How Taiwan does it: seeing more patients for less.

Taiwan is the most recent advanced economy to adopt a universal health insurance program, more specifically, a single-payer national health insurance program financed through the combination of premiums and taxes.

However, even after eight years, Taiwan's National Health Insurance (NHI) program has received little attention from the American health policy community who continue to recognize a need for change in America's own health care system.

This is perhaps because Taiwan is not a member of the World Health Organization (WHO) or the Organization for Economic Cooperation and Development (OECD), which provide worldwide data and analysis for health policymakers. (1)

Although the U.S. may never adopt a single-payer system, Taiwan's experience still offers lessons for the current Medicare system. (1) One interesting fact that sets Taiwan apart from other developed countries is that Taiwanese physicians see approximately 50 percent more patients than their counterparts in the U.S. on a weekly basis. (2)

The average number of patients seen by a physician for a primary care office visit per week in Taiwan is 128 compared to 85 in the U.S. (2)

Taiwan also recently recorded the highest average number of outpatient visits per capita in the world. (3) The average number of outpatient visits in Taiwan per person per year is 11.8 compared to 5.8 in the U.S. (4)

However, Taiwan has a modest health care expenditure as measured by total health spending as a percent of GDP, and comparable health status indicators when compared to other developed economies such as the U.S. (5)

In July of 2004, in-depth interviews and observations were performed at various health care facilities through-out the island of Taiwan to gain insight on why Taiwanese physicians carry significantly higher patient loads compared to their American counterparts.

A variety of facilities and physicians were included in the study. For example, private "specialty" clinics including otolaryngology and gynecology, community family practice and surgery, as well as hospital-based endocrinology and internal medicine clinics were included.

Both fee-for-service, as well as facilities participating in the government-supported single-payer system, were studied. Several main factors attribute to the higher patient loads of Taiwanese physicians including:

* Financial incentives that drive physician decision making

* Cultural differences and historical factors that affect physician behavior

* Logistical differences in the day-to-day operations of clinics

Financial incentives

Physicians perceive and run medicine as a business in Taiwan. Taiwan has a market-driven health care delivery system where 63 percent of physicians are employed by hospitals and paid on a salaried basis: many receive bonus payments based on productivity. (5)

Physicians feel pressure to obtain and maintain a high patient load to maintain high pay. The more patients a physician sees, the higher the salary, up to a certain point. It is not uncommon for physicians to see patients late into the night when the demand is high, which is the case for physicians with "good" reputations.

Physicians respond to the financial incentive to see more patients, while also expressing a sense of social responsibility to see all patients that request care.

Studies have shown that incentives are much more effective drivers of productivity then regulations or mandates. Using this principle in the way physicians are rewarded or compensated may yield higher results than requiring specific levels of productivity.

Cultural and historical factors

Cultural and historical factors play a large role in how and why Taiwanese physicians see so many patients on a daily basis.

For generations, patients have developed a physician usage culture that includes consulting physicians for minor ailments, visiting different physicians to find one that will do what the patient "wants," and finding and using the most popular doctor, even when they do not specialize in what the patient needs.

Because NHI coverage is accepted by virtually all physicians in all specialties, patients are in the position to choose. Even after the implementation of the NHI and the introduction of the IC-Card (a credit card-size database containing important personal and clinical information) to prevent duplication of services, the patient habit of "doctor shopping" (4) persists.

This usage pattern has, in essence, forced Taiwanese physicians to work efficiently and effectively, and with the patient's personal needs and preferences as one of the foremost concerns.

Perhaps U.S. practitioners should more strongly consider the service expectations of their patients. Both quality of care and compliance are associated with the level of service perceived by patients.

Service begins from the moment a patient enters a clinic to any follow-up care received. Some applicable examples include:

* Reducing wait times Adopt a technique similar to Taiwan's by providing estimated wait times so patients are free to leave and come back if the wait will be long. Develop a formal system to accommodate walk-ins, prioritize efficiency in scheduling that respects patients' time and needs.

* Hiring friendly, service-oriented staff

* Adopting patient-centered treatment inside and outside of the exam room

Although it may make sense, it is not necessarily true that in order for physicians to see so many patients in Taiwan, they must spend less time than desired by the physician and be less familiar with the patient.

