【期刊發表】Real-world trends and reform imperatives for Taiwan National Health Insurance

A review of Taiwan’s NHI system data reveals deep-rooted structural imbalances that jeopardize the long-term sustainability of our healthcare delivery. Outpatient services consistently absorb around 70 % of total healthcare expenditures, leaving only 30 % for inpatient care—despite the latter’s critical role in managing complex conditions such as surgeries, invasive diagnostics, and emergency interventions. This skewed allocation can be traced to the original system design, wherein the reimbursement for inpatient services was set too low. Over time, this has led to serious workforce issues, as younger physicians increasingly avoid specialties involving night duties or high-acuity inpatient care. The undervaluation of inpatient services has not only strained frontline providers but also contributed to the rise of so-called “sweatshop hospitals.” Ensuring fair and adequate reimbursement for inpatient care must be a central priority in any meaningful NHI reform. In practice, when policymakers lack firsthand experience in clinical settings and rely solely on public health or administrative viewpoints, critical nuances are often overlooked. This disconnect becomes even more pronounced when the system is expected to function like a universal healthcare coverage model, while being fundamentally financed as an insurance-based program. Unlike tax-funded universal healthcare coverage systems, Taiwan’s NHI relies heavily on premiums. However, premium adjustments are frequently postponed because of political reasons, which results in structural deficits. This fosters unrealistic public expectations—unlimited access to medical services within a limited financial framework.

Utilization patterns further illustrate the inefficiencies. Taiwan’s population averages around 15 medical visits per person per year, ranking among the highest globally. The elderly, who constitute a growing segment of the population, account for nearly 40 % of total health expenditures. Despite having advanced medical infrastructure, Taiwan continues to lag behind regional neighbors in life expectancy [5]. A closer look at service delivery reveals that primary care clinics are largely occupied with acute, minor ailments (about 156 million visits), whereas only a fraction (approximately 37 million visits) are devoted to chronic disease management. In hospitals, patient volume is more evenly split, with 55 million non-chronic and 53 million chronic care visits, indicating potential gaps in the ability of primary care to manage long-term conditions effectively.

In 2023, drug costs accounted for 32·58 % of the total healthcare budget, with outpatient prescriptions comprising nearly 87 % of that figure. The cultural norm of expecting a prescription with each visit contributes to the overuse of medication. Low copayment levels do little to curb unnecessary consumption, and patients lack meaningful incentives to moderate their healthcare-seeking behavior. The fee-for-service model inadvertently encourages high patient turnover rather than promoting continuity or quality of care. Like many systems globally, Taiwan faces the challenge of overutilization—particularly in diagnostic testing—fueled by defensive medicine and misaligned financial incentives [6].

Other countries have introduced corrective mechanisms. Singapore emphasizes personal responsibility and uses targeted subsidies to manage utilization, whereas Japan has implemented modest copayments for older adults to reduce unnecessary visits. These examples offer valuable lessons [7]. For Taiwan, introducing a fair “user-pays” copayment system could improve public understanding of healthcare costs and promote more responsible use of services.