【Opinion】Liberty Republic | Lee Po-Chang: National Health Insurance Reform Must Continue—The Purpose of the National Health Insurance Administration Is to Enable Better Healthcare, Not to Manage Physicians
Liberty Republic | Lee Po-Chang: National Health Insurance Reform Must Continue—The Purpose of the National Health Insurance Administration Is to Enable Better Healthcare, Not to Manage Physicians
August 2, 2026 | 5:30 AM
By Lee Po-Chang
Distinguished Professor, School of Public Health, Taipei Medical University
Ten years ago, when I assumed the position of Director-General of the National Health Insurance Administration (NHIA), I told all of my colleagues:
“I come from the medical profession. I understand the challenges faced by frontline healthcare workers, and I know that the NHIA serves the entire healthcare system. The role of the NHIA is not to stand in opposition to healthcare professionals, nor to focus every day on denying claims or policing physicians. Rather, it should create an institutional environment in which healthcare professionals can practice with confidence and devote themselves to caring for patients. When medical professionals are able to provide care with satisfaction and peace of mind, the public naturally receives the best possible healthcare. Only then can NHIA staff truly fulfill the ideal of public service.”
This is the true value of Taiwan’s National Health Insurance system.
Recently, a primary care physician who has long been dedicated to colorectal cancer screening came to discuss a reimbursement denial with me. Naturally, I first asked whether there had been any fraudulent claims. He made it clear that he fully supports lawful, fair, and reasonable claims review. His concern was that medical professionalism should not be replaced by statistical averages.
According to NHIA data, he was selected for retrospective review because the average number of pathology specimens submitted after colonoscopy at his clinic exceeded the regional average. His clinic submitted an average of 3.85 pathology specimens per colonoscopy, compared with a regional average of 1.7 specimens. The NHIA reviewed 66 randomly selected cases, reduced reimbursement for 60 of them, and then extrapolated the results to all claims submitted during the year. The clinic was required to voluntarily return approximately 1.57 million reimbursement points and was placed under ongoing monitoring.
This reminded me of 2016, shortly after I became Director-General of the NHIA. An orthopedic surgeon in Yilan, Dr. Wang, staged a hunger strike outside the NHIA to protest the reimbursement review system, attracting widespread public attention. I knew many in the medical community viewed the incident as a confrontation between physicians and the NHIA. I saw it differently—as a warning from frontline physicians about flaws in the system.
Rather than responding defensively, I invited Dr. Wang to work with us to examine the problems in the review mechanism. After numerous discussions, I realized that physicians’ dissatisfaction stemmed not merely from reimbursement reviews themselves, but from the system of extrapolated reimbursement reductions. Under this mechanism, reimbursement reductions identified in a small sample of cases could be projected onto an entire year’s claims. This imposed a heavy administrative burden on healthcare providers and seriously undermined physicians’ trust in the system.
With the support of then-Minister of Health and Welfare Lin Tsou-Yien, we introduced named reviewers, a two-stage review process, and reformed the extrapolated deduction mechanism so that reimbursement reductions would adhere to the principles of proportionality and procedural justice. That reform reinforced my belief that institutions are not immutable—they can and should be changed when problems are recognized.
Taiwan’s global budget system should manage reimbursement through transparent procedures and fair review mechanisms. If physicians perceive increases in reimbursement point values only because they fear reimbursement reductions or worry about exceeding statistical averages, they may gradually alter their medical judgment. Such increases are merely an illusion—they do not represent genuine improvements in healthcare efficiency or value.
I have always believed that the overwhelming majority of physicians are not the greatest risk to Taiwan’s National Health Insurance system. The real challenge lies in the design of the system itself. A well-designed system enables good physicians to make even better clinical decisions. A flawed system, however, may force even the most conscientious physicians to practice according to administrative indicators rather than patients’ needs.
Government oversight has rarely addressed the underlying drivers of healthcare utilization. Duplicate consultations, repeated diagnostic tests, repeated prescriptions, and imaging or laboratory examinations with little medical necessity remain widespread. Meanwhile, high-value services that require sophisticated professional judgment—such as emergency and critical care, organ transplantation, and integrated chronic disease management—continue to receive insufficient support. This is perhaps the greatest contradiction in the governance of Taiwan’s National Health Insurance.
International healthcare reform in recent years has increasingly emphasized high-value care, value-based healthcare, and the Choosing Wisely movement. Their common objective is to direct limited resources toward healthcare services that genuinely improve health outcomes. This should also become the guiding principle for the second thirty years of Taiwan’s National Health Insurance.
Another issue that has long been overlooked is the shared responsibility of society. National Health Insurance resources do not belong to the government, the NHIA, or hospitals. They are a public asset built from the insurance premiums contributed collectively by Taiwan’s 23 million people.
Therefore, while healthcare providers have a responsibility to use resources wisely, every citizen also has a duty to cherish healthcare resources. Establishing a reasonable cost-sharing system is not intended to prevent people from seeking medical care, but to cultivate an appropriate awareness of healthcare costs. Those who are genuinely disadvantaged should continue to receive comprehensive protection through the social welfare system. National Health Insurance is designed to provide universal access to essential healthcare—not unlimited medical consumption.
A few days ago, I received a letter from Dr. Huang Ta-Fu, the respected founder of Koo Foundation Sun Yat-Sen Cancer Center, whom I deeply admire. He wrote that, over the past three decades, his greatest concern has not simply been the payment system itself, but the distorted incentives created by the system, which have left physicians increasingly occupied with outpatient volume and reimbursement rules, while teaching, research, and healthcare quality have gradually been squeezed.
He concluded with a sentence that deeply moved me:
“I hope to see National Health Insurance reformed in the right direction during my lifetime.”
I believe this hope is shared not only by Dr. Huang, but also by countless frontline physicians, hospital administrators, and everyone who cares about the future of Taiwan’s healthcare system.
The physician who consulted me also proposed several concrete reforms to the review system, including:
- Making peer comparison and early warning mechanisms publicly available;
- Establishing a transparent and predictable review process;
- Returning reviews to case-by-case professional assessment;
- Ensuring that reimbursement is not withheld before appeals are completed; and
- Setting reasonable limits on the frequency of sampling audits.
These proposals deserve open public discussion as important directions for improving National Health Insurance governance.
National Health Insurance reform should continue along five key directions:
- Reform the governance philosophy: Managing reimbursement points is not the same as managing healthcare, and controlling statistical averages does not necessarily improve healthcare quality.
- Reform the review system: Make review standards and early warning mechanisms transparent, return decision-making to medical necessity and professional judgment, and ensure procedural justice.
- Reform the payment system: Prioritize limited resources for high-value healthcare that genuinely improves patient outcomes, rather than encouraging service volume and point accumulation.
- Reform the public’s healthcare utilization culture: Establish reasonable cost-sharing mechanisms, reduce unnecessary healthcare utilization, and encourage all citizens to value healthcare resources.
- Build a high-value healthcare governance model: Reduce low-value care while directing limited resources toward emergency and critical care, cancer treatment, organ transplantation, integrated chronic disease management, and other healthcare services that deliver substantial health benefits.
Everyone Should Receive Healthcare That Truly Creates Value
Taiwan has successfully ensured that everyone can access medical care. Our next goal should be to ensure that everyone receives healthcare that truly creates value.
Healthcare reform must not stop. National Health Insurance is not a completed system—it is an ongoing national governance project that must continue to evolve.
