An inconvenient truth behind high accessibility to medical services

One of the missions of National Health Insurance (NHI) is to help the sick and the uninsured by providing access to medical services at an affordable cost in Taiwan. Nearly 98% of Taiwanese citizens are enrolled in this government-run, single-payer social insurance program. People can seek ambulatory care at around 9500 NHI-contracted physician clinics or at some 500 hospital-based outpatient departments without referral. Accumulating evidence has shown that people in Taiwan have had more equal access to health care, greater financial risk protection, and increased equity in health care financing since the implementation of the NHI. A recent study revealed that the life expectancy of the poorer and previously uninsured group had improved more substantially than that of more affluent and insured individuals 10 years after the introduction of the NHI. The NHI program consistently receives a 70% public satisfaction rating and is recommended as a successful model for countries pursing universal health care. In this issue of the Journal of the Chinese Medical Association, Shao et al report that 92.6% of the randomly sampled NHI beneficiaries had utilized the medical service at least once in 2005. Around 82.3% of the population had visited physician clinics, 48.6% had visited a hospital outpatient department at least once in their lives, and 8% had had at least one experience of hospitalization over their lifetime. Shao et al conclude that people in Taiwan utilize NHI services frequently and tend to seek medical help at hospitals. The investigators also note their concern about the issue of overutilization that is associated with the high availability of and accessibility to medical services. Such concerns have been raised before, but policymakers have not yet come up with a solution. Nevertheless, if the public, health care authorities and health care providers are unwilling to address the drawbacks caused by unregulated accessibility to medical services, the marvelous achievements of the NHI will be less likely to be sustained. First, the NHI budget is inadequate and capped, whereas the demand for high-quality care is rapidly increasing and unregulated. Since the implementation of a global budgeting payment scheme in 2000, the financial risks have been shifted from the government to all NHI-contracted hospitals and clinics. The annual national cost of health care services was around 5e6% of the gross domestic product, significantly lower than the expected 7e8% measured against international standards. Moreover, the annual increase in the NHI budget was around 3e4%, lagging behind the real expenses of the