The Center for Chinese Studies, the David Geffen School of Medicine at UCLA, and the North American Taiwan Medicial Assoc. cosponsor a conference on healthcare issues in Taiwan
The worldwide pandemic of AIDS, and the more recent epidemic of SARS (Severe Acute Respiratory Syndrome), which in 2002 and 2003 was reported in thirty countries in four continents, have demonstrated once again that disease knows no borders. Playing politics with health — attempting to hide the outbreak of disease or limit effective international, scientific cooperation in fighting disease — only contributes to increased suffering and ill-health for the people of all the countries affected. These were perhaps the major conclusions reached at a conference on Healthcare in Taiwan: Opportunities and Success, cosponsored by the UCLA Center for Chinese Studies, the David Geffen School of Medicine at UCLA, and the North American Taiwan Medical Association (NATMA), held at UCLA on September 12, 2004.
Lee Hilborne, MD, MPH (Professor of Pathology and Director of the Center for Patient Safety & Quality, David Geffen School of Medicine at UCLA), who moderated the conference presentations, answered the question of why we should discuss Taiwan’s healthcare challenges by pointing out that Taiwan and the United States share much in common.
- Both have strong healthcare infrastructures
- Our standards of practice are similar
- Advances and innovations diffuse rapidly across the Pacific
In today’s global society, Dr. Hilborne observed, “Taiwan’s challenges are our challenges. There is much we can learn from each other. By sharing, we can improve care in the U.S. and in Taiwan.”
The Battle Against SARS: Taiwan’s Experience
The conference began with a detailed presentation of Taiwan’s battle against SARS by Twu Shiing-jer, MD, MPH, PhD, Taiwan’s Minister of Health when SARS exploded on the scene in Taiwan in the spring of 2003.
Etiology and Clinical Symptoms & Features. Dr. Twu (who is now Vice Chairman, Forum, National Health Research Institutes and Visiting Professor, Division of Health Policy Research, National Health Research Institutes in Taiwan) explored the etiology of SARS and its clinical symptoms and features. Dr. Twu explained that when SARS first appeared in November 2002, it was an entirely new disease and as such nothing was known about it. Health officials wondered if might be a genetic mutation (in other words, a product of nature), or perhaps a creation of man — might it even be an agent of bioterrorism? Analysis revealed that SARS was a novel coronavirus, that is a version of the virus responsible for the common cold, but unlike the common cold it was highly fatal. (At the end of the epidemic, the World Health Organization [WHO] reported that roughly 10 percent of reported cases of SARS resulted in death. Among patients over the age of 60, the fatality rate may have been as high as 45 percent.) Moreover, SARS turned out to be a zoonotic disease (that is, one that is transmitted from animals to humans) that began in China’s southeastern province of Guangdong with the consumption of infected palm civets, a wild animal prized as a delicacy by some connoisseurs in China.
The clinical symptoms and features of SARS are well-known to everyone who kept up with the news. On the first day of symptoms, the patient suffers from fever, followed by cough and diarrhea — flu-like symptoms, in other words — and an abnormal chest X-ray by the fourth or fifth day, with difficult or labored breathing occurring by the second week, followed by respiratory failure. Maddeningly, frequently the patient improved, but within four to seven days after the initial improvement, suffered a relapse.
The method of transmission is similar to that of common cold or flu. Droplets created by coughing will land on the surface within a one-meter-diameter area surrounding the patient. If the patient is immobile (for instance, is quarantined), then close contact can be controlled. However, close contact, which appears to be a culprit, can occur if one cares for or has lived with a person infected with SARS or has unprotected contact with bodily secretions from such a person (leading to the fact that 15 percent to 60 percent of SARS patients were healthcare workers).
During the epidemic, it became clear that it was essential to break the transmission dynamics by first identifying who might be inflected, and second by isolating inflected individuals. Taiwan initiated vigorous quarantine measures to reduce the transmission of SARS. Fever screening was begun at the entrance to all public buildings and passengers entering intercity long-distance buses and trains were screened. Ambulance service was provided to those who had symptoms, and confirmed cases were quarantined. By mid-2003, nearly 120,000 people in Taiwan had been quarantined.
Lessons Learned. The SARS epidemic taught us much, Dr. Twu stated.
The danger of delayed altering and reporting — When SARS first appeared on the Chinese mainland, the authorities attempted to suppress reporting and discussion of the outbreak. Needless to say, turning a blind eye to what proved to be a major public health disaster was exactly the wrong policy.
Hospital infection — Close contact with hospitalized patients is necessary and unavoidable. Initially, lack of procedures and processes to protect healthcare workers resulted in an alarmingly high infection rate among nurses in particular.
Ineffective command channels and logistical exhaustion — Combating SARS required a massive, organized effort. At first, there was simply not an organization in place to lead and coordinate this effort. Furthermore, the immense logical demands of the war on SARS quickly exhausted the capabilities of public health agencies.
High cost of quarantining — Quarantining a huge number of individuals, and following best practices in their care, entailed a very high cost.
Economic costs — The economic toll taken by the SARS epidemic was staggering. Dr. Twu estimated that worldwide lost economic output and revenue from travel amounted to roughly US$50 billion.
Can SARS Be Eradicated? From a physical or scientific standpoint, SARS can potentially be eradicated, Dr. Twu stated, provided
- there are no human carriers
- it does not establish an ecological niche in animals in a new location
- the natural host can be identified
But much more important in answering the question of whether SARS can be eradicated, Dr. Twu argued, is political policy: Will political considerations stand in the way of effective health measures? First, is China capable of transparency in disease reporting? In the 2002–03 SARS outbreak, the Chinese authorities at first attempted to suppress all reports of SARS and denied there was a problem. When it became impossible to sustain this charade, the authorities still attempted to control and limit the amount of information that was released concerning the incidence of SARS. Second, can Taiwan secure good international cooperation in fighting pandemics such as SARS? Taiwan is denied membership in WHO, and lacks regular channels of communication with WHO. Many in Taiwan feel the island nation is unjustly put at risk since fighting the spread of diseases like SARS requires quick and effect communications.
Taiwan’s National Health Insurance: Successes and Challenges
The second speaker, Ernest Yen, MD (Associate Professor in the David Geffen School of Medicine at UCLA), addressed long-term historical and cultural developments that have contributed to making Taiwan what it is today. Dr. Yen briefly traced the historical origins of Chinese settlement in Taiwan, and then delved into the cultural factors that over time increasingly separated the people in Taiwan from those on the mainland.
Following Dr. Yen’s talk, Dr. Jason Wang, MD (of the Pardee RAND Graduate School and the David Geffen School of Medicine at UCLA) spoke of the challenges faced by Taiwan’s national health insurance system as well as its successes. A major success of the system is that it is very nearly universal. Everyone has access to medical services. And Taiwanese take advantage of this access by, on aggregate, visiting the doctor much more frequently than do patients in the United States. But each doctor visit in Taiwan is extremely short: on the order to 2 to 5 minutes per patient per visit.
The visits are so short because physicians are called upon to see an extremely large number of patients each day. This leads to a vicious cycle, as Dr. Wang explained. Doctors do not have sufficient time to take a complete patient history and give a thorough physical exam, they do not have the time to explain conditions properly to the patient, physicians feel they are not adequately reimbursed for their services, and they prescribe medications as the main therapeutic tool and suggest frequent follow-ups, which contributes to a high patient volume, which in turn leads to short visits.
Patients too are share responsibility for this vicious cycle. In general, Taiwanese patients, Dr. Wang contended, need to improve their medical knowledge. Because they now lack sufficient knowledge about health, they often feel their problems have not been adequately addressed and they exhibit a low rate of compliance to treatment plans and medication, which in turn leads to repeat visits to the clinic or hospital out of continual concern over illness.
