Huang San-Kuei, Director-General of the National Health Insurance Administration (NHIA) under the Ministry of Health and Welfare since 2013, is both a medical doctor (from Chung Shan Medical University) and holder of a Master’s degree in Hospital and Health Care Administration from National Yang-Ming University, where he continues to be an adjunct professor.
He was interviewed for Taiwan Business TOPICS by Editor-in-chief Don Shapiro. Excerpts follow.
On the Pharma Cloud initiative launched by NHIA:
Since access to Taiwan’s National Health Insurance is so convenient and because this is a third-party payer system, there’s a potential moral hazard when people use the system. It’s easy for resources to be wasted because the users aren’t bearing the bulk of the cost – the third-party payer (the government) is. And there are no restrictions on access to health providers. You can see a doctor at a clinic and then go see another one at a medical center for the same ailment.
Besides, in Taiwan the patient expects to be prescribed medicine. If you don’t receive medication, you feel like you haven’t actually seen a doctor. That’s quite different from the West, where physicians are very cautious about prescribing medication, knowing that drugs can treat illness but may also have adverse effects on the body. So in Europe and America, you’re only prescribed medicine if you absolutely need it, while in Taiwan patients consider it very strange if they don’t receive medication.
Besides, in Taiwan the patient expects to be prescribed medicine. If you don’t receive medication, you feel like you haven’t actually seen a doctor.
Over the years there’s been a lot of criticism about the over-use of medication that this situation has caused. We needed to come up with a solution. Fortunately, Taiwan has a highly developed information and communications technology (ICT) sector. After several years of reviewing the situation, we felt that the time had come where we could rely on that strong ITC capability to help provide a solution by creating the Pharma Cloud.
What does Pharma Cloud entail? Physicians can now see patients’ complete medical record for the previous three months on their computer screen – all the medical visits and medications prescribed anywhere on the island. But to protect their privacy, patients must first give permission, in case there are some medical issues they don’t wish to share with that doctor out of embarrassment or other reasons.
But with the patient’s consent, the physician can see, for example, whether the patient was already prescribed hypertension or cholesterol-control medicine by another doctor – so he will know not to duplicate that prescription. The physician will also be able to tell whether there is a history of allergy to some medication.
We started to promote the system about two years ago and have continued to work with healthcare providers to expand its utilization. As of now, in most hospitals doctors are using the system as long as the patient agrees. And it’s very rare for the patient to withhold permission – since if you don’t trust the doctor, you generally wouldn’t be going to consult him or her in the first place. There are some exceptions, however, such as patients with AIDS who might not want others to know about their condition.
On the benefits derived from Pharma Cloud:
In Taiwan, seeing a doctor is just too convenient. In a population of 23 million people, an average of one million doctor visits take place every single day. One million! It’s terrible! If we didn’t use our ICT capability to monitor the situation, it would be impossible for our health insurance system to continue to run smoothly.
In a population of 23 million people, an average of one million doctor visits take place every single day.
In 2015, the monetary value of duplicate prescriptions that were prevented through Pharma Cloud came to NT$10.5 billion. This amount is significant for two reasons. First, without this program, what would have happened? If patients had taken the extra medicine, it would have done them no good and probably a lot of harm. If they hadn’t consumed the medicine, it would have been a waste of resources. And if they had thrown the medicine away, it would have contributed to pollution of the environment.
In 2015, the monetary value of duplicate prescriptions that were prevented through Pharma Cloud came to NT$10.5 billion.
Secondly, the NT$10.5 billion we saved was returned to the healthcare providers to enable them to reallocate their resources, using the funds where they can do the most good, for example for the Emergency Room or Intensive Care Unit.
You might wonder why we didn’t start this program even earlier. Actually, we tried implementing the program six or seven years ago, but at that time both Internet speed and data storage space was still insufficient. If it takes five or six minutes for the patient’s medical record to appear on the screen, the physician would find it intolerable. But our IT department is really strong, and now the time has been reduced to five or six seconds.
On monitoring the frequency of doctor visits:
We also analyze how often patients are seeking medical treatment. If more than 10 times in the past month, the doctor’s computer screen will show an alert. That doesn’t mean that the consultation can’t proceed, but it cautions the physician to pay special attention to the case. The main motivation is concern for the patient. If you ingest a lot of unnecessary medication or undergo unnecessary medical tests, it may put your health at risk.
Also, if your medical visits exceed 50, 70 or 100 times in a year, you will be subject to an individual healthcare visit by a member of the NHIA staff to check on your situation. If the visits are judged to be more than necessary and continue to be excessive, you may be restricted to seeking medical attention at certain designated facilities only. If you go elsewhere, NHI won’t pay for it.
