Comparing Access to Primary, Preventive Healthcare in Canada and Taiwan Reflections from the Comparative Healthcare Systems Program Kate Y.

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1 Comparing Access to Primary, Preventive Healthcare in Canada and Taiwan Reflections from the Comparative Healthcare Systems Program 2014 ABSTRACT Kate Y. Gong McGill University, Montreal, Quebec, Canada In response to aging populations and rising healthcare costs, primary care is becoming increasingly important in the public health establishment. Preventive interventions in particular, may effectively lessen the social and economic burdens of chronic disease. While both Canadian and Taiwanese health insurance provides universal coverage to their populations, patients in Canada report difficulty accessing care on a regular, timely basis. Drawing from experiences during the 2014 McGill Comparative Healthcare Systems Program, this report identifies structural and cultural differences in the healthcare system of Taiwan compared with that of Canada and evaluates the performance of Taiwanese healthcare in the area of primary care delivery. INTRODUCTION Healthcare systems have traditionally emerged for the purpose of treating acute illnesses. However, rising hospital costs, accentuated by aging populations and increasing prevalence of chronic diseases, have resulted in novel challenges for the provision of care. As many chronic diseases are influenced by a complex set of social, environmental, and economic forces, they can often be prevented, identified early or ameliorated by screening or through individual behaviour. Populations increasingly need an integrated medical system that addresses not only standard curative care but also disease prevention, health promotion and social support (1). The delivery and utilization of primary 1

2 healthcare services are thus crucial in the maintenance and improvement of individuals health status. A strong correlation exists between health outcomes and the strength of primary care systems in OECD countries (2). Studies in western countries have shown that utilization of appropriate preventive care services can bring about a general improvement in health, provide early detection of illnesses, and in effect reduce the demand for curative inpatient care (3, 4). Moreover, investment in prevention can lessen the economic impact of disease and premature death (5). Individuals who experience difficulty accessing the care they need may delay seeking and obtaining treatment, underuse preventive healthcare services and be at greater risk for the complications of delayed diagnoses. These potential consequences may then exert increased financial pressure on the healthcare system if individuals arrive in the system sicker and stay in it longer. Following this rationale, the Canadian Task Force on Preventive Health Care (CTFPHC) was established by the Public Health Agency of Canada (PHAC) to develop clinical practice guidelines that support primary care providers in delivering appropriate preventive services. In Canada, access to primary healthcare services continues to sit at the forefront of the health policy debate. Although universal coverage provides Canadians with free access to all medically necessary services, the system s performance is poorly ranked among developed countries in terms of care for chronic disease due at least in part to its traditional focus on acute care (for example, medications that must be covered within inpatient hospital settings are not necessarily required to be covered when prescribed in ambulatory settings), fragmented delivery spawning from inadequate public funding, and 2

3 deficiencies in patient centeredness. Emergency room utilization rates are high, and wait times are long (6, 7, 8). According to results from the Health Services Access Survey (HSAS), 15% of Canadians needing first-contact health services reported difficulty accessing routine care and 23% reported difficulties obtaining immediate care. Having a regular family doctor has been shown to improve access to routine care such as preventive services (9, 10) and reduce the inappropriate use of services such as emergency rooms (11), but over 25% of the Quebec population (and 32.4% of people in Montreal) lack access to a regular source of care. The recognition of these challenges have led to a series of reviews, reforms and large-scale funding initiatives such as reorganization of primary health delivery into Family Medicine Groups (FMGs) in Quebec (12) and the creation of the Primary Healthcare Transition Fund (Health Council of Canada 2010). The Taiwanese healthcare system is an internationally appraised model for healthcare reform and consistently achieves high satisfaction rates among the Taiwanese people (14). Unlike the healthcare system in mainland China which currently still procures significant out of pocket costs from users, the implementation of the singlepayer national health insurance (NHI) system in Taiwan overcomes financial barriers to access by ensuring comprehensive medical services for over 98% of the Taiwanese population. Remarkably, the NHI achieves highly on international health indicators while spending merely 6% of its GDP, compared to 10% for Canada and 16% for the United States on healthcare (OECD 2010). Key strengths of the NHI also include good accessibility, short waiting times, very low administrative costs and a national health insurance databank for monitoring and evaluating health services (15). These positive 3

