Prognosis Positive for Taiwan's Medical Industry

A doctor uses acupuncture to treat a patient at Chang Gung Memorial Hospital, which provides a wide range of medical services at four locations. (Courtesy of Chang Gung Memorial Hospital)

Publication Date：02/01/2008
Byline：KELLY HER

Leading hospitals are taking their world-class medical services, training and research to new levels.

Susan Wu has received medical care both in her native Taiwan and in the United States, where she lived for six years. Now back in Taiwan, the 40-year-old says she remembers being frustrated with long waiting times at physicians' offices in America, but she was always impressed with the amount of time doctors would spend examining her and the care they took to explain their diagnosis and any drugs they prescribed. But as much as she liked her doctors, she hated paying for expensive medical services. "One time, I had a rash and called the hospital to make an appointment," she recalls. "I was told the earliest they could schedule an appointment was in two months--or I could go to the emergency room [for a premium fee]."

On the whole, Wu is happier with medical services in Taiwan, in large part because they are convenient. "I can visit a doctor at any time," she says, adding that she can choose from many clinics and hospitals in her area. And the costs are very reasonable. For example, for those without dental insurance, a basic root canal would cost at least US$350 in the United States, but only about NT$1,500 (US$45) in Taiwan. However, 99 percent of Taiwanese are covered by the National Health Insurance (NHI) program, which includes dental care, so they would only pay a user fee, which is rarely more than NT$200 (US$6).

Despite these advantages, Wu is disappointed that Taiwanese doctors are usually too busy to spend time with patients. They often prescribe antibiotics too easily, she adds. Nevertheless, overall, she gives medical services in Taiwan a "thumbs up."

Cathy Wung, Taiwan Joint Commission on Hospital Accreditation (TJCHA) chief executive officer, concurs. "Taiwan's medical services, which are characterized by accessibility and freedom for patients to choose from among doctors, constitute a high-quality healthcare system rarely matched anywhere in the world," she says. "Plus, [Taiwan's] medical facilities and technologies compare well with those in the United States and Europe. Many surgeries that are deemed difficult in some of those countries are now considered commonplace in Taiwan."

Wung, a pediatrician, lived in the United States for 30 years, but returned to Taiwan two years ago to take the reins at TJCHA, which is funded by Taiwan's Department of Health (DOH), Taiwan Medical Association, Taiwan Hospital Association and Taiwan Non-governmental Hospitals & Clinics Association. TJCHA began accrediting hospitals in 1986, making Taiwan the world's fourth country (behind the United States, Canada and Australia) and Asia's first to launch such a system.

Wung thinks Taiwan should adopt a primary care physician system similar to that found under managed healthcare insurance plans in the United States. Despite some inconvenience--people in the US with managed healthcare plans can only seek initial treatment from a handful of designated physicians, who then may or may not refer them to specialists--she believes the pros outweigh the cons. In a primary care physician system, general practitioners act as gatekeepers by limiting the overuse of services as a result of, for example, "doctor shopping." Another benefit is that primary care doctors can usually spend more time with patients, at least cumulatively. A primary care physician system would reduce the incidence of poor care associated with often very short appointments in Taiwan, in which doctors rarely spend more than five minutes with any given patient. In the United States, primary care doctors spend 19 to 21 minutes with patients on average, according to Wung.

Since 2003, the DOH has sought to encourage members of the general public to see family doctors at clinics before going to hospitals, but the idea has yet to catch on. Wung says more campaigns are needed to encourage Taiwanese to think twice before seeking medical care for minor complaints.

Ho Hong-nerng, vice superintendent at National Taiwan University Hospital (NTUH), says that by global standards, Taiwan's medical industry ranks just short of the top tier, which is populated by North American and European nations, but the standard of medical treatment available in Taiwan is well above average.

Thanks to the NHI, which was launched in 1996, costs have been driven down. Ho says that hospitals have had to improve resource utilization efficiency under the insurance regimen, but that quality of care has not suffered.

Cream of the Crop

Established in 1895 in Taipei, NTUH, staffed by more than 1,200 College of Medicine faculty and nearly 5,000 medical service professionals, is Taiwan's most prestigious teaching hospital, providing comprehensive care for some 2,000 inpatients and 7,000 outpatients daily.

NTUH has been recognized for pioneering research and clinical practice in the areas of organ transplantation, in vitro fertilization and treatment of hepatitis as well as liver and stomach cancers. The hospital's primary mission is to train medical professionals, with research coming a close second. Ho says the current focus of research is in cellular and molecular bioscience.

In order to enhance its competitiveness, NTUH has been investing in advanced diagnostic and research equipment while also encouraging joint research projects among departments. The hospital boasts nine joint research laboratories.

Min-Sheng is one of just two hospitals in Taiwan accredited by the US-based Joint Commission International. (Photo by Huang Chung-hsin)

In the past, Ho says, NTUH used to be invited by internationally renowned medical centers to participate in their research programs. Now, it is the other way around. NTUH has taken the initiative to plan programs and call for the participation of foreign counterparts.

Current partners in clinical studies on hepatitis and cervical cancer include the University of Sydney in Australia as well as Duke University and the University of Washington in the United States. NTUH also helps train medical personnel from Southeast Asia and since 1963, when it sent a medical mission to Liberia, the hospital has set up free clinics in developing countries around the world.

Ho says NTUH is working to streamline procedures to shorten patient waiting times and building a philosophy of patient-centered care. At the same time, the hospital is stressing patient safety. One recent innovation is making information on prescribed drugs available online. Patients can enter their national ID number and details from their prescription receipt to obtain detailed information about drugs they have been directed to take.

Another system currently in place allows patients' test results to be instantly sent to attending doctors via email and mobile phone text messages. The doctor is required to follow up with the patient promptly.

Coordinated Treatment

Chang Gung Memorial Hospital, established in 1976, is another leading Taiwan medical institution. It too engages in education (with Chang Gung University), research and medical services. With four branches, it serves some 6,800 inpatients and 27,000 outpatients per day.

Chang Gung offers a wide range of medical services, but specializes in bone marrow, cord blood and liver transplantation, reconstructive surgery, and treatment of thalassemia (a genetic condition that causes defects in red blood cells, but that also affords protection against malaria). Chang Gung has the highest survival rate among liver transplant patients in Asia. For live-donor liver transplants, 95 percent of recipients survive after one year, 91 percent after five years.

Chen Yu-ray, Chang Gung's steering committee chairman, says his hospital launched joint outpatient services in 1998. With joint services, a single outpatient can have several attendant specialists, each representing a different department. Chen explains using the example of craniofacial surgery: "We'll ask physicians from ear, nose and throat, dental, plastic and reconstructive, orthopedics and language therapy departments to meet and map out a treatment plan before the surgery is performed. This team approach ensures quality care."

Chang Gung also integrates Chinese and Western medicine teams, which provide joint services for patients with arthritis, cervical cancer, nasopharyngeal cancer and diabetes.

Whenever possible, the hospital uses minimally invasive surgical techniques--procedures that reduce the size of incisions to speed recovery time--for cardiothoracic, gynecologic and urologic therapies. It recently purchased a computer-assisted platform to facilitate such surgeries, and it plans to build a state-of-the-art proton therapy cancer treatment facility in three years. Proton therapy is used as an alternative to X-ray radiotherapy to treat tumors, with less damage to surrounding tissue.

Chang Gung takes on research commissioned by the DOH and the National Science Council, and also allocates NT$200 million (US$6 million) annually to research projects initiated in-house.

Over the years, many foreign doctors--from India, Malaysia, Thailand ,Vietnam, even Canada--have sought out training opportunities at Chang Gung. Last year, 211 people, just over half from Taiwan and the rest from 20 other nations, paid to participate in a forum on a type of facial reconstruction surgery. The hospital has held international forums annually since 2000. Participants attend lectures, view live operations and get hands-on experience using non-surgical techniques. "For the live surgery, the camera in our operating room is fed into the conference hall so participants can watch and ask questions," Chen says. "These demonstrations are educational and they advertise our strengths to the international community."

Meanwhile, to better serve foreigners, Chang Gung established an international service center in December 2006. English- and Japanese-speaking coordinators at the center communicate with foreign nationals either face-to-face, by telephone or over the Internet. They tell them how to get to the hospital, book appointments, provide fee estimates and--for people contemplating a visit to Taiwan for check-ups or treatment--discuss accommodation options.

Medical Mission

Min-Sheng General Hospital, located in Taoyuan, northern Taiwan and established in 1975, is also positioning itself to serve international patients. With its MissionCare brand name, the hospital's vision is to provide "healthcare without national boundaries" and to develop from "being a regional to a global healthcare provider."

Patients can register or pay for services with hospital staff at mobile medical carts at Chang Bing Show Chwan. (Photo by Huang Chung-hsin)

Frederick Yang, president of Min-Sheng Hospital, says, "MissionCare offers all-inclusive pre-arrival planning, surgery arrangements and lodging services to allow people from the world over to conveniently receive high-quality medical care." He points to accreditation from the US-based Joint Commission International as incontrovertible evidence that "our medical performance, service efficiency and patient safety and rights have achieved international standards."

Yang says that in recent years, he has moved to enhance the quality of his hospital's doctors and facilities. One point of pride is that 85 percent of his staff was recruited from NTUH and he says that Min-Sheng's center for minimally invasive surgery was the first facility of its kind in Asia. The technology that makes minimally invasive surgery possible is endoscopy, a procedure that involves inserting a tube into the body that beams back images and may be used to remove tissue.

Min-Sheng has gained a reputation for its work in several areas, including endoscopy, cardiovascular disease treatment and for effective use of extra-corporeal membrane oxygenation (ECMO), a process that simulates the function of lungs with a device that is located outside the body.

Min-Sheng's deputy superintendent, Lee Wei-jei, has performed more than 1,800 weight-loss operations using endoscopic procedures, a record in Asia. Ko Wen-je, another specialist at the hospital, has overseen ECMO treatment in 950 cases, the second highest number worldwide.

Yang established a holding company, MissionCare Inc., in 1997 to facilitate the expansion of his healthcare network. MissionCare's holdings currently comprise 11 entities, including hospitals, nursing homes and extended care centers, as well as a pharmaceutical firm and a management consulting company.

Yang says MissionCare is ready to expand overseas. He is now trying to attract foreign capital to facilitate a foray into the global medical services market.

He expects MissionCare to apply for a stock listing in Singapore within three years. "We aim to expand our operations continually in Taiwan and elsewhere by issuing shares and forming strategic alliances," he says. "We want to be the best hospital chain in Asia by 2010." Yang anticipates 100 MissionCare hospitals will eventually be established throughout East Asia. He says the best way to approach internationalization is to establish a "mega chain" that will allow for practically unlimited scalability. New hospitals could be set up quickly based on existing models and expenditures could be minimized through joint procurement and resource sharing.

The Changing Face of Medical Services

Show Chwan Memorial Hospital is also expanding through chain operations. The first Show Chwan hospital was established in 1980 in Changhua City, central Taiwan. So far, the Show Chwan healthcare system includes six hospitals, a foundation and an information technology (IT) company.

Responsible for maintaining the group's computer and networking systems, the IT company is located at Show Chwan's headquarters, sharing space with administration, finance, human resources, marketing and procurement departments.

The group's newest hospital, Chang Bing Show Chwan, was established in the Changhua Coastal Industrial Park in 2006. It showcases innovations in high-end medical services. "It was our ideal to build a new hospital that incorporates the types of services and facilities you might find in a five-star hotel, one that provides not only treatment, but also health-related information and leisure opportunities," says Shyu Horng-jeng, superintendent at Chang Bing Show Chwan. "We run our hospital like a 'health park' that emphasizes the promotion of health concepts, since we believe that preventative medicine is the future of healthcare."

After entering Chang Bing Show Chwan's well-appointed lobby, patients and other visitors are warmly welcomed by staff wearing purple uniforms similar to those worn by luxury hotel staff. Patients are guided to a service center, which resembles a hotel's reception counter, and are offered a seat where registration forms can be filled out. Alternatively, incoming patients can register with hospital staff manning mobile medical carts.

A guide leads a tour at Chang Bing Show Chwan's medical science museum. (Photo by Huang Chung-hsin)

Artworks grace hallway and waiting room walls, potted plants oxygenate the air and strains of a piano being played in the lobby fill the air. Hospital waiting areas are also equipped with large-screen plasma TVs and furnished with comfortable sofas. Soft lighting rounds out the pleasant atmosphere.

Whereas at most hospitals in Taiwan, outpatients must wait in lines to pick up prescriptions at chest-level counters topped by small service windows, Chang Bing Show Chwan outpatients sit at numbered tables and are offered tea after emerging from medical consultations. Pharmacists bring prescriptions to these tables and explain how medications should be taken.

"All our services are designed based on a patient-centered philosophy aimed at eliminating patients' anxiety and ensuring their safety," Shyu says. "Our hospital has a wireless network, so when doctors go on their rounds, they can show patients relevant data or images on laptop computers they carry with them, and laptops on mobile medical carts can provide instant information to patients as well."

Shyu believes that a person's health should be addressed on multiple levels to achieve soundness in body, mind and soul. Hence, he gives the same weight to medical therapy, art therapy, recreation and medical education.

"In the past, patients had to put up with an indifferent environment, filled with the odious smell of drugs," Shyu says. "They were deprived of the right to enjoy quality services in pleasant surroundings. That's why we built our hospital based on a shopping mall model. In addition to medical facilities, we have a convenience store, beauty salon, food court, art gallery, spa and a fitness center."

Shyu notes people who are not sick can also make use of the hospital's facilities, including a library and a medical science museum, which features interpretive and interactive displays that present health-related information in an entertaining and informative way.

As befits a brand-new hospital, Chang Bing Show Chwan boasts sophisticated equipment, including some of the most advanced devices used to diagnose and treat cancer. A minimally invasive surgical skills center is being built in cooperation with the France-based IRCAD, a prominent cancer research center. The skills center is expected to attract cancer specialists from around the world who wish to receive advanced training and conduct research in surgical robotics.

Healthy Diagnosis

Cathy Wung of TJCHA says that substantial improvement has been made in patient safety since her organization began accrediting hospitals. She points out that doctors and pharmacists are now more careful about instructing patients on how to take drugs and how to differentiate among them, and surgeries have become safer. Hospitals have not just upgraded their facilities, she says. Most have also established standard operating procedures for staff training and filing medical records. The ratio of medical staff to patients is also on the rise.

Hospitals that obtain TJCHA accreditation can claim increased government funding. By the end of 2006, Wung's organization had accredited 547 hospitals. Hospitals must renew their accreditation every three years. In 2006, all five medical centers that applied for the accreditation passed. Of the combined 279 hospitals that applied that year, 264, or 95 percent, earned a passing grade. The accreditation system examines three domains--administration, medicine and nursing--evaluating 508 criteria that range from management to patient rights to comfort.

Wung says the most widespread problems in Taiwan are an overemphasis on specialization at the expense of general practice and insufficient coordination among physicians.

"Family doctors, for instance, can deal with many problems, including high blood pressure and diabetes," she explains. "Since they're familiar with their patients' medical histories, they can make quick diagnoses. But in Taiwan, due to convenient access, many patients go directly to hospitals to see different doctors. This leads to over-prescription of medications and a waste of medical resources."

Still, Wung gives high marks to Taiwan's medical services overall and thinks its successes are worth sharing with other countries. "Quality medical services are available in Taiwan, but this is not widely known due to low visibility in the international community and the fact that Taiwan has been denied admission to the World Health Organization," she says. "We should do more to promote our medical expertise among our peers. I believe that they'd be amazed at what we've been able to accomplish."

Write to Kelly Her at kelly@mail.gio.gov.tw