{"id":6611,"date":"2025-07-07T13:11:50","date_gmt":"2025-07-07T05:11:50","guid":{"rendered":"https:\/\/tmuhprc.tmu.edu.tw\/?p=6611"},"modified":"2025-07-07T13:18:51","modified_gmt":"2025-07-07T05:18:51","slug":"%e3%80%90journal-publication%e3%80%91real-world-trends-and-reform-imperatives-for-taiwan-national-health-insurance","status":"publish","type":"post","link":"https:\/\/tmuhprc.tmu.edu.tw\/en\/%e3%80%90journal-publication%e3%80%91real-world-trends-and-reform-imperatives-for-taiwan-national-health-insurance\/","title":{"rendered":"\u3010Journal Publication\u3011Real-world trends and reform imperatives for Taiwan National Health Insurance"},"content":{"rendered":"

\"\"<\/p>\n

Taiwan’s National Health Insurance (NHI) is recognized as a landmark achievement in universal healthcare coverage. Established in 1995, this mandatory single-payer system has successfully extended coverage to all citizens and legal residents, with 93 % of medical providers contracted under it [1<\/span><\/span><\/a>]. It operates under a self-sustaining global budget that is negotiated annually. Despite notable reforms, the system faces recurring financial challenges [2<\/span><\/span><\/a>]. Physician burnout, under-compensation, and misaligned incentives have emerged owing to the dominance of the fee-for-service model, creating inefficiencies in care delivery [3<\/span><\/span><\/a>]. This study aims to assess NHI resource allocation trends and identify potential reforms to enhance sustainability [4<\/span><\/span><\/a>].<\/div>\n
<\/div>\n
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Analysis of the expenditure data from 1996 to 2021 reveals the following: Treatment Fees (including surgery and anesthesia) declined from over 40 %\u201335.1 % (US$9.076 billion). This trend may reflect the growth of outpatient and minimally invasive services. Drug Fees increased significantly to 28.9 % (US$7.483 billion), driven by the introduction of high-cost oncology medications, increased chronic disease prevalence. Examination Fees rose to 12.7 % (US$3.283 billion), showing widespread reliance on diagnostic imaging and molecular tests. Diagnosis Fees decreased to 16.8 % (US$4.346 billion), suggesting under compensation for clinical judgment and time spent with patients. Special Medical Supply Fees and Dispensing Service Fees rose modestly to 4.1 % and 2.4 %, respectively. (see\u00a0Fig. 1<\/span><\/span><\/a>).<\/div>\n
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Fig. 1<\/span>.\u00a0Proportion of medical sub-item expenditures in Taiwan’s NHI system, 1996\u20132021. Hospitalization diagnostic fees (excluding examination fees) include room charges, tube-feeding diets, radiotherapy, treatment fees, surgeries, rehabilitation, blood\/plasma transfusions, dialysis, psychotherapy, and injection fees.<\/div>\n<\/div>\n
<\/div>\n
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A review of Taiwan’s NHI system data reveals deep-rooted structural imbalances that jeopardize the long-term sustainability of our healthcare delivery. Outpatient services consistently absorb around 70 % of total healthcare expenditures, leaving only 30 % for inpatient care\u2014despite the latter’s critical role in managing complex conditions such as surgeries, invasive diagnostics, and emergency interventions. This skewed allocation can be traced to the original system design, wherein the reimbursement for inpatient services was set too low. Over time, this has led to serious workforce issues, as younger physicians increasingly avoid specialties involving night duties or high-acuity inpatient care. The undervaluation of inpatient services has not only strained frontline providers but also contributed to the rise of so-called \u201csweatshop hospitals.\u201d Ensuring fair and adequate reimbursement for inpatient care must be a central priority in any meaningful NHI reform. In practice, when policymakers lack firsthand experience in clinical settings and rely solely on public health or administrative viewpoints, critical nuances are often overlooked. This disconnect becomes even more pronounced when the system is expected to function like a universal healthcare coverage model, while being fundamentally financed as an insurance-based program. Unlike tax-funded universal healthcare coverage systems, Taiwan’s NHI relies heavily on premiums. However, premium adjustments are frequently postponed because of political reasons, which results in structural deficits. This fosters unrealistic public expectations\u2014unlimited access to medical services within a limited financial framework.<\/div>\n
<\/div>\n
Utilization patterns further illustrate the inefficiencies. Taiwan’s population averages around 15 medical visits per person per year, ranking among the highest globally. The elderly, who constitute a growing segment of the population, account for nearly 40 % of total health expenditures. Despite having advanced medical infrastructure, Taiwan continues to lag behind regional neighbors in life expectancy [5<\/span><\/span><\/a>]. A closer look at service delivery reveals that primary care clinics are largely occupied with acute, minor ailments (about 156 million visits), whereas only a fraction (approximately 37 million visits) are devoted to chronic disease management. In hospitals, patient volume is more evenly split, with 55 million non-chronic and 53 million chronic care visits, indicating potential gaps in the ability of primary care to manage long-term conditions effectively.<\/div>\n
<\/div>\n
In 2023, drug costs accounted for 32\u00b758 % of the total healthcare budget, with outpatient prescriptions comprising nearly 87 % of that figure. The cultural norm of expecting a prescription with each visit contributes to the overuse of medication. Low copayment levels do little to curb unnecessary consumption, and patients lack meaningful incentives to moderate their healthcare-seeking behavior. The fee-for-service model inadvertently encourages high patient turnover rather than promoting continuity or quality of care. Like many systems globally, Taiwan faces the challenge of overutilization\u2014particularly in diagnostic testing\u2014fueled by defensive medicine and misaligned financial incentives [6<\/span><\/span><\/a>].<\/div>\n
<\/div>\n
Other countries have introduced corrective mechanisms. Singapore emphasizes personal responsibility and uses targeted subsidies to manage utilization, whereas Japan has implemented modest copayments for older adults to reduce unnecessary visits. These examples offer valuable lessons [7<\/span><\/span><\/a>]. For Taiwan, introducing a fair \u201cuser-pays\u201d copayment system could improve public understanding of healthcare costs and promote more responsible use of services.<\/div>\n
\n

