TAIWAN'S NATIONAL HEALTH INSURANCE: TUNING UP A

C O N F I D E N T I A L SECTION 01 OF 04 TAIPEI 001881 SIPDIS STATE FOR EAP/RSP/TC STATE PASS AIT/W AND USTR, USDOC FOR 4431/ITA/MAC//AP/OPB/TAIWAN/MBMORGAN E.O. 12958: DECL: 04/20/2015 TAGS: ECON ETRD TW SUBJECT: TAIWAN'S NATIONAL HEALTH INSURANCE: TUNING UP A BROKEN DOWN VEHICLE REF: A. 04 TAIPEI 4021 ¶B. TAIPEI 478 Classified By: Director Douglas Paal, Reasons 1.4 b/d ¶1. (SBU) Summary: Facing a severe budget shortfall for 2005 that is projected to increase dramatically in coming years, the Taiwan Bureau of National Health Insurance (BNHI) and the Department of Health in April began to implement several measures designed to increase revenue and cut expenses. Even together, the changes do not come close to closing the National Health Insurance (NHI) financing gap. Public response to individual measures to increase revenue has been muted thus far, but BNHI officials tell us continued concern over political fall-out is preventing Taiwan,s leadership from approving badly needed increases in Taiwan,s health insurance premium rate. A premium increase and changes in co-payment requirements could bring BNHI's books back into the black, but only radical reform of the NHI system will eliminate the "black hole", the pricing differential between the official NHI reimbursement price and what hospitals really pay suppliers for medical equipment and pharmaceuticals. Medical facilities use this price differential to subsidize their administrative costs. In the meantime, BNHI's efforts to control spending through capping reimbursements are pushing many hospitals toward bankruptcy and inspired more than 30,000 medical workers to take to the streets on April 20. End Summary. ¶2. (U) AIT met with BNHI Vice President Lee Cheng-hua April 14 to discuss NHI's recent moves to address the agency's projected FY05 budget shortfall of NT$171 billion (approx. US$5.5 billion). This estimate does not include an additional NT$40 billion that BNHI claims it is owed by the cities of Taipei and Kaohsiung under a local expense-sharing scheme that both municipalities have refused to pay since ¶2002. Part of that deficit will be covered by the last of Taiwan,s legislatively mandated NHI reserve fund (NT$74 billion). But even after all reserves have been exhausted, NHI is still expected to face a NT$97 billion deficit in 2005, and a NT$253 billion deficit in 2006. Under the sobriquet of the "Multiple Tune-Up Policy", BNHI has created a plan to continue near-term operations by cutting costs and incrementally raising revenues through a series of piecemeal measures. ============================ Chipping away at the deficit ============================ ¶3. (U) As a first step towards chipping away at its budget deficit, BNHI in February announced it had shifted NT$11 billion in public health expenditures back to the Department of Health. Beginning on April 1, BNHI raised the upper limit on salary subject to NHI premiums from NT$87,600/month to NT$131,700/month. This means upper income earners now pay health premiums calculated on a higher base salary. BNHI expects this reform to generate an additional NT$3.4 billion in revenue for 2005. BNHI also revised its policy for calculating premiums for public employees including military and civil servants and teachers. Prior to April 1, premiums for government employees were calculated based on 82% of their basic salary. Beginning in April, the premium is calculated based on 87% of their basic salary. There have been no public demonstrations nor has there been significant public comment about these increases. ¶4. (SBU) BNHI also hopes the legislature will approve a plan to double the excise tax on tobacco products from NT$5 to NT$10 during the current session. Lee told AIT he foresees no significant opposition in the LY to such a move. A proposal to reallocate a portion of revenue collected from emission taxes to support the NHI was rejected by LY members and has been dropped. Finally, BNHI would like to raise outpatient co-payments at bigger hospitals in metropolitan regions. This would meet the dual goals of raising revenue for NHI and encouraging patients to visit smaller hospitals and clinics for routine outpatient care, freeing larger hospitals to focus on treatment of more serious cases. BNHI projects this could raise NT$5.3 billion in 2005. This proposal is opposed by consumer groups concerned about convenience and quality of care and by hospitals. ===================================== Bank loans to fill the short-term gap ===================================== ¶5. (SBU) BNHI's dire financial situation has forced the bureau to turn to the banking sector for funding. According to Lee, BNHI in February borrowed NT$80 billion from a consortium of eight Taiwan banks on commercial terms. The loan carries a market rate of interest of 1.1% and will cover the gap caused by the failure of Taipei and Kaohsiung to pay their share of municipal health