Hierarchically Integrated Health Systems Planning
To promote balanced development of medical resources and rationally distribute existing medical institutions and human resources, the National Health Insurance Administration promotes hierarchically integrated health policies, including two-way referrals to provide comprehensive care for patients.
In March 2017, an electronic referral platform was established. As of the end of November 2018, a total of 9,866 medical institutions used this referral platform, transferring 745,000 person-times.
In March 2018, the Yanxing Team began to encourage vertical integration of medical institutions. As of the end of November 2018, 76 teams were established, including 6,271 medical institutions.
The government encourages hospitals to share medical treatment information and test/examination records through the NHI MediCloud System. From July to December 2017, nearly five million fewer images were made for computed tomography (CT scans), magnetic resonance images (MRIs), blood examination and 20 other categories with 274 examinations and inspections compared with the same period the previous year, saving about NT$ 1.2 billion. Six common chronic disease medications' overlap ratio was reduced by more than half from 2014 to 2017, saving about NT$ 340 million.
To explain the hierarchically integrated health system policy to the public, NHIA has strengthened publicity through various channels. Director General Po-Chang Lee visited the heads of cities to support the policy, and visited the Minister of Education to study the question of including health insurance topics in elementary school textbooks so children learn to conserve health care resources and develop correct ideas about medicine and health.
We also are strengthening the functions of the My Health Bank System to be used more conveniently through phone applications. As of December 2018, the number of people who use the system exceeded one million.
NHIA will continue to use the electronic referral platform and the NHI MediCloud System to adjust payment standards so medical institutions will refer and to require large hospitals to reduce their numbers of outpatients. These and other measures constitute a hierarchically integrated health policy.
The Patient Autonomy Act
According to the global palliative care ranking on Quality of Death published by the Economist in 2015, Taiwan was at position six among all 80 countries and ranked first in Asia, indicating international recognition of Taiwan's palliative care. The Ministry of Health and Welfare has cooperated with local governments, medical institutions and the Taiwan Hospice Organization to advocate and promote the Advance Hospice Palliative Care and Life-Sustaining Treatment Choices of Intent and the Registration National Health Insurance IC card since 12 years ago. By the end of November 2018, 586,013 citizens signed the Advance Hospice Palliative Care & Life-Sustaining Treatment Choices of Intent and registered their decisions on their National Health Insurance IC cards.
Taiwan promulgated the Patient Right to Autonomy Act in January 2016 to legalize the majority's right to make binding advance decisions in writing to choose to receive or decline medical care through the consultation on advance care planning. This act is expected to become law in January 2019. The Ministry of Health and Welfare also drafted Regulations Governing Management of Advance Care Planning Consulted Institutions and an Advance Directive Form. Implementation regulations were drafted in June 2018 to ensure the smooth implementation of the Act as scheduled. The Patient Right to Autonomy Act is the first of its kind in Asia, and it is a huge step toward Taiwanese patients having the right to choose a dignified and “good death.”
Policy Effectiveness and Prospects: Protection of Physician Labor Rights
The Ministry of Health and Welfare announced guidelines for the labor rights and working hours of medical residents in March 2017 after referring to the Accreditation Council for Graduate Medical Education (ACGME) working hour standards and consensus in the medical industry. These guidelines include regulations for employment contracts, principles of working hours and holidays, etc. The guideline was implemented in August 2017.
To ensure people's rights to medical access, the Ministry of Health and Welfare consulted with the Ministry of Labor and announced that the Labor Standards Act and the regulations of working hour agreements in Article 84-1 will be applicable to medical residents as of September 1, 2019. As for attending physicians, due to current conflicting opinions, including the potential impacts of working hour limitations on attending physicians' clinical work, education and research, health-care continuity and health care in rural and remote areas, coordination and communication will continue.
Medical disputes processing mechanism
(1) Promotion of delivery accident assistance regulations: the country has undertaken the risk of delivery since June 30, 2016, improving the active care of medical institutions. The government provides assistance promptly, reducing medical litigation: obstetric judicial litigation has fallen by 6%.