When asked, physicians say they feel quite familiar with each patient. They explain that, although each individual visit may be short, patients visit or contact the same doctor quite frequently. This situation is described as providing typical Taiwanese citizens with a "medical home" or usual place of care.

By opening channels of communication with providers through Web sites, directed e-mails, phone calls, or several short follow-up visits, patients will feel more at ease about their health care and medical home. This can also increase compliance and offer satisfaction for both physicians and patients.

Taiwanese physicians do see more patients on a daily basis than U.S. physicians. But, do Taiwanese physicians, themselves, feel that they are seeing too many patients?

The typical response is, "No, it is a choice I make as part of the job." Overall, we found that physicians feel that they are adequately paid, but work hard for the money. Taiwanese physicians who are happy with their relationship with patients are more productive, value their team members, and remain in the workplace because of a sense of accomplishment.

Logistical factors

Examination rooms in Taiwan are also designed for efficiency.

At China Medical College Hospital outpatient clinics, computer stations in every exam room allow doctors, nurses, and assistants to collaborate to set appointments, make prescriptions, see lab results, as well as make medical records (history of present illness, chief complaint) all while the patient is present in the room.

Specialized nurses take vital measurements prior to the patient entering the room, and explain the specific details of how to take prescribed medications after exiting the examination room.

Mutual respect between physicians and other health care providers such as nurses and assistants is key to a productive workplace. Expecting and fostering teamwork between all providers is a standard goal.

Information technology similar to Taiwan's is another area that provides great potential for increasing efficiency in the U.S. health care system. One notable result that should interest Americans is that Taiwan's universal insurance single-payer system greatly reduced transaction costs and also offered the information and tools to manage health care costs. (5)

By investing in an integrated patient database, like the Taiwanese IC-Card that provides access to each patient's information for all health care providers, duplication and misuse of services, as well as transaction costs can be decreased. These technologies can also play a role in reducing medical errors and maintaining continuity of care between physicians and through different facilities.

These lessons from Taiwan show that increased efficiency and productivity not only means decreased costs, but also the opportunity for equal or better care for more patients.

Tammy Chang is a MD/MPH student at the University of Michigan in Ann Arbor.

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Jersey Liang, PhD is a professor of health management and policy at the University of Michigan in Ann Arbor.

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Scott Ransom, DO, MBA, MPH, CPE, FACPE is the director of the Program for Healthcare Improvement and Leadership Development and an associate professor in obstetrics, gynecology, health management and policy at the University of Michigan, Ann Arbor. He can be reached by phone at 734-615-4575 or [e-mail].

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References

1. Cheng T. "Universal coverage in Taiwan." Health Affairs. Vol. 22(3) May/Jun 2003.

2. AMA Physician Socioeconomic Statistics 2004, and Taiwan Data

3. Chen, L. "An analysis of private health insurance purchasing decisions with national health insurance in Taiwan." Social Science & Medicine. Vol. 55, Sept. 2002.

4. OECD Health Database 2003.

5. Lu JR and Hsiao WC. "Does Universal Health Insurance Make Health Care Unaffordable? Lessons from Taiwan." Health Affairs. Vol.22(3) May/Jun2003.

6. Cheng, T. "Taiwan's new national health insurance program: Genesis and experience so far." Health Affairs. Vol.22(3) May/Jun 2003.

By Tammy Chang, Jersey Liang, PhD, and Scott Ransom, DO, MPH, MBA, FACPE, CPE

Health Spending and Health Status Indicators In Selected OECD Countries,
1999

           Total health  Total health  Life
           spending as   spending per  expectancy  Infant mortality
           percent of    person (US$   at birth    rate (deaths per
Country    GDP           PP)           (years)     1,000 live births)

Taiwan      6.0%           686         74.9        6.5
United     13.0          4,373         76.7        7.1
  States
Canada      9.2          2,616         79          5.3
United      7.1          1,666         77.4        5.8
  Kingdom

SOURCE: Organization for Economic Cooperation and Development, OECD
Health Data 2002 (Paris; OECD, 2002); and J.R. Lu and W.C. Hsiao,
"Development of Taiwan's National Health Account," Taiwan Economic
Review 29, no. 4 (2001):547-576.
NOTES: GDP is gross domestic product, U.S. $ based on exchange rates for
Taiwan.