expenses, to cover over reimbursements to hospitals (NT$27 billion),and to provide BNHI with one month of working capital (NT$13 billion). Opposition legislators have criticized BNHI for borrowing money from the private sector and warned that future premium increases should not be used to pay interest on the debt. ================ A penny saved... ================ ¶6. (U) BNHI also plans to cut its reimbursement costs through stricter management of services. The introduction of integrated circuit (IC) health cards in 2003 allowed BNHI to more easily monitor health system usage and identify those patients whose usage of health services appears unusual or excessive. Those users whose patterns of activity raise red flags will be monitored by BNHI to identify problems. By actively discouraging the commoen practice of "doctor-shopping" and scrutinizing suspicious prescription drug usage, BNHI hopes to deter fraud and discourage patients and medical providers from abusing the healthcare system by repeated unnecessary doctor visits, lab tests, and prescriptions. BNHI plans to aggressively investigate fraud and will work with DOH to increase public education and awareness of the appropriate use of the healthcare system. ¶7. (U) Official statistics from BNHI show that the average Taiwan resident visits a doctor over 15 times per year and takes away 4 prescriptions each time. In an attempt to control drug expenditures, BNHI is considering de-listing 1200 over-the-counter (OTC) medications currently eligible for reimbursement. Beginning in July 2005, BNHI will no longer reimburse hospitals or patients for these pharmaceuticals. In 2004, BNHI spent NT$2.3 billion to cover non-prescription drugs. Consumer groups and local pharmaceutical associations oppose this reform, arguing that Taiwan patients need professional guidance to ensure medicines are taken properly. ¶8. (C) For several years, BNHI has used price/volume surveys (PVS) to review its reimbursement rates and to adjust these rates periodically to reflect actual prices paid by hospitals to distributors. Pharmaceutical companies in Taiwan are actively opposing reimbursement reductions expected to follow the latest PVS. The International Research Pharmaceutical Manufacturers Association (IRPMA) believes the PVS and subsequent reimbursement cuts are non-transparent and has joined Taiwan,s five other pharmaceutical associations in refusing to provide price and sales volume data on 802 products requested by BNHI. Instead, they have proposed an across the board 2.5% reimbursement cut on virtually all pharmaceutical products, potentially saving BNHI approximately NT$2.75 billion, a figure they believe is equivalent to what BNHI would save after implementing PVS inspired reimbursement cuts. BNHI has agreed to consider the proposal, but BNHI Vice President Lee told AIT that the industry proposal was too stingy and would not result in sufficient savings for BNHI. He suggested a proposal in the 5-7% range would be more likely to pique BNHI's interest. However, even this would have a minimal impact on BNHI's overall deficit. ============================================= === ...doesn't mean much when you're losing billions ============================================= === ¶9. (C) These measures, even taken together, do not come close to closing BNHI's fiscal gap. But political considerations continue to block an increase in health insurance premiums, the one reform that would quickly bring Taiwan,s NHI back into the black. The current premium is set at 4.55% of wages and was last raised in September 2002, a move that faced heavy public opposition and cost then Health Minister Lee Ming-liang his job. BNHI has the authority to increase premiums to 6% of wages without legislative approval but was unwilling to do so during last year's election season. BNHI economists believe an immediate increase to just over 5% could keep the NHI afloat for another 2-3 years without necessitating major systemic reforms. With LY elections next scheduled for 2007, BNHI was considering proposing premium increases in 2005, according to Lee. However, newly installed Premier Frank Hsieh reportedly told BNHI President and CEO Liu Chien-hsiang that the current political situation made discussion of premium increases difficult to consider. Instead, BNHI will instead pursue its "Multiple Tune-up Policy" while it attempts to build consensus for a premium increase sometime in 2006. ¶10. (C) Minister of Health Hou Sheng-mou acknowledged that the current policy does not address the core problems of the NHI. But he hopes that by implementing a series of small changes he can buy time to build consensus for a "revolutionary" reform that will create a second-generation NHI system that will tie premiums to household income instead of salary and increase charges as health care usage increases. In a March 20 press interview, Hou briefly discussed the need for reform of insurance rates and suggested that in