Healthcare in Taiwan is famously cheap, convenient and universal. Visits to the doctor cost about NT$300 (approximately US$10) and, in Taipei at least, you don’t have to walk far from your house or office to find a clinic. But is this easy access, low-cost system actually harming patients? Dr. Jonathan Tseng believes so.
Dr. Tseng works at Taiwan Adventist Hospital in central Taipei. Hospitals and clinics across the island “urge” doctors to see as many patients as possible, he says. And some patients “do not care” about the brief consultation time, they just want a quick prescription.
“If the doctor doesn’t give them any medication, they think it was not worth their while to go to the doctor,” says Tseng.
At 40, Tseng is now the chairman at his hospital’s dermatology department and takes his time with patients, but he recounts his “exhausting” workload in recent years.
“What I am saying is maybe you get to see more than 150 to 200 patients a day,” he says. “When I see the last patient, do I still have a clear mind?”
Tseng’s concern that Taiwanese are taking more and more medication appears to be backed up by the numbers.
According to PWC, sales revenue for pharmaceutical companies from Taiwan’s domestic market increased from US$3 billion in 2004 to US$5.4 billion in 2013. Prescription drugs sales account for more than 90% of the total pharma market. PWC says Business Monitor International has forecast pharmaceutical sales in Taiwan will, from 2013-2018, grow at a faster rate than in the five years prior.
PWC says that as prescribing and dispensing functions are not separated in most hospitals and clinics, “doctors have both the incentive and ability to over-prescribe drugs.”
What is more, Taiwanese visit a doctor nearly 16 times a year on average – more than double the OECD average and nearly four times that of the United States. That means Taiwan’s 23 million people make about 360 million visits to the doctor each year. The Brookings Institute says that overall outpatient visits increased by 20% from 2003 to 2013 while inpatient episodes lifted by 18%.
In addition to building resistance to the effectiveness of drugs, Tseng says people who take medication for a long time may cause damage to their internal organs. This not only threatens the wellbeing of patients, but also weighs on the healthcare system.
“This is not the right thinking, not the right policy,” he says.
He notes that Taiwan already has one of the highest rates of end-stage renal disease (ESRD) – loss of kidney function – in the world. People with kidney disease often have to go to a clinic to receive dialysis treatment three times a week for the rest of their lives.
According to the Brookings Institute, chronic renal failure was the highest of Taiwan’s outpatient costs in 2013, accounting for 45% of the National Health Insurance (NHI) total annual outpatient care expenditure. Cancer was the second highest at 33.5%.
Drug stores and private clinics adding to the problem
Tseng says the easy access of drugs over the counter at pharmacies and the proliferation of private beauty clinics is also problematic.
“You can get all the medication you want in a drug store in Taiwan,” he says. “You can get antibiotics easily, and this is creating antibiotic resistance.”
Not only does this exacerbate the high rate of medication overuse, but also increases the risk of misdiagnosis.
“The pharmacists, maybe they know about the function of this drug, but ‘Is it really suitable for this patient?’ We doctors, we study when to use what kind of drug.”
He suggests tougher regulations on pharmacies and medication advertising is required.
The Brookings Institute says there are 1.7 doctors in Taiwan for every 1,000 people, about half the OECD average. The report notes that the low ratio is inadequate by OECD standards, “especially in view of the high utilization of health care services in Taiwan.”
Some doctors in Taiwan, attracted by better hours and higher pay, leave general practices and work instead at clinics practicing aesthetic medicine – some leave the country or do short stints at hospitals in China.
As a dermatologist, Tseng is worried that doctors at these beauty clinics may miss the early signs of potentially fatal diseases like skin cancer. For example, he says, a doctor who has not studied dermatology may not necessarily know a certain skin abnormality needs to be tested for cancer.
“It is so easy to remove, but the question of what is behind the lesion, that is important,” he says. “This does not only apply to skin, it applies to everything.”
Doctor responsibility, higher costs
Tseng says that doctors should focus more on educating their patients, rather than just handing out prescriptions or administering quick procedures. He gives the example of a patient with a common issue like acne.
“I can just give you medication in one minute, easily,” he says. If, however, a doctor takes a little longer and interviews the patient on factors like diet and stress, “they will have less acne and less medication.”
There is evidence Taiwanese actually want a more thorough approach from their doctors. The Brookings Institute report noted that, “large segments of Taiwan’s public view visit lengths [to both family doctors and hospital-based specialists] to be too short.”
The US think tank says that while the National Health Insurance Administration (NHIA) has since 2006 had a ‘reasonable outpatient visit volume’ policy to discourage high volume and therefore allow for more time per visit, “satisfaction on this issue remains low.”
“The clear message is that doctors in Taiwan need to spend significantly more time and communicate more effectively with their patients on visits,” says the institute.
Of course, for doctors, seeing fewer patients may mean less pay, Tseng says.
“How many doctors are willing to sacrifice this?”
Ultimately, Tseng believes, Taiwan will have to pay doctors more, and patients will individually have to bear a greater share of the costs. He points to Japan where patients pay about 30% of their own medical costs, with the remainder covered by the government.
“More or less I think this is fair,” Tseng says. “Fair in the way that this is your own health, you have to take good care of yourself. If you are not taking good care, then you have to pay.”
However, he notes that in Taiwan any changes that lead to healthcare becoming more expensive are likely to be difficult politically. That is why educating patients is so important, he says.