to accelerate patients access to the latest treatments while minimizing the financial impacts new drugs bring.
Chapter 9: Coverage of Advanced Treatments and Medical Devices
This chapter is primarily about the rationale and decision-making process of including advanced treatments (Immuno-Oncology IO Therapy, Hepatitis B and C Medications), test (Next Generation Sequencing) and medical devices in the benefit package of the National Health Insurance.
Because of the high prevalence of hepatic cirrhosis and advancement in treatment, Taiwan aims to expand the benefits scope for medication on Hepatitis B and eradicate Hepatitis C in 2025. This chapter documents the history of treatment eligibility expansion and achievement so far. As for NGS, though recognized as essential for personalized oncology treatment, it still requires regulation support to expand its coverage.
The chapter ends in detailed discussion on why and how NHIA expanded its coverage for medical devices as well as strategies used to improve cost transparency for out-of-pocket medical devices.
Chapter 10: Upload the comprehensive claim data timely for the review system of the NHI
The big data generated by the NHI medical information system is the most important asset which Taiwan processes in promoting national digital policies. Hence it is NHIs priority to maintain the quality of the dataset and its interoperability with health care facilities.
This chapter portrays the process of the medical expenses claim in detail as well as gives examples on how NHIA proactively assists providers to submit accurate claims.
Though most test results, images, etc. are uploaded to NHI medical information system timely, the NHIA plans to bundle the reimbursement to the provider with data upload to further its accuracy.
The author explains strategies applied to further strengthen the connection between the Hospital Information System of contracted institutions and the NHI MediCloud System to improve accuracy of data uploaded, such as medical identification code, instant upload, and the write off mechanism.
The long-time collaboration between the NHI, contracted institutions and information system vendors is the key to guarantee the quality of the dataset.
Chapter 11: Application of Big Data and AI
The last chapter introduced the application of NHI big data on creating digital claim review tools, training AI to improve review efficacy. By analyzing abundant data in the NHI medical information system, the NHIA is able to detect abnormal claims and efficiently reduce medical waste. AI models are further generated with the NHI Big Data to identify duplicate medical images and monitor the quality of images and test results uploaded.
The NHI also seeks external resources to explore diverse AI application possibilities. A collaboration with medical centers uses the NHI Big Data to create an AI-based COVID-19 detection platform. By automatically detecting high-risk patients with chest x-ray images and then sending alert information to doctors, nosocomial COVID-19 infection could be prevented.
Besides the convenient digital expense claim, NHI further provides contracted institutions with useful reminders, reference and graphic functions to assist the claim management.
Chapter 12: Digital Transformation of the NHI in the Digital Era
The virtual NHI card not only represents the digitization, but becomes a solution of contactless healthcare under the epidemic. During the process of full-scale digitization, the NHIA continues to refine the health service delivery measures, especially in the field of home-based medical care and telemedicine.
Under the personal data protection regulation, the NHI data is opened for academic research purposes. More than 6,550 journal articles using the NHI data have been published and made searchable online to support health policy management and clinical research. The NHI medical images combined with the AI application are the cornerstones of Taiwans smart healthcare. Domestic research teams are eligible to use the NHI database to verify or build their AI models after their research proposals are approved by the Management Council of AI Application with NHI Data. The NHIA also plans to develop digital patient decision aids with NHI big data by establishing a two-way digital interaction model to solve concerned issue of the healthcare providers and the public.
By comparing the secondary use of health data in different countries, Taiwan will seek a balance between innovation and conservative policies and create an environment that assures well-being of the next generation.
Back Matter
Appendix 1 (Historical Photos of NHI)
Appendix 1 (National Health Insurance Act)
Index