4 characteristics, as well as the fundamental similarity of the single-payer public insurance private delivery design of the Canadian and Taiwanese systems, make the NHI a good model for comparative analysis and learning. The following sections will aim to describe observations gained from the 2014 Comparative Health Systems Program regarding (1) important differences in the organization of the front line between Taiwan and Canada, (2) some interesting programs in Taiwan that are operating to improve access, and (3) how Traditional Chinese Medicine and culture come to influence the utilization of preventive health services. Patient-Centred Structuring of Service Delivery Primary care in Taiwan consists of a combination of Western and traditional Chinese medicine clinics, with the majority being privately operated Western medical clinics, such as the Health Centre of Lujhu in Kaohsiung. The Bureau of National Health Insurance had contracted 88% of the private clinics into the program, providing citizens access to over 10,500 clinics and over 18,000 doctors in the area of Taiwan. 368 health stations and 500 health rooms also operate in the mountain and island areas (16). The Taiwanese healthcare system heavily prioritizes the autonomy and convenience of its users. Compared to Canadian health insurance, the NHI program extends a more comprehensive benefits package including services ranging from dental care to preventive services and to elderly home care, thus allowing patients the freedom of choice in a system of cheap and abundant care. Taiwanese citizens may also see any doctor at any level of hospital without a referral. Except in large hospital centres or when the physician whom the patient wants to see is very popular, access to specialists involves 4

5 only short waiting times because a significant number of private providers compete for patients and payments from the NHI. As a result of many patients wishing to visit specialists directly, general practitioners are accessible for immediate and cheap care (15). Patients will often choose to see a family doctor for minor illnesses, preventive care, and health checkups when they would like immediate consultations as primary health clinics are closely situated next to or within communities. The main drawbacks of this generous accessibility are the sometimes brief consultation times due to large patient volumes and weak gatekeeper role of family doctors, leading to inappropriate use of resources. As a part of its efforts to integrate primary care services with more specialized treatment when needed, the BNHI launched a family doctor plan in 2003, which enabled families to obtain primary care through local clinics or neighborhood doctors who are networked with contracted hospitals; a lower copayment is then charged for patients who are referred to specialists by GPs. Another way in which the Taiwanese healthcare system has made patients experience as convenient as possible is the orientation of the family medicine department within the hospital setting. In Canada, patients always have to return to the family doctor the first point of access whenever he or she needed a referral to a specialist. The amount of time and effort demanded of the patient increases substantially when referrals to several specialists are required because the patient would need to make multiple trips back to their private clinic or CLSC in between hospital visits. In contrast, the family medicine department of Taiwanese hospitals such as that affiliated with the National Cheng Kung University is located on the same floor immediately adjacent to a number of specialist departments such that the patient could easily navigate from the family 5

6 medicine clinic to the dermatology clinic down the hall and back in a matter of minutes. Different aspects of primary care such as health examination, education, and quit smoking consultations could be managed in one visit sequentially by multiple physicians who communicate with one another to coordinate their activities. This approach maximizes continuity of care while minimizing wait times for the patient. Interestingly, not all doctors working in the family medicine department are general practitioners but some are in fact specialists. It is also possible for physicians who specialize in particular areas of family medicine (eg. weight control, addiction counselling etc.) to receive referrals from other doctors. For example, National Cheng Kung University recently piloted the first combined weight control clinic in Taiwan. Patients who come to the clinic enter a circuit in which they consult with an endocrinologist, a bariatric surgeon, and a nutritionist (in the order which requires the least waiting) on the same visit. During my shadowing experience, it was clear that such a multidisciplinary approach has the potential to offer a more informed opinion on whether someone is a suitable candidate for bariatric surgery, and would provide multiple dimensions of psychological counselling to help patients set appropriate health goals. Initiatives to Improve Prevention To support the transition of the Taiwanese healthcare system from being focused exclusively on curative medicine to health promotion, many innovative programs have been put into place to intervene at every level of disease prevention. At the Dalin Tzu Chi Buddhist Hospital, primary prevention takes the form of health promoting activities organized for healthcare employees, and in some ways similar to CLSCs in Quebec, are rooted in the local communities. For example, hospital staff is 6

7 offered subsidies to engage in physical activity and to host sport events in schools and other community settings. The implementation of these programs has led to significant improvement in the health of those who participate in the annual mandatory fitness assessment. The hospital also sets up health stations to facilitate chronic disease prevention and control, rehabilitation, and education efforts for various populations within the community. In order to extend access to residents in more remote mountain and island regions, mobile teams centred at the hospital engage in outreach activities for over 250 days of the year. Another important project is the secondary prevention of cancer, the leading cause of death in Taiwan since Cancer is also the leading cause of mortality in Canada and screening rates among eligible Canadians, especially in Quebec, are low (Canadian Cancer Society 2014). The Kaohsiung Department of Health oversees district health centres and over 800 primary healthcare clinics in the delivery of screening against cervical, breast, colorectal and oral cancers, which account for one third of all cancer cases in Taiwan. Since 1994, the implementation of recommendations for screens covered by the NHI has dramatically decreased mortality rate. The free annual pap smear for women over thirty years of age for instance has led to a 60-90% decline in mortality associated with cervical cancer. Next, strategies to promote equal access to medical services in rural areas were implemented to enable screening for a greater portion of the population. Mobile clinics often use schools or other community gathering sites to encourage usage of screening services through education and maintaining a friendly environment. Screening subsidies are available for uninsured citizens and transportation subsidies are offered to people living in even more inaccessible areas. 7

