【Opinion Column】Liberty Republic — Lee Po-Chang: Why I Chose to Revisit Health Insurance Reform Through the Lens of “Unnecessary Medical Care”
◎ Lee Po-Chang (Chair Professor, College of Public Health, Taipei Medical University)
Debates on National Health Insurance (NHI) reform in Taiwan have never lacked voices. Some argue that the global budget is insufficient, while others contend that reimbursement point values are too low. Some discussions focus on the shortage of healthcare manpower, while others approach the issue from the perspective of social justice and equity. Each of these viewpoints has its own practical basis. Yet over the years, I have consistently felt that one fundamental question has been repeatedly avoided: What kinds of medical services are we actually paying for? If the system continues to reimburse medical practices with limited marginal benefit—or even those that provide little real help to patients—then no matter how much the global budget increases or how reimbursement points are recalculated, the healthcare system will never truly deliver fair professional returns.
At first, I focused my attention on medical fraud. Fraud certainly exists and must be addressed. But after years of observation and reflection, I came to realize something clearly: the real drain on healthcare resources is not explicit illegal fraud, but rather the vast volume of medical services that are legally reimbursed yet not necessarily necessary. These services comply with regulations and are properly reported for reimbursement; they do not violate professional standards. Yet under the incentives of the payment system, they are repeatedly expanded, replicated, and accumulated.
I began to realize that if we interpret the problem solely through the lens of “fraud,” governance will remain confined to post hoc investigation and case-by-case punishment. The more fundamental question is: Why does the system continue to pay for these services? And why do those who act honestly bear the greatest pressure? This reflects one of the most serious governance mistakes in Taiwan’s healthcare system—confusing medical disputes with medical fraud. As a result, those who truly commit fraud continue to grow within the gaps of the system, while the majority of rule-abiding healthcare professionals bear the burden of audits, public suspicion, and legal scrutiny. NHI audits have become increasingly aggressive, yet increasingly ineffective at targeting the real problems. Meanwhile, commercial health insurance loss ratios continue to rise, leaving insurers with little choice but to suspend products or raise premiums. The public, caught in the paradox of “healthcare becoming more expensive yet less reassuring,” gradually loses trust.
1. I Have Never Believed That NHI “Lacks Money”
This may be my greatest divergence from many public health and healthcare management experts. I do not believe that Taiwan’s NHI problem is primarily a lack of funding. On the contrary, when large volumes of unnecessary medical services—excessive testing, examinations, and procedures—are reimbursed, resources are inevitably diverted to areas that should not be prioritized. As a result, the healthcare system cannot provide appropriate compensation for the medical professionals and services that truly matter. Financial pressure is only the symptom; the real root cause is that the system’s design fails to direct resources toward high-value healthcare.
2. Unnecessary Medical Care Is Not a Moral Problem of Physicians
Most unnecessary medical practices occur under circumstances that are legal, compliant, and even professionally defensible. The problem lies not with individuals but with the system itself. As long as the system continues to pay for such services, they will inevitably be replicated. This is not physician negligence but the inevitable consequence of distorted payment signals. When the reimbursement mechanism rewards “doing more to earn more,” while narrowing the space for professional judgment, the system naturally expands volume rather than quality.
3. From “Tiered Cost-Sharing” to a “User-Pay” Mindset
I fully understand that the idea of tiered cost-sharing would immediately provoke opposition from sociologists and advocates of social equity in Taiwan. Such concerns are not unfounded; if poorly designed, the system could indeed affect access to care for vulnerable groups. Therefore, I chose a different approach. I advocate user-pay cost-sharing, rather than penalizing patients based on status or hierarchical categories. This is particularly relevant for highly discretionary medical services such as laboratory tests and diagnostic imaging. Reasonable user-pay cost-sharing can prompt both physicians and patients to pause and genuinely discuss whether a service is necessary. Without cost awareness, there can be no meaningful shared decision-making between physicians and patients.
4. The Limitations of the Claims System and the Need for Governance Upgrades
Given human nature, I have never placed excessive expectations on the honesty of medical claims within the NHI reporting system. A system based on itemized claims and post-hoc audits, without the assistance of big data and Artificial Intelligence (AI), simply cannot detect cumulative patterns of improper reporting or behavior. When auditing remains dependent on manpower and paper-based processes, the system effectively loses its governance function. This is why I repeatedly emphasize in my book that unnecessary medical care cannot be solved merely by claim rejections or administrative audits—it requires simultaneous reforms in payment design, behavioral incentives, and technological regulation.
5. From Idealistic Expectations of “Commercial Insurance Complementing NHI” to Pragmatic Cooperation
I must honestly admit that I once held somewhat naive expectations regarding the role of commercial insurance. I once believed that private insurers could naturally become governance partners of the NHI. But the reality is that insurance companies operate in a commercial environment—they must answer to shareholders rather than to social welfare ideals. Under the reimbursement-based insurance model, loss ratios in medical insurance continue to rise, clearly demonstrating that the market will not automatically correct systemic distortions. For this reason, I now advocate a more pragmatic strategy of cooperation between NHI and commercial insurance, including data sharing, risk consensus, and claims collaboration, to build a sustainable payment ecosystem rather than relying on moral expectations alone.
6. Why I Entrust the Momentum for Reform to the Insurance Industry and Financial Regulators
I do not expect administrative officials within the Ministry of Health and Welfare to proactively propose such a governance framework. This is not a matter of personal capability but rather the limitations of institutional culture. In contrast, the insurance industry and financial regulators may actually possess stronger incentives and tools to address the erosion of the payment system caused by unnecessary medical care. When both NHI and commercial insurers face the pressures created by unnecessary medical services, genuine reform becomes more likely to emerge. This is not about shifting responsibility—it is about recognizing that reform requires cross-sector collaboration and diverse sources of momentum.
Conclusion: Not a Critique, but a Responsibility
I wrote this book not to criticize anyone, but to offer Taiwan another possible path for NHI reform. It does not shift blame onto physicians, does not morally condemn patients, and does not focus solely on whether funding is sufficient. Instead, it calls for recalibrating the direction of the payment system itself.
If this book encourages more people to ask the same question—What kinds of medical care are we actually paying for?—then it will have fulfilled my responsibility as a physician and as someone who has participated in the design of the system.
Editor’s note: This article is the author’s preface to the book “Paid but Unnecessary Medical Care: The Invisible Drain on Healthcare.”
Original source:
https://talk.ltn.com.tw/article/paper/1746894
