Yue-Chune Lee

The impact of universal National Health Insurance on population health: the experience of Taiwan.

BackgroundTaiwan established a system of universal National Health Insurance (NHI) in March, 1995. Today, the NHI covers more than 98% of Taiwans population and enrollees enjoy almost free access to healthcare with small co-payment by most clinics and hospitals. Yet while this expansion of coverage will almost inevitably have improved access to health care, however, it cannot be assumed that it will necessarily have improved the health of the population. The aim of this study was to determine whether the introduction of National Health Insurance (NHI) in Taiwan in 1995 was associated with a change in deaths from causes amenable to health care.MethodsIdentification of discontinuities in trends in mortality considered amenable to health care and all other conditions (non-amenable mortality) using joinpoint regression analysis from 1981 to 2005.ResultsDeaths from amenable causes declined between 1981 and 1993 but slowed between 1993 and 1996. Once NHI was implemented, the decline accelerated significantly, falling at 5.83% per year between 1996 and 1999. In contrast, there was little change in non-amenable causes (0.64% per year between 1981 and 1999). The effect of NHI was highest among the young and old, and lowest among those of working age, consistent with changes in the pattern of coverage. NHI was associated with substantial reductions in deaths from circulatory disorders and, for men, infections, whilst an earlier upward trend in female cancer deaths was reversed.ConclusionsNHI was associated in a reduction in deaths considered amenable to health care; particularly among those age groups least likely to have been insured previously.

Edinburgh Feeding Evaluation in Dementia (EdFED) scale: cross-cultural validation of the Chinese version

AIM This paper is a report of an assessment of the construct validity of the Chinese version of the Edinburgh Feeding Evaluation in Dementia scale. BACKGROUND The Edinburgh Feeding Evaluation in Dementia scale has previously been translated and back-translated and to determine the equality of the Chinese and English versions. However, the construct validity of the Chinese version has not been investigated. METHODS Participants (n = 477) were selected from residents with dementia in licensed long-term care facilities in Taiwan in 2006-2007. Data collectors received training before observing feeding for 2 days during lunch and dinner. Data were analysed using principal component analysis, Mokken scaling and correlation. FINDINGS A two-factor structure was demonstrated for the 11 items of the Chinese version of the scale and six items conformed to a Mokken scale. The Chinese version of the scale correlated with external constructs such as weight and body mass index, as predicted by the unmet needs model. CONCLUSION A confirmatory factor analysis is needed to confirm that the Chinese version measures the same qualities, in the same proportions, and with the same factor structure as the original Edinburgh Feeding Evaluation in Dementia scale.

Differences in patient reports on the quality of care in a diabetes pay-for-performance program between 1 year enrolled and newly enrolled patients

OBJECTIVE This study aimed to assess the quality of care from the perspective of patients who participated in the diabetes pay-for-performance (P4P) program in Taiwan. DESIGN A cross-sectional telephone interview to measure the quality of care for patients with diabetes mellitus. SETTING A stratified sampling according to the level and region of the health-care providers in Taiwan. PARTICIPANTS A total of 1796 patients with diabetes mellitus responded to the telephone survey. INTERVENTIONS The patients were divided into two groups according to the length of time they had participated in the program: (1) the case group, who had received comprehensive care for at least 1 year and (2) the control group, who were newly enrolled in the diabetes mellitus P4P program for <3 months. MAIN OUTCOME MEASURES The compliance of diabetes self-care and the level of satisfaction with the quality of care from the perspective of the patients. RESULTS After controlling for the characteristics of the health-care providers involved, pattern of diabetes treatment, self-reported health status and other patient characteristics, the case group performed better in exercise, had regular medication and better foot care and showed overall compliance with diabetes self-care and perceived better quality of care than the control group. CONCLUSIONS The patients who had received comprehensive care for 1 year showed better compliance with self-care and were more satisfied with the quality of care they had received. The P4P program appears to be associated with this enhanced care.

Evaluating the Supports Intensity Scale as a Potential Assessment Instrument for Resource Allocation for Persons with Intellectual Disability.

This study evaluated the potential of using the Supports Intensity Scale (SIS) for resource allocation for people with intellectual disabilities (ID) in Taiwan. SIS scores were compared with those obtained from three tools that are currently used in Taiwan for homecare services: the medical diagnosis issued by local authorities and two scales measuring Activities of Daily Life (ADL) and Instrumental Activities of Daily Life (IADL). Data were collected on 139 persons with ID aged 16 or older. The correlation between SIS subscales and the other three tools were calculated and compared. Six subscales of the SIS demonstrated adequate reliability and validity and had higher correlations with the IADL than the ADL and medical diagnosis. The results of these analyses suggest that the SIS can be used as a reference tool for resources allocation in this population in Taiwan.

A cost-benefit analysis of the outpatient smoking cessation services in Taiwan from a societal viewpoint.

INTRODUCTION This study applied a cost-benefit analysis from a societal viewpoint to evaluate the Outpatient Smoking Cessation Services (OSCS) program. METHODS The costs measured in this study include the cost to the health sector, non-health sectors, the patients and their family, as well as the loss of productivity as a result of smoking. The benefits measured the medical costs savings and the earnings due to the increased life expectancy of a person that has stopped smoking for 15 years. Data were obtained from the primary data of a telephone survey, the literatures and reports from the Outpatient Smoking Cessation Management Center and government. Sensitivity analyses were conducted to verify the robustness of the results. RESULTS There were 169,761 cases that participated in the outpatient smoking cessation program in the years 2007 and 2008, of those cases, 8,282 successfully stopped smoking. The total cost of the OSCS program was 18 million USD. The total benefits of the program were 215 million USD with a 3% discount rate; the net benefit to society was 196 million USD. After conducting sensitivity analyses on the different abstinence, relapse, and discount rates, from a societal perspective, the benefits still far exceeded the costs, while from a health care perspective, there was only a net benefit when the respondents abstinence rate was used. CONCLUSIONS From a societal perspective, the OSCS program in Taiwan is cost-beneficial. This study provides partial support for the policy makers to increase the budget and expand the OSCS program.

The relationship between smoking status and health-related quality of life among smokers who participated in a 1-year smoking cessation programme in Taiwan: a cohort study using the EQ-5D

Objective To assess the relationship between smoking status and health-related quality of life 1 year after participation in a smoking cessation programme in Taiwan. Design A cohort study of smokers who voluntarily participated in a smoking cessation programme with two follow-up assessments of smoking status via telephone interview, conducted 6 months and 1 year after finishing the smoking cessation programme. Setting Hospitals and clinics providing smoking cessation services. Participants A total of 3514 participants completed both telephone interviews, which represents a response rate of 64%. After the interviews, participants were divided into four groups according to their smoking status: (1) long-term quitters: participants who had quit tobacco use for 1 year; (2) short-term quitters: participants who had been smoking for at least 6 months and then quit tobacco for 6 months after participating in the programme; (3) relapsed smokers: participants who relapsed into tobacco use after ceasing tobacco use for 6 months; and (4) continuing smokers: participants who failed to quit smoking for at least 1 year, despite participating in the programme. Interventions The Outpatient Smoking Cessation Service of Taiwan provides counselling and pharmacotherapy to individuals seeking to quit smoking. Primary outcomes The health-related quality of life of the participants was measured using an approved Chinese version of the EuroQol-5D-3L (EQ-5D-3L) descriptive system. Results After controlling for sex, age, education, marital status, job status, monthly income and disease status at baseline, our results revealed that long-term (OR=0.61 (0.48 to 0.77)) and short-term (OR=0.65 (0.54 to 0.79)) quitters experienced less anxiety and depression than did continuing smokers. Conclusions Our study provides evidence to support claims that all quitters, regardless of whether they stop smoking for 6 months or 1 year, have better quality of life with regard to anxiety or depression.

Hospitalization for ambulatory-care-sensitive conditions in Taiwan following the SARS outbreak: a population-based interrupted time series study.

Background/Purpose In 2003, the severe acute respiratory syndrome (SARS) outbreak resulted in 8096 probable cases and 774 deaths in 26 countries. The purpose of this study was to explore the effect of the SARS outbreak on hospitalization for chronic ambulatory-care-sensitive conditions (ACSCs) in Taiwan. Methods We applied a population-based interrupted time series study design and used the time series auto-regressive integrated moving-average model to compare the actual and predicted admission rates of seven selected chronic ACSCs. The analyses were based on National Health Insurance hospital inpatient claims data from 1997 to 2003. Results The impact of SARS on ACSCs after the outbreak varied among seven selected chronic conditions. Hospitalization for respiratory conditions was significantly lower than the predicted values, whereas hospitalization for diabetes was significantly higher than the predicted values after the outbreak. Conclusion Admission rates for most ACSCs, except for diabetes, did not change in the post-SARS period. The reductions in outpatient utilization during the SARS outbreak did not appear to affect adversely admissions for most ACSCs.

Managing health expenditure inflation under a single-payer system: Taiwan's National Health Insurance

As nations strive to achieve and sustain universal health coverage (UHC), they seek answers as to what health system structures are more effective in managing health expenditure inflation. A fundamental macro-level choice a nation has to make is whether to adopt a single- or a multiple-payer health system. Using Taiwans National Health Insurance (NHI) as a case, this paper examines how a single-payer system manages its health expenditure growth and draws lessons for other countries whose socioeconomic development is similar to Taiwans. Our analyses show that as a single payer, Taiwans NHI is able to exercise its monopsony power to manage its health expenditure growth. This is achieved primarily through the adoption of a system-wide global budget. The global budget sets a hard aggregate budget cap to limit NHIs total spending to its expected revenue, with the annual budget growth rate established by a process of negotiation among key stakeholders. The global budget system is complemented by comprehensive and continuous monitoring and review of encounter records of all providers and patients, enabled by the NHIs advanced information technology. However, by paying its providers using a point-based fee schedule, Taiwans NHI suffers from inefficient service provision. In particular, providers have incentives to increase use of services and drugs with positive profit margins. Furthermore, Taiwan demonstrates that its control of NHI expenditure growth might be leading it to inadequately meet the changing needs of the population, resulting in the rapid growth of private insurance to cover services excluded or not fully covered by the NHI. If this trend persists and results in a two-tier system, Taiwans NHI may risk compromising the equity it has achieved in the past two decades.

Proposed mechanism for reviewing the coverage of National Health Insurance benefits: New mission for the National Health Insurance Committee

The National Health Insurance Committee (NHIC) is an organization merging the National Health Insurance (NHI) Supervisory Committee and the NHI Medical Expenditure Negotiation Committee for the establishment of a mechanism linking NHI revenue and expenditures. According to Article 5 of the NHI Act implemented on January 1, 2013, one of the major functions of the NHIC involves reviewing changes in the scope of NHI benefit packages. This represents a new mission for the allocation of healthcare resources and prioritizing benefits. In reviewing the scope of NHI packages, the NHIC is tasked with the following activities: (1) revising the scope of NHI benefit packages; (2) reviewing the resource allocation and financial balance plan; (3) conducting global budget negotiations and allocations; (4) reviewing noncoverage items; (5) reviewing plans of the National Health Insurance Administration (NHIA) aimed at reducing the inappropriate use of healthcare resources; and (6)