Per Capita Health Spending in Taiwan, Selected Other Asian Countries, and the U.S.
|Income per capita, US$ thousand||Annual healthcare expense per capita, 1998 (US$)||Share of expense not covered by insurance or the gov’t (out of pocket), percent||Hospital beds per 1,000 population|
|South Korea|| |
|United States|| |
source: Andrew T. Huang, C. Jason Wang, and Chih-Liang Yaung, “Insuring Taiwan’s Health,” McKinsey Quarterlyno. 4, 2001.
Dr. Wang next assessed Taiwan’s healthcare system according to six criteria. Whether healthcare overall is (1) safe and (2) effective, the evidence from Taiwan is inconclusive or incomplete. Whether healthcare is (3) patient-centered (respectful of and responsive to individual patient preferences, needs, and values, etc.), the record, Dr. Wang observed, is mixed. Healthcare in Taiwan is generally (4) timely and (5) equitable (i.e., healthcare does not vary in quality because of personal characteristics), but it is definitely not (6) efficient (in the sense of avoiding waste, in particular waste of equipment, supplies, ideas and energy).
What Taiwan needs, Dr. Wang argued, is much greater attention to quality of care. The first step in that direction must be the collection and analysis of good, solid documentary evidence. Such evidence is particular needed because health providers now complain that payments from the National Health Insurance Bureau are too low, but “in the absence of good documentation on the quality of healthcare, consumers will not be convinced that quality of care is an important issue or that paying more for healthcare would improve their care.”
Just how good (or poor) is the quality of healthcare in Taiwan? We simply cannot say because rigorous documentation does not exist. If one looks, for example, at the United States, where technical quality of care is often thought to be among the highest — if not the highest — in the world, studies show that quality of care is actually disturbingly low. In the largest relevant American study (which involved medical records for 6,712 patients), it was found that fewer than 55 percent of the patients in the sample received “scientifically indicated care.” Overall, the study concluded that the “failure rate” in the technical quality of American healthcare is approximately 45 percent (E. McGlynn, S. Asch, et al., “The Quality of Care Delivered to Adults in the United States,” New England Journal of Medicine; June 2003). Dr. Wang hinted that one can only guess how much lower technical quality of care must be in Taiwan.
But guessing will not do. What is needed, according to Dr. Wang, is a systematic effort to gather relevant documentation and data. In particular, studies are needed to:
- Document variations in care
- Benchmark Taiwanese data against data from other countries
- Identify potential areas of overuse, underuse, and misuse
- Assess the technical quality of care using indicators of quality (such as the RAND Quality Assessment tools)
- Assess patients’ experience with care
- Guide the setting of goals to improve quality
On the issue of assessment, Dr. Wang reported that collaboration between UCLA/RAND and Taiwan is starting. In collaboration with the Koo Foundation Sun Yat-sen Cancer Center, UCLA and RAND are assisting in the formation of a Center for Healthcare Improvement. They are also helping with the training of Taiwanese health services researchers. Finally, they are providing technical assistance with a pay-for-performance quality initiative in breast cancer.
In the panel discussion that followed Jason Wang’s talk, Steven Asch, MD, MPH (Deputy Chief of Staff for Health Service Research, Veterans Administration; and a policy analyst at RAND) commented in particular on the pay-for-performance initiative. Dr. Asch noted that the public readily accepts the idea that in business and commerce one should expect to pay more for a better product or service. But the public — and service providers — are not yet accustomed to the notion that health professionals should be paid according to the quality of service they provide. The pay-for-performance initiative in Taiwan will, it is hoped, help reinforce the notion that quality of care is crucial (and hence, high quality care is worth a premium) and serve as an incentive to raise the level of healthcare delivered to the people of Taiwan.
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The conference was supported by an Educational Grant from the Government Information Office, Taipei, Taiwan
Date Posted: 9/30/2004