【Column Article】 Silver Horizon, “Lee Po-Chang’s Column | Living Amidst Scenic Beauty but Traveling Far for Healthcare: Why Is Telemedicine Stalled?”

Under Pressure from Medical Associations, Taiwan Lifts Caps on Registration Fees

On March 4, 2024, in response to demands from the medical associations, Taiwan’s Ministry of Health and Welfare announced the discontinuation of the “Reference Range for Registration Fees Charged by Medical Institutions”. This effectively abolished the cap on registration fees that had been in place since July 1, 2010, allowing medical institutions to set registration fees without any upper limit.

Local health bureaus can now only require institutions to report their fee adjustments. Medical providers are no longer required to apply for prior approval before increasing registration fees. This move has garnered unanimous support from groups such as the Taiwan Hospital Association, Taiwan Private Medical Institution Association, and Taiwan Association of Healthcare Management.

Registration Fees with No Limit: A Boiling Frog Scenario?

Under the original Medical Care Act, medical expenses required approval from the municipal or county (city) authorities. However, registration fees were classified as administrative costs and were exempt from such approval.

To address the disparity in fee standards among medical institutions, the Department of Health issued a guideline in 2010 setting an upper limit of NT$150 for outpatient registration fees. Fees exceeding this limit required notification to local health bureaus.

Now, medical institutions have full autonomy over registration fees, sparking public discontent. The Ministry of Health and Welfare (MOHW) clarified that the previous unified fee cap had been in place for nearly 15 years, during which many institutions complained it no longer reflected current realities. Moreover, the removal of a standard cap was intended to address urban-rural disparities. Local governments may still set their own limits and maintain a reporting system but are restricted from conducting substantive reviews or inquiries into the details.

Despite MOHW assurances and oversight by the Fair Trade Commission, concerns persist about a “boiling frog” effect, with fees gradually increasing to NT$500–600 in the coming years. This could lead to higher costs for primary care compared to major hospitals, undermining the tiered healthcare system.

Balancing Human Nature and System Design

Policymaking must account for human nature—not just for patients but also for the medical system. What steps will stakeholders take? While Taiwan’s National Health Insurance Administration (NHIA) has mechanisms in place to mitigate the financial burden on economically disadvantaged groups, the removal of the fee ceiling significantly increases out-of-pocket costs for patients. Medical institutions, for their part, argue that paying for services is a fundamental principle in a free market.

Registration fees directly contribute to the net revenue of medical institutions and are independent of NHIA’s total healthcare budget. However, when proposing copayment adjustments for diagnostic tests, institutions frequently express concerns about patients delaying treatment due to financial pressures, potentially worsening their conditions.

Copayments: Burdening the Public or Threatening Hospital Revenue?

Is the resistance to copayments genuinely about patient welfare?

The truth is that copayments are allocated back into the NHIA’s budget and do not impact hospital income. The real issue lies in the reduction of patient visits, which leads to fewer registration fees—a reality that must be pragmatically addressed in discussions with stakeholders.

For years, some medical professionals have resisted innovations like home-based or telemedicine services, insisting that proper care requires face-to-face interaction between doctors and patients. This stance stems from concerns similar to those surrounding copayments. Primary care clinics, for instance, oppose the widespread adoption of telemedicine, citing the need for additional facilities and fearing competition from larger hospitals with specialists.

However, as Taiwan’s aging population grows, home-based and telemedicine services are becoming increasingly necessary. During the COVID-19 pandemic, these approaches proved effective and garnered recognition. It is now time to advance to the next phase by extending telemedicine to chronic disease management. Technological capabilities have made this feasible—for example, physicians at National Taiwan University Hospital can provide consultations to overseas patients via telemedicine.

Overcoming Barriers in Rural and Island Areas

For patients living in remote or island regions, scenic surroundings often turn into obstacles when seeking medical care. Many endure significant hardships to access treatment, particularly in emergencies requiring helicopter transfers to major hospitals on the main island, incurring high costs and delays.

To address these challenges, the primary solution lies in equipping island hospitals with advanced surgical instruments and offering competitive salaries and benefits to attract experienced specialists. For instance, the Naval General Hospital in Penghu, under the leadership of Director Tsai Chien-Sung, has made significant strides by installing equipment and recruiting heart specialists to form a medical team capable of performing heart and cardiac catheterization surgeries. This eliminates the need for patients to travel to Taichung Veterans General Hospital for treatment.

Not all specialties, however, can follow this model. In such cases, telemedicine becomes an indispensable tool. Tiered healthcare should guide telemedicine practices, with costs varying significantly depending on whether patients consult clinics, regional hospitals, or medical centers. Coupled with pharmacist home delivery services, telemedicine can address many healthcare needs.

The Challenges of Home-Based Care

Home-based care faces similar obstacles. Currently, family physicians often transfer critically ill patients to larger hospitals for specialist care. When promoting home-based care for severe conditions, many family doctors hesitate due to concerns about medical disputes.

If a comprehensive home-based care system is implemented, bedridden patients could receive adequate care at home, reducing hospital admissions. However, this would require amendments to existing medical laws to reassure physicians about their legal protections during consultations.

(The author, Lee Po-Chang, is a Distinguished Professor at the College of Public Health, Taipei Medical University, and former Director-General of the NHIA. Edited by Lin Hsing-Fei.)

Excerpt from Facing Human Nature: Pragmatic Healthcare Reform, by Lee Po-Chang and Lee Shu-Jen, published by New Scholar Publishing.

Original Source: Silver Horizon, “Lee Po-Chang’s Column | Living Amidst Scenic Beauty but Traveling Far for Healthcare: Why Is Telemedicine Stalled?”