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Dr. Hung-Bin TsaiDivision of Hospital Medicine, Department of

Traumatology, National Taiwan University HospitalMarch 25, 2014

Hospital Medicine Around the World- Taiwan Experience

Special Interest Forum 2014

National Health Insurance in Taiwan (TNHI)

Started on March 1, 1995

Spend 6.6% GDP for health in 2011.

Compulsory social health insurance program for all citizens from birth

Health Insurance IC Card

Second Generation National Health Insurance System

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Payment System of TNHI Healthcare institutions signed contracts with the BNHI:

92.47% Early years : “fee-for-service”

→ spiraling growth of medical cost

Pay-for-performance system (first introduced in 2001) breast cancer therapy, diabetes, asthma and hypertension treatment

Global Budget Payment System

Taiwanese version of the Diagnosis Related Groups (Tw-DRGs) adopted 111 DRGs into practice for the first year (2010) and would take 5

years to phase in the complete system (more than 500)

The Hospitalist Program in National Taiwan University Hospital (NTUH)

Founded in Oct. 2009 Current 8 Hospitalists Teaching: yes Services offered:

Medical management of multimorbid patients Consultative services Co-management of surgical patients Palliative care Medical education to nurse practitioners & nurses Quality improvement Information technology Integrated post-discharge transitional care (PDTC)

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Current situation of Hospital Medicine in Taiwan

Leading hospitalist program in Taiwan: NTUH, since Oct 2009.

Hospitalist program for 2-year young VS obligation for primary care: Chang-Gang Medical Center, since 2006

ED observation units model: Chi Mei Medical Center in Southern Taiwan,

since Aug 2012.

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Potential implications of Hospital Medicine in the development of best practice models in Taiwan.

Co-management for surgical patients

Reduce weekend effect of adverse outcome for weekend admission patients

Post-discharge transitional care

Palliative care for multimorbid aged patients

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J Hosp Med 2011;378-382

Higher clinical severities of patients in hospitalist-run vs. Internalist-run ward

Hospitalist-run vs. Internalist-run Ward:[After Propensity score matching]

Less LOS for 6 days

Less admission cost per patient: 3,590 USD

Less paid by NHI per patient: 3,202 USD

Risk Factors for 30-day readmission:

Intern Med J 2011 Jul 25.

- CCI - Cancer - LOS - Anemia

NTUH Hospitalist program reduce weekend effect of adverse outcome

 (Propensity score matching)

Weekday admission (n =496)

Weekend admission

(n=496)

P value

Age (yr) 70.1 15.6 70.0 15.8 0.930 a

Male gender 249 (50.2) 251 (50.6) 0.899 b

Chronic disease       CCI, unadjusted 2.6 2.5 2.5 2.4 0.432 a

ED triage level     0.703 b

1-2 256 (51.6) 262 (52.8)   3-5 240 (48.4) 234 (47.2)  BI at admssion 53.9 36.9 51.3 36.5 0.276 a

Malignancy 103 (20.8) 109 (22.0) 0.699 b

Outcomes       ICU admission 9 (1.8) 5 (1.0) 0.299 b

CPR event 1 (0.2) 3 (0.3) 0.374 b

DNR consent 97 (19.6) 94 (19.0) 0.872b

Hospital mortality 42 (8.5) 40 (8.1) 0.818b

BMC Med. 2011 Aug 17;9:96.PLoS One 2013

Post-discharge Transitional Care (PDTC)Can Reduce Readmission Rate and Mortality

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Pearls of PDTC:8AM-8PM Call Center + Follow-up clinic in hospitalist-run ward2 case managers to make phone callsFollowed on post-discharge 1,7,14,30 days

Our Challenges

What are the needs to run local programs and chapters of Hospital Medicine?

To redesign clinical schedule (need time for academic work) - Pair hospitalists, 2 wards by 4 teams 8a-6p for 7 or 14 days - Each team care 18 patients by 1 doc & 2 NPs

To relieve night shift burden - on duty 6 nights per month - we need moonlighters/nocturist!

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Our Challenges What is the potential role of SHM in terms of

teaching, research and networking?1.One of the successful hospitalist programs in North-

East Asia.2.We wound design more detailed post-discharge

transitional care model to link intermediate care (post-acute care)

3.To compare different interprofessional coordinated care models in USA, EU, Asia.

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Suggestions to improve the international section and the HMX community

Regional annual experts meeting for consensus of best practice model in hospital medicine.

Encourage short-term (6 month to 1 year) exchange program for fellows to learn different models in healthcare system (such as palliative care).

To compare the burn-out index of hospitalists in different healthcare systems.

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Acknowledgement:NTUH hospitalists provided holistic, integrated, non-border and trusted (HINT) services in Taiwan

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Hot-blooded Hospitalists

Thanks for your attention!

My Official E-mail: hbtsai@ntuh.gov.tw

If you talk to a man in a language he understands, that goes to his head.

If you talk to him in his language, that goes to his heart.

~Nelson Rolihlahla Mandela