a society with an aging population and changing medical technology it is impossible to keep insurance rates pegged at the same rate. Although Hou took pains to emphasize the need to guarantee to the people that the money would be used effectively, he insisted that premiums must be increased in order to maintain the viability of the system. BNHI Vice President Lee told AIT that he believes to ensure the fiscal health of the NHI was to change the law to allow premiums to be adjusted automatically to reflect inflation and increasing healthcare costs. Taiwan politicians lack the courage to risk political opposition and approve necessary premium increases, he said, insisting it was better to take the responsibility out of their hands. =========================================== Doctors Protest BNHI reimbursement policies =========================================== ¶11. (U) Doctors and other medical personnel held a very large demonstration April 20 to protest the NHI's current reimbursement policy. AIT Econoff estimates over 25,000 people, from all parts of the island, rallied at the Chiang Kai-shek Memorial and marched to the Legislative Yuan to oppose BNHI imposed reimbursement caps (known as "global budgeting") and a BNHI demand that hospitals refund NT$30 billion in disputed reimbursement payments. Protesting medical workers say that the implementation of "global budgeting" is driving hospitals into bankruptcy, forcing them to cut salaries and services. When asked, they insisted they were not opposed to the NHI system, but that they could not effectively treat patients without adequate reimbursement from BNHI. However, protesters informally surveyed by Econoff were generally unwilling to support increasing premiums and co-payments for patients, instead asking BNHI to more effectively use its current resources. Chinese Medical Association (CMA) President Huang Nan-ho claims that under the current system hospitals are reimbursed for only 60 percent of their costs, and that one-third of Taiwan's 700 hospitals and medical centers are on the verge of bankruptcy. BNHI's recent announcement that they would request refunds of reimbursements from several hospitals which were overpaid previously is further fueling the medical workers protest. Organizers had predicted that 12,000 medical workers would participate in the protest and were surprised that the actual participation was more than double expectations. =========================================== Hospitals want Suppliers to Feel their Pain =========================================== ¶12. (C) As BNHI's financial position continues to deteriorate, the pressure from hospitals on medical suppliers to provide further discounts is increasing. In concert with BNHI's request that medical facilities return disputed over-reimbursements from 2003-4, Taiwan's biggest public hospital (Veterans General Hospital) has already informed pharmaceutical suppliers that they must make cash "donations" to the hospital based on their sales in those years. Pfizer's Taiwan representative alleges that most have already complied. =============================== Comment: Living in a Black Hole =============================== (C) 13. Comment: BNHI continues to search for ways to get out of the financial straitjacket imposed by the combination of rising healthcare costs and fixed premiums. Taiwan spends only 6 percent of GDP on healthcare (compared to 15 percent in the US) and Taiwan residents are frequent users. 97 percent of residents are covered by the NHI. BNHI believes that the only way to keep the system afloat in the near term is to pass the pain on to hospitals and medical suppliers, including pharmaceutical companies, by capping payments to hospitals and by continuously reducing reimbursement prices for medical supplies. Hospitals then squeeze suppliers by negotiating further discounts and pressing for "donations", creating a spread between the actual and reimbursement price (the black hole) that they count on to cover their administrative expenses. ¶14. (C) As BNHI's financial position continues to deteriorate, the pressure from hospitals on medical suppliers to provide further discounts will increase, expanding the "black hole" in the near term. Without it, Taiwan's national health insurance system would face collapse. The NHI needs radical reform to shift more of the burden of healthcare costs to consumers, who receive high quality care at prices US consumers would find staggeringly low, by increasing premiums to better cover operating expenses and co-payments to reduce frivolous use of services. Until hospital expenses can be met from transparent revenues, efforts to implement transaction price reimbursements that could eliminate the black hole are unlikely to succeed. Given the timidity of Taiwan politicians on changes to the healthcare system, it is likely that only the imminent collapse of the system will open the door to this kind of radical reform. End comment. PAAL