A 10-year review of health care reform on Family Practice Integrated Care Project—Taiwan experience

A 10-year review of health care reform on Family Practice Integrated Care Project—Taiwan... Abstract Objective Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including ‘family doctor’, ‘primary care’, ‘integrated care’ and ‘Taiwan’. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results Up to June 2015, the project had enrolled a total of 10.5% of Taiwan’s population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system. Continuity of care, family, integrated health care systems, physician, primary care Introduction Taiwan has implemented a compulsory national health insurance (NHI) programme that provides universal health care coverage to all of its residents since 1995. Aside from providing equal access to health care, the NHI system is equipped with tools to manage the increase in health expenditure, curtail financial risk and initiate payment reform (1). Taiwan’s NHI system has continued to deliver affordable modern health care met with high levels of public satisfaction ever since its implementation. However, there are still challenges, notably balancing the system’s budget, improving the quality of health care and achieving greater cost-effectiveness, that the NHI has to overcome in the face of a rapidly aging population that has triggered an unprecedented increase in medical demands and cost (2). Hospitals, as well as primary care clinics, in Taiwan have undergone a large-scale M-shaped development during the past two decades (3), while overemphasis on the division of medical specialties has led to the deficiency of family physicians, which in turn has weakened the strength of community care in Taiwan. As indicated in the literature, the health of a country’s population is related to the strength of its primary care system (4–6). Though without abundant resources, family doctors can play a vital role in re-vitalizing a country’s health care system by providing comprehensive care for patients and facilitating coordination between clinics and hospitals. In Taiwan, with the awareness of the need to reinforce primary care heightened by the disastrous 921 earthquake and the SARS outbreak, the Bureau of NHI (now NHI Administration, the Ministry of Health and Welfare) implemented in March 2003 the Family Practice Integrated Care Project (FPICP) to promote community health care group (CHCG)-based practice in the primary care sector after the preliminary success of five pilot programmes launched in northern, central and southern Taiwan (7,8). In brief, with the implementation of the FPICP, the NHI administration (NHIA) strives to recruit more primary care practitioners to join force in establishing primary community care networks (PCCNs) islandwide in Taiwan. About 5 to 10 clinics in a community form a primary care team called a CHCG as the basic unit of a PCCN. More than half of the physicians in a CHCG are specialized in family medicine, internal medicine, surgery, obstetrics and gynaecology, and paediatrics. To obtain CHCG certification, physicians are required to take part in the CHCG family doctor training programme incorporating administration and education courses (4 hours for family medicine, 12 hours for internal medicine, surgery, obstetrics and gynaecology and 20 hours for other specialties). Each CHCG needs to build and maintain collaboration with at least one community hospital or medical centre in the same region for backup and mutual referral. The CHCG and its backup hospital(s) work together to form a PCCN (9). Prior to 2009, citizens were free to decide whether they would like to utilize CHCG services. Later, NHIA started to enrol citizens as CHCG ‘members’ based on their annual utilization frequency and other related NHI data. Therefore, the majority of CHCG members in Taiwan are those reporting high utilization rates of medical care due to chronic or serious diseases. In regard to their major tasks, CHCG family doctors are responsible for building up family-oriented medical profiles, establishing a mutual referral information system and providing members with 24-hour helpline consultation. Moreover, to improve quality of care, they have to take vigorous parts in shared care activities, working with colleagues and collaborating hospital(s) in matters concerning medical care plan, shared care clinic, continuing medical education, case discussion, home visit and promotion of community-oriented primary care (Figs. 1 and 2). Aside from medical service that is based on the current fee-for-service payment system, NHIA subsidizes these additional activities with an annual expense reaching NTD 1 billion (USD30 million) for the FPICP. Figure 1. View largeDownload slide The five major tasks of community health care groups to build a healthy community. Figure 1. View largeDownload slide The five major tasks of community health care groups to build a healthy community. Figure 2. View largeDownload slide The community health care groups and collaborating hospitals work together to improve the health of community residents. Figure 2. View largeDownload slide The community health care groups and collaborating hospitals work together to improve the health of community residents. Several performance indicators including structure, process and outcome components are used for programme monitoring. The quality indicators include emergency visit rate, hospitalization rate, number of visit to CHCG family doctors, questionnaire-based patient satisfaction survey, adult preventive care examination rate, Pap smear rate, utilization of flu shot for the elderly and immuno-faecal occult blood test for colon cancer screening, case management including shared care activities, outpatient/hospitalization referral rates by CHCGs and, most importantly, utilization of the 24-hour helpline service. It should be noted that these are mainly structure and process indicators, rather than indicators measuring health income. After presenting a general picture of the FPICP, the article proceeds to share the experience of Taiwan in building an accountable family doctor system in the past decade with the hope to help develop a bright future for the family physician-based integrated