【Column Article】Yin Tien Hsia – “Lee Po-Chang’s Column | Three Consecutive Declines in Cancer Mortality, No Excess Deaths! Is Hierarchical Medical Care Showing Its Worth?”
During the COVID-19 pandemic, cancer patients were reluctant to return to hospitals for follow-up visits, leading the medical community to worry about delayed treatments. Surprisingly, outpatient and inpatient visits at medical centers decreased, and cancer mortality rates dropped for three consecutive years.
Written by Lee Po-Chang
Published on: 2024-11-08
In 2012, I was seconded from National Cheng Kung University Hospital to serve as the Director of the Ministry of Health and Welfare’s Tainan Hospital. In 2015, Tainan experienced the most severe dengue fever outbreak in its history. One day, the ER director informed me of a dengue patient who had to be protected with a mosquito net to prevent mosquitoes from biting him and infecting other ER patients.
Unexpectedly, that night, dozens of dengue patients flooded into the ER, with mosquito nets hanging everywhere. Fortunately, the Nursing Department Director, Hsieh Li-Wei, acted quickly, mobilizing nurses to ensure that the public felt secure.
I vividly recall Deputy Minister Lin Tzou-Yien of the Ministry of Health and Welfare calling me, requesting that I free up two wards. I thought, “No matter how slow Tainan Hospital’s ‘business’ might be, freeing up two wards isn’t easy.” Nonetheless, I decided to temporarily halt admitting outpatient referrals and posted a notice in the ER stating, “If your condition isn’t severe, please don’t come to Tainan Hospital.” Eventually, this was amended to “If it’s not dengue fever, don’t come.”
Leveraging Individual Strengths as the Best Management Strategy
Though dengue fever isn’t as contagious as SARS, being a public hospital meant taking on public health responsibilities. At the time, Tainan residents, out of fear, flooded the ER at Cheng Kung University Hospital, which couldn’t handle the volume, especially with many patients needing critical surgical or internal care. We established a “green channel” with Cheng Kung University Hospital, where stable patients were transferred to Tainan Hospital for observation, while high-risk elderly patients or those requiring advanced care were directed to Cheng Kung University Hospital. Together, we effectively managed the dengue crisis, with many citizens gaining new confidence in Tainan Hospital’s medical standards.
This experience solidified my understanding of the value and importance of hierarchical medical care. Both the medical center (Cheng Kung University Hospital) and the regional hospital (Tainan Hospital) supported each other, leveraging their respective strengths, which is the best strategy for hospital management.
I realized that while patients may not know if their illness is major or minor, they care deeply about having access to top-tier doctors and medical centers. Although all medical institutions’ physicians have received comprehensive training at medical centers, the facilities and services at different levels vary. Changing public attitudes about healthcare requires strong government advocacy and user-pay measures to ensure realistic and sustainable outcomes.
Changing public healthcare habits isn’t easy, but with correct direction and strategy, a positive mindset can bring about change.
The National Health Insurance Administration (NHIA) gathered feedback from public hearings, the Legislative Yuan’s Health and Environment Committee, and experts, forming six strategies for hierarchical medical care:
- Enhance primary care services.
- Encourage referral practices and adjust co-payment structures.
- Increase reimbursement standards for severe cases to guide hospitals to reduce minor treatments.
- Strengthen cooperation between hospitals and clinics for continuous care.
- Improve public health literacy for self-care.
- Strengthen the management of medical foundations.
To promote hierarchical medical care and encourage vertical integration among institutions, NHIA leaders and I visited hospitals across regions. By the end of March 2022, we had formed 81 strategic alliances, with 7,173 contracted institutions participating.
Cancer Mortality Decreased Despite the Pandemic
Interestingly, efforts to promote hierarchical medical care gradually materialized during the COVID-19 pandemic. In early 2024, a study by Taipei Medical University’s Dean of Public Health, Chen Yi-Hua, showed Taiwan’s average excess mortality rate from 2020 to 2023 was around 3.3%, about half that of OECD countries and significantly lower than the U.S., U.K., and Germany. There was no significant increase in excess deaths from stroke, heart disease, or cancer.
Additionally, during the pandemic, people naturally leaned towards hierarchical medical care, reducing visits to large hospitals. Before the pandemic, NHIA aimed to reduce outpatient volumes at major hospitals by 2% annually, but outpatient numbers declined organically during the pandemic.
Data from 2015 to 2021 showed a significant shift in hospital visits before and after the outbreak. Due to infection fears, outpatient and ER visits at major hospitals sharply declined in 2020 and 2021, with many chronic patients opting to fill prescriptions at pharmacies instead. Pharmacists played a crucial role in pandemic prevention.
A closer analysis revealed outpatient visits dropped 16%, inpatient visits 23%, and ER visits by 59% in 2021, with even steeper declines in 2022. Major hospitals experienced the largest reduction in medical capacity, while primary clinics were less affected, indicating many patients didn’t need to visit large medical centers for outpatient care.
Moreover, despite predictions that many cancer patients would experience delayed treatments, cancer mortality rates surprisingly continued to decline, contradicting public health and clinical expectations. Compared to the previous year, cancer deaths decreased by 2.7% in 2020, 1.6% in 2021, and 2.9% in 2022.
There’s often a gap between our expectations and real-world data. The most intriguing finding was that there was no “excess mortality” as predicted by public health experts. Analysis of the Ministry of the Interior’s death registration data revealed that actual deaths were lower than anticipated, contradicting expert forecasts.
Among the cancer types, liver cancer showed the most significant decline, likely due to the National Health Insurance’s full coverage of antiviral drugs for hepatitis C patients, effectively treating hepatitis and prolonging survival for liver cancer patients.
Another reason could be Taiwan’s successful “non-pharmaceutical interventions.” For instance, the “real-name mask rationing system” ensured everyone had access to masks, powered by the NHIA’s cloud data system. Initially designed to reduce unnecessary medical services and waste, this platform became invaluable during the COVID-19 pandemic.
We have long hoped that people would reduce unnecessary medical visits, thereby lowering the healthcare service point system. This would mean doctors no longer need to perform excessive procedures, allowing healthcare resources to be fairly allocated.
However, if a physician only seeks to maximize earnings, they might encourage patients to pursue additional self-funded treatments.
In summary, to implement hierarchical medical care, the burden can’t solely be on hospitals and doctors. This is why we must promote “user-pay co-payment.” Once the public understands this user-pay concept, optimizing doctor-patient decision-making will make hierarchical healthcare reform achievable.
(Editor: Lin Hsing-Fei)
(Lee Po-Chang is the former NHIA Director-General. This article is excerpted from Lee Po-Chang and Lee Shu-Jen’s book, “Facing Human Nature, Realistic Health Insurance Reform: What the People of Taiwan Should Know About National Health Insurance,” published by New Learning.)