Patient and other Consent(s)<\/h3>\n
This study was reviewed and deemed exempt from ethical oversight by the Taipei Medical University Joint Institutional Review Board (TMU-JIRB; Certificate No. N202412107).<\/div>\n
All human research was conducted according to the declaration of Helsinki. Because the database contains only deidentified data, the IRB waived the requirement for written informed consent.<\/div>\n<\/section>\n
\n

Insights and future direction<\/h3>\n
Key strategies should include instituting appropriate copayment policies, strengthening the referral and tiered care system to ensure proper case distribution Initiatives such as the \u201cStar-Moon Project\u201d at National Taiwan University Hospital, which fosters partnerships between major medical centers and community clinics, demonstrate how system-level collaboration can enhance efficiency and rebuild trust in primary care [8<\/span><\/span><\/a>]. Taiwan’s healthcare model must evolve beyond prioritizing accessibility alone and begin aligning with a sustainability-centered vision that harmonizes public expectations with financial reality.<\/div>\n<\/section>\n
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Role of the medical Writer(s) or Editor(s)<\/h3>\n
No medical writer or editor was involved in the preparation of this manuscript. All writing and editing was carried out by the authors.<\/div>\n<\/section>\n
\n

Author contributions<\/h3>\n
P.-C. Lee conceived the study concept, conducted data interpretation, led the drafting and critical revision of the manuscript, and approved the final version. He is responsible for the integrity and accuracy of the data presented.<\/div>\n<\/section>\n
\n

Ethics approval<\/h3>\n
This study was reviewed and deemed exempt from ethical review by the TMU-Joint Institutional Review Board (Certificate No: N202412107). The data used were publicly available and de-identified.<\/div>\n<\/section>\n
\n

Data availability statement<\/h3>\n
The data supporting the findings of this study are publicly available from the\u00a0National Health Insurance Administration, Taiwan<\/span>\u00a0open database.<\/div>\n<\/section>\n
\n

Funding statement<\/h3>\n
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.<\/div>\n<\/section>\n<\/div>\n
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Conflict of interest disclosure<\/h3>\n
The author declares no conflicts of interest related to this work.<\/div>\n<\/section>\n
\n

Acknowledgments<\/h3>\n
Declaration of Interest(s). The authors have no conflict of interest to the report.<\/div>\n<\/section>\n
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References<\/h3>\n

[1] Wang T-H, Tsai Y-T, Lee P-C. Health big data in Taiwan: a national health insurance research database. J Formos Med Assoc 2023;122:296\u20138.
\n[2] Tsuei S-H-T. Reflection on 30 years of Taiwanese national health insurance: analysis of Taiwanese health system progress, challenges, and opportunities. J Formos Med Assoc 2024;123:S180\u20137.
\n[3] Tung Y-C, Chou Y-Y, Chang Y-H, Chung K-P. Association of intrinsic and extrinsic motivating factors with physician burnout and job satisfaction: a nationwide crosssectional survey in Taiwan. BMJ Open 2020;10:e035948.
\n[4] Hsu A-Y, Lin C-J. The Taiwan health-care system: approaching a crisis point? Lancet 2024;404:745\u20136.
\n[5] Wu Y-C, Lo W-C, Lu T-H, et al. Mortality, morbidity, and risk factors in Taiwan, 1990\u20132017: findings from the global Burden of disease study 2017. J Formos Med Assoc 2021;120:1340\u20139.
\n[6] Kraft K-B, Hoff E-H, Nylenna M, et al. Time is money: general practitioners\u2019 reflections on the fee-for-service system. BMC Health Serv Res 2024;24:472\u201381.
\n[7] Tan C-C, Lam C-S-P, Matchar D-B, et al. Singapore\u2019s health-care system: key features, challenges, and shifts. Lancet 2021;398:1091\u2013103.
\n[8] Yan Y-H, Kung C-M, Yeh H-M. Impacts of the hierarchical medical system on National Health Insurance and residents\u2019 health-seeking behavior in Taiwan: a case study on the policy to reduce hospital visits. Int J Environ Res Publ Health 2019;16:3167.<\/p>\n<\/div>\n<\/div>\n

<\/div>\n
Original Source:https:\/\/www.sciencedirect.com\/science\/article\/pii\/S0929664625003316<\/a><\/strong><\/div>\n","protected":false},"excerpt":{"rendered":"

Taiwan’s National Health Insurance (NHI) is recognized as a landmark achievement in universal healthcare coverage. Established in 1995, this mandatory single-payer system has successfully extended coverage to all citizens and legal residents, with 93 % of medical providers contracted under it [1]. It operates under a self-sustaining global budget that is negotiated annually. 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