8 Lastly, primary health clinics serve as convenience stations where patients can access screening services with the greatest ease. Financial incentives are awarded to primary care physicians for screening of patients in the high risk category and annual targets for screening are established. In parallel with the increase in number of primary care clinics involved in this prevention network, an 18% increase was observed in the number of annual cancer screens, corresponding to successful early detection of 13,344 pre-cancerous changes. Finally, tertiary prevention describes the range of services that help people manage complicated, long-term health problems so as to avoid further deterioration and hospitalization. The long term care plan offered by Kaohsiung Department of Health provides a huge number of services which assist the aging population in a large variety of activities such as housekeeping, cleaning, meal delivery, drug advising. The focus on high quality care delivered right in people s homes improves medical compliance and has the potential to promote healthy living in a family-based rather than institutional setting. Information technologies are widely used to promote all of the preventive services mentioned above. Traditional Chinese Medicine and the Role of Culture There is a high level of health seeking behaviour in Taiwan: the average Taiwanese person makes 14.4 outpatient visits per year compared to only 6.4 visits for Canadians (18). Patients expect to access care in a timely fashion and consider their freedom to choose among a large number of healthcare providers a right. It is part of the Taiwanese culture to take medicines or seek medical help frequently, even for minor ailments such IV drips for the common cold (15). 8

9 Unlike health insurance in Canada, under which one would have to pay out of pocket or with supplemental insurance for alternative care, the NHI provides coverage for use of Traditional Chinese Medicine. TCM thus increases the number of treatment options patients have when seeking care and can be used alone or in combination with standard western medical treatments. Discussions with doctors of TCM at the Southeastern University-affiliated Zhongda Hospital in China suggested that users of traditional medicine can be roughly categorized into two groups: those who cannot afford western medicine because it is a cheaper alternative, and those who look to TCM because western medicine is inadequate in areas such as prevention. The concept of preventive medical interventions is strongly echoed by philosophies found in traditional practise. As stated long ago in the Huangdi Neijing ( 黄帝内经 ), a classic scripture of traditional medicine of the Yellow Emperor, the superior medicine prevents illness, while the mediocre medicine takes care of syndromes, and the inferior medicine treats disease. Therefore, certain TCM interventions are believed to help fortify one s body in the absence of disease or restore the forces of yin and yang to balance when changes in the external world such as cold weather threaten to disrupt it. Patients will use acupuncture for example to treat symptoms of stress such as insomnia, and take particular herbs believed to regulate the immune system. TCM treatments are also known for its ability to deliver personalized therapies and mediate spiritual healing. Because traditional medicines can require cumbersome preparation and are generally slow to take effect, they must be taken often for months at a time and thus become part of people s daily self-care regimes. The fact that more Taiwanese are willing to subscribe to TCM treatments is also reflective of a lifestyle choice a state of heightened awareness about one s own health. 9

10 CONCLUSION It is evident that the NHI has made impressive strides to provide the use of primary health services to promote healthy lifestyles, increase early disease detection and manage chronic disease. How much these improvements contribute to cost containment and financial sustainability is yet to be quantified. In Taiwan, accessibility to primary care is not currently a main concern as waiting times are generally short and medical resources are abundant (Bureau of National Health Insurance 2010). Nevertheless, a stronger gatekeeper role by family physicians will be critical for ensuring quality of care and overcoming issues of inappropriate usage resulting in medical waste. Canada on the other hand, enforces the gatekeeper system, but attains low public satisfaction in terms of timely access to family physicians and primary services. Reform of primary healthcare in both Canada and Taiwan have unfinished agendas. Although they have different strengths and currently confront different challenges, finding a sustainable balance between healthcare expenditures and system responsiveness will be key to improving overall performance in both nations. 10

11 Figure 1. Department of Family Medicine at National Cheng Kung University, Kaohsiung, Taiwan. Figure 2. Mobile clinic containing equipment for cancer screening based at the Dalin Tzu Chi Buddhist Hospital. Figure 3. Dr. Wang performing palpation, the most common diagnostic method used in Traditional Chinese Medicine. 11

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