care model. Method FPICP-related papers and reports published both in English and in Chinese from 2003 to 2015 were systematically collected from PubMed, the National Digital Library of Theses and Dissertations in Taiwan and the Airiti Library, a leading databank of Chinese academic e-journals based on searching for the following keywords: ‘family Doctor’ or ‘family physician’, ‘primary care’, ‘integrated care’ and ‘Taiwan’. Also collected were NHIA reports and publications of the Taiwan Association of Family Medicine (TAFM). Managing Taiwan’s single-payer universal health care system, NHIA as the legal proprietor of FPCIP data analyses the data to assess the effectiveness of the CHCG programme. NHIA reports the outcome data of quality indicators at the end of every year as the basis to make payment to individual CHCGs and consults TAFM for project implement adjustment through a FPICP committee on an annual basis. The focus of this study was directed to report on performance indicators and health care utilization. The main outcomes of NHIA data on the preventive care services between CHCG members and non-members were compared. For measuring satisfaction of CHCG members, NHIA conducted telephone interviews using cluster sampling by area and asking members to indicate their overall satisfaction and their feedback to individual services such as the provision of health and related education information, general and 24-hour helpline health consultation, and assistance in understanding personal health condition. Results According to the 2015 NHIA statistics, the FPICP had enrolled 10.5% of Taiwan’s population (2.48 million people) and organized a total of 426 CHCGs composed of 24.9% of the primary care physicians and 29.7% of the community clinics in Taiwan (Table 1). The CHCGs in central Taiwan accounted for nearly one-third of the total number of CHCGs (10). Table 1. The Taiwan Family Practice Integrated Care Project data (2003–2015) (data source: National Health Insurance Administration, Ministry of Health and Welfare, Taiwan) Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 CHCG, community health care group. View Large Table 1. The Taiwan Family Practice Integrated Care Project data (2003–2015) (data source: National Health Insurance Administration, Ministry of Health and Welfare, Taiwan) Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 CHCG, community health care group. View Large The concise systematic review by Chang et al. in 2011 summarized the effectiveness of the FPICP in the initial years of its implementation: First of all, the FPICP was estimated to help reduce medical expenditure by 5.4%–8.0% for outpatient visits and 7.5–20% for hospitalization. Secondly, the FPICP was met with high level of overall satisfaction (80%) from the participating members, and over 90% of the enrolled members preferred to consult their CHCG family doctors first and go to a hospital for further examination or treatment when a referral was issued. The review further found the FPICP capable of encouraging members to better utilize preventive health services. For example, the utilization rates of adult health examination and Pap smear were higher in CHCG members than in the general population (51.9% versus 34.9% and 33.7% versus 28.5%, respectively). Moreover, the FPICP could improve the quality of health care through observing the performance indicators developed by NHIA (11). Pan et al. used the difference-in-difference estimation approach, propensity score method and multivariate regression models to evaluate the FPICP effects on health care utilization and outcome based on 2004–2011 NHIA data. Their results also indicated an increase in utilization of adult preventive health services; although no significant impact was observed in other aspects (12). NHIA reports in 2016 showed a steady annual progress in FPICP performance from 2013 to 2015. Compared to non-members, CHCG members made better use of preventive health services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (iFOBT; 43% versus 31%; P < 0.01) (Fig. 3) (10). CHCG members slightly outran non-members (51.0% versus 48.0%) in terms of the fixed doctors’ rate but reported no significant difference from non-members in either emergency rate or admission rate. With regard to 24-hour helpline consultation, 73.2–81.2% of members were satisfied with the service provided by CHCGs. Members reported an impressive overall satisfaction rate (98.0%%) and responded well to the CHCG provision of health consultation, health information and assistance in understanding personal health condition. For the cost of outpatient visits, approximately NTD 700 million (USD 21 million) and NTD 1.7 billion (USD51 million) were saved in 2013 and 2014, respectively. Figure 3. View largeDownload slide The performance indicators comparison between community health care group members (black bar) and non-members (grey bar). Fixed doctors: percentage of CHCG members visiting family doctors in the same CHCG group versus percentage in non-members. Adult health examination: percentage of CHCG members aged over 40 years utilizing adult health examination service versus percentage in non-members. Pap smear: percentage of sexually active female CHCG members older than 30 years receiving Pap smear service for cervical cancer screening versus percentage in non-members. Elderly influenza vaccination: percentage of CHCG members older than 65 years receiving the annual influenza shot versus percentage in non-members. iFOBT: percentage of CHCG members aged over 50 years receiving the stool iFOBT for colon cancer screening versus percentage in non-members. Figure 3. View largeDownload slide The performance indicators comparison between community health care group members (black bar) and non-members (grey bar). Fixed doctors: percentage of CHCG members visiting family doctors in the same CHCG group versus percentage in non-members. Adult health examination: percentage of CHCG members aged over 40 years utilizing adult health examination service versus percentage in non-members. Pap smear: percentage of sexually active female CHCG members older than 30 years receiving Pap smear service for cervical cancer screening versus percentage in non-members. Elderly influenