Is the development of a diabetes care system important for quality care? An analysis in Taiwan

A good community‐based or hospital‐based program involving physicians and nurses is deemed useful for the management of chronic illnesses, such as diabetes, as this program would reduce health‐care costs, admission rates and emergency room visits1. Therefore, establishment of a health‐care system for the management of diabetes in a highly cost‐effective way is important from the viewpoint of public health. In 1990, the first government‐subsidized diabetes center with educators in Taiwan was founded at the National Taiwan University Hospital, wherein an integrated clinic for screening diabetic complications (retinopathy, microalbuminuria, peripheral neuropathy and ankle‐brachial index) was set up to monitor the outcomes of individuals with diabetes. Because of the increasing rate of diabetes prevalence and its associated chronic complications, the Department of Health commissioned the Diabetes Association of the Republic of China to help set up more diabetes centers in 1991, and 2 years later, the name was changed to Center for Health Promotion of Persons with Diabetes. As smaller units were set up in the regional hospitals and clinics, they were called Classroom for Health Promotion of Persons with Diabetes, and Clinic for Health Promotion of Persons with Diabetes, respectively. To date, 167 small and large units of Health Promotion of Persons with Diabetes have been set up with aid from the Taiwanese Association of Diabetes Educators (TADE), which was established in 1996 to train health professionals. The Bureau of National Health Insurance (BNHI) offers free Health Check‐Up for Adults every 3 years for persons aged over 40 years, and every year for persons aged over 65 years. To improve the quality of care for diabetic patients, a pilot program called Improvement Plan for Diabetes Medical Benefits was launched in November 2001. The pilot program was replaced by a formal program with introduction of a pay‐for‐performance (P4P)2 scheme in 2007. For the first time in the history of diabetes education in Taiwan, the program reimbursed the cost of patient education by a certified nurse and dietitian included in the case management fee, in addition to the usual physician’s fees and the medication fees. To be eligible for this program, the patients must undergo a baseline assessment, and an annual check‐up for a complete biochemical examination and screening for complications. The data of these assessments have to be uploaded to the BNHI website. To date, approximately 30% of diabetic patients in Taiwan have been covered by the improvement program.