There used to be a lot of “medical shopping” – people going around to consult numerous doctors for the same ailment. Of the 365 days in a year, there were quite a few cases of people who saw a doctor more than 100 times. But with the help of monitoring through Pharma Cloud, we now have a better handle on controlling this problem than any other country in the world. We can do it in Taiwan because of our ICT strength, because we are a single-payer system, and because a social consensus has developed that the overuse of medication is a big problem that needs to be controlled.
Of the 365 days in a year, there were quite a few cases of people who saw a doctor more than 100 times.
The success of Pharma Cloud has given us the confidence to work on the next stage of guarding against the overuse of procedures such as CT scans and MRIs. Repeat tests should be eliminated if the one done already is sufficient. We need to make the best use of IT as a control.
On the impact on the pharmaceutical industry:
Every year NHIA sets a Drug Expenditure Target (DET), and if the target is exceeded, the following year the drug companies are committed to make up the difference. Last year if we hadn’t saved NT$10. 5 billion through Pharma Cloud, drug expenditures would have been that much higher. But because of that saving, the amount in excess of the target that the pharmaceutical industry will need to repay is much, much less than was expected. The exact number isn’t ready to be announced, but I can tell you that it’s a huge difference. Pharma Cloud is bringing benefits to everyone, including both patients and the drug companies.
On implementing the My Health Bank system:
All countries in the world that have implemented a universal healthcare system have encountered a problem in maintaining its viability. Populations are aging and the cost of healthcare for the elderly is very expensive, but it’s very difficult to increase premiums. England, Germany, Japan…many countries have run into this problem.
Our NHI system provides care at the acute stage, but that’s already late. We should be thinking about whether we can help patients take better care of their health at an earlier stage before it becomes an acute condition. The objective should be to ensure that patients receive sufficient primary care so that they don’t need secondary care or have to be treated in an ICU, prolonging the process. In other words, educating the public to look on their healthcare as their own responsibility, not that of the government or NHI.
To accomplish that, however, it’s the government’s duty to provide a suitable tool to the insured. Again, the best way is to rely on ITC to make data available, while assuring security and privacy. Now you can use your NHI card and go online to register to get a password, and with the password you can download all your medical history from Taiwan for the past three years, including dental and Chinese medicine, and both inpatient and outpatient information. You can see all the medication that was prescribed and which hospitals you were examined at and the results. Reviewing that record, you have a clearer picture of what your medical conditions are and what you need to pay attention to in your daily life.
In the beginning, it was a rather boring-looking document, but we’ve now given it a more colorful and animated design to make it more interesting for people to look at. The concept behind all this is “My data, my decision.” This is your data – NHIA wants to make it available to you so you can make your own healthcare decisions.
The concept behind all this is “My data, my decision.” This is your data – NHIA wants to make it available to you so you can make your own healthcare decisions.
Our responsibility is to make sure it is accurate and up-to-date. We update the data [including some information in English] daily. So far Taiwan is one of just a few countries in the world with this kind of system.
On the progress of My Health Bank:
In the year since we launched My Health Bank, 300,000 people have registered to participate, and our goal for this year is to reach one million. The promotion is being done mainly through the health departments and social affairs departments of the city and county governments. Involvement by the local health centers is beneficial because later they can give reminders to patients in their community when necessary – for example, for those with hypertension to regularly check their blood pressure. People are grateful to the government for looking after them, and we are happy to do it because if people take better care of their health, the burden on NHI is reduced. The job is difficult but the reward is high.
After downloading the data, people will know how much they paid in the past year for premiums and co-payments and how much NHI paid on their behalf. In a way it will also help NHIA to monitor the healthcare providers – helping us watch out whether the clinics and hospitals are following the regulations. But more important is that it will enable people to take better care of their own health. Young people can help their parents and grandparents to download the data.
The My Health Bank platform will follow someone’s healthcare “from womb to tomb” – from childhood vaccinations through treatments in adolescence, middle age, and old age, including long-term care. In this way, healthcare providers will be better able to provide holistic care.
The My Health Bank platform will follow someone’s healthcare “from womb to tomb” – from childhood vaccinations through treatments in adolescence, middle age, and old age, including long-term care.
It can also provide economic advantages. We have already entered into cooperation with the Shin Kong, Fubon, and Nan Shan life insurance companies. With the policyholders’ permission, their customers are entered into the My Health Bank system. It’s good for the policyholders, and if they can remain in better health as a result, it’s also good for the insurance companies in reducing their claims.
We’re also working with Taiwan companies on a wearable device that can monitor your heartbeat, breathing, and other health indicators. Integrating that information into My Health Bank will make it especially useful. In addition, My Health Bank data can be downloaded to your mobile phone and we have an app that serves as a Heart Disease Crisis Assessment to warn you if you’re in danger of a heart attack. We also plan to develop an app to monitor kidney function to help people avoid the need for dialysis.
All of this is altering the traditional form of public health education. Rather than approaching people one by one, we can now do it for the public in general. Through the system, as one example, we can identify those most at risk of liver cancer and alert them to take precautions. The impact can be enormous.