(2) Reinforce alternative dispute resolution: the Prevention of Medical Malpractice and Dispute Resolving Law strengthens alternative dispute resolution to handle medical disputes properly. The draft was submitted to the Legislative Yuan for deliberation by the Executive Yuan on April 13, 2018, and was reviewed on May 24, 2018, pending consultations by the party group.
Improvement of nurses' workplace and innovation career model
In order to improve the working conditions and retention of nursing staff, our department has promoted friendly care in the workplace, the mechanism of NHI feed according to nurse–patient ratios and legalization, and established a platform for anonymous dispute reporting in the workplace. These measures significantly altered the turnover rate（13.14%→9.98%）and vacancy rate（7.22%→6.73%） and increased salaries and numbers of registered nurses. Based on the demands of community health care, we are promoting Neighborhood Nursing Facilities for Home Care 2025 Multiplication. This involves counseling the annual leaving nursing staff and transferring creatively to a community care model, which extends the life of nursing practice and increases health care accessibility.
Aboriginal area and offshore island care policy
The 2018 Aboriginal Area and Offshore Districts action plan was established to reduce health inequities in rural or isolated areas and remedy the uneven medical resources of the Offshore Districts while improving care in aboriginal and outlying island areas. Medical policies focus on strengthening local care supplemented by emergency air medical transportation, emergency medical evacuation, and critically ill patient transportation integration. In addition, the remote multi-party video consultation program will be established in 2019 to improve emergency medical evacuation performance.
Dedicated to Rural Medical Services
A main focus of our policy this year is to promote rural health through localizing medical services. To begin with, we plan to strengthen emergency medical service provision by establishing 18 permanent medical facilities throughout Taiwan to provide emergency care. We plan to establish at least one Critical First Aid Responsibility Hospital in every county and city by subsidizing existing establishments, and to help develop Critical First Aid Responsibility Hospitals in Miaoli County and Taitung County. To reach the goal of localizing medical services, we will mobilize medical specialists in rural regions and adjust desired goals for each hospital eligible for National Medical Centers and Critical First Aid Responsibility Hospitals subsidy to support offshore islands and regional hospitals with insufficient emergency medical resources (醫學中心或重度級急救責任醫院支援離島及醫療資源不足地區醫院緊急醫療照護服務獎勵計畫).
Founding Regional Mutual Aid System
Following changes in modern lifestyles, recent Taiwan death statistics showed the top five causes of death are cancers, cardiovascular disease, cerebrovascular disease, pneumonia and diabetes mellitus. To ensure that critical patients receive appropriate medical care within the "golden hour," Emergency Medical Competency Grading (醫院緊急醫療能力分級評定計畫) was founded in 2009 to adjust standards of medical service in accordance with each disease. Through reviewing the current emergency medical services system and promoting first aid responsibility hospital grading, we integrated 41 critical and 79 intermediate first aid responsibility hospitals with 14 emergency referral networks to reinforce capacities to provide emergency medical care.
Taitung Telemedicine Outpatient Trial
The trial program to establish a telemedicine outpatient service in the Taitung area used communication technology and telemedicine equipment to help people in remote areas access services provided by a medical center physician. The trial program opened on November 6, 2017, and served 103 people as of December 20.
Building a Comprehensive Child Wellness Network
Taiwan's total fertility rate is low, and neonatal and childhood mortality rates are high. The government should increase children's health resources from the start of life, and improve perinatal and emergency medical care for children to reduce preventable deaths in newborns and children. Efforts to establish a hierarchical medical system for children and a maternal care network include:
- Optimizing the reproductive environment and completing the perinatal medical system.
- Improving the accessibility of emergency medical care for children and establishing a hierarchical medical system.
- Training professional transfer teams for children's critical care.
- Integrating inter-hospital resources to strengthen children's critical care.
- Developing a family pediatrician system.
- Training pediatric professionals for local demands.