A patient at National Taiwan University Hospital (NTUH) reportedly died after waiting 12 days in the emergency department for an inpatient bed. While the medical circumstances surrounding the individual case warrant further clarification, overcrowding in NTUH’s emergency department is not merely a matter of insufficient inpatient beds. The more fundamental problem is that Taiwan has failed for years to fully implement a truly effective tiered healthcare system. Even the largest medical centers cannot have unlimited doctors, nurses, or hospital beds. The question we should be asking is not what more NTUH can do, but why patients continue to concentrate at major medical centers.

I have long believed that strengthening tiered healthcare should be one of the highest priorities of Taiwan’s healthcare reform. The National Health Insurance Administration has previously promoted 76 strategic alliances vertically integrating medical centers, regional hospitals, district hospitals, and clinics. NTUH has also launched its “Star and Moon Project,” establishing referral and collaborative networks among healthcare institutions. Hospitals can work with the government to build these referral pathways, but they cannot educate the public on their own. The government should help people understand that physicians at regional hospitals, district hospitals, and community clinics have also undergone comprehensive specialist training, and that seeking care outside a medical center does not mean receiving inferior medical treatment. A well-functioning healthcare system ensures that patients receive care at the most appropriate level, while preserving the resources of medical centers for patients with acute, severe, complex, and rare conditions.

Public education alone, however, is not enough. If the actual differences in out-of-pocket costs across different levels of healthcare are too small to influence patients’ choices, people will naturally ask, “If everything is covered by National Health Insurance, why not just go directly to a medical center?” This is not irrational behavior on the part of patients. Rather, the system itself makes such a choice rational. I have therefore consistently argued that reasonable cost-sharing and copayments are an unavoidable component of an effective tiered healthcare system. Their purpose is not to “punish patients,” but to manage demand through appropriate price signals. Patients requiring emergency or critical care, those with major illnesses or injuries, those referred for higher-level care, and economically disadvantaged patients should, of course, be fully protected. However, patients who choose to go directly to a medical center without a referral or genuine need for higher-level care should face a meaningful difference in copayments—one sufficient to influence their choice of where to seek care.

The government has recently been actively promoting Urgent Care Centers (UCCs) for patients with less severe conditions during weekends and holidays. But a more fundamental question should be asked first: Why have existing district hospitals not been fully utilized? District hospitals are already embedded in local communities and are staffed with physicians, nurses, and medical technologists, with access to X-ray services; many also have CT scanners and inpatient beds. Rather than launching another new program, allocating additional budgets, and conducting yet another round of pilot projects and evaluations, the government should first assess and make better use of existing healthcare capacity. District hospitals should receive adequate and stable reimbursement so that they can maintain nighttime, weekend, and urgent care services for less severe conditions. Patients whose needs exceed their treatment capacity can then be referred to regional hospitals or medical centers. One of the greatest problems in healthcare policy is often not a lack of resources, but a failure to deploy existing resources where they are most needed.

Managing hospitals is not the same as governing the healthcare system. What the government truly needs to address is why patients are concentrated at medical centers, what functions healthcare institutions at each level should perform, whether the payment system adequately supports hospitals at every level, why referrals and reverse referrals to lower-level facilities have failed to function effectively, and whether copayments actually help redirect patient flows. Without reform on the demand side, patients will continue to flood medical centers. Requiring individual hospitals to control their own bed capacity and service volumes merely shifts the responsibility for system governance onto medical centers. Illness does not disappear simply because every hospital bed is occupied. The inevitable result is only more waiting.

The government has emphasized the goals of a “Healthy Taiwan” and a “resilient healthcare system.” True resilience, however, requires a well-functioning tiered healthcare system in everyday practice: community clinics serving as the first line of care, district hospitals managing common illnesses and community-based urgent care, regional hospitals treating moderately severe and complex conditions, and medical centers concentrating their resources on acute, severe, complex, and rare diseases, as well as advanced medical care. The government must take responsibility for managing healthcare demand and guiding the public toward the appropriate use of medical resources.

Ensuring that the right patient receives care at the right level of the healthcare system at the right time is the essence of an effective tiered healthcare system. Taiwan does not lack new initiatives. What it lacks is the determination to fully implement reforms that have long been recognized as necessary.

(The author, Po-Chang Lee, is a Chair Professor at the College of Public Health, Taipei Medical University, and former Director-General of the National Health Insurance Administration.)

Original article:https://udn.com/news/story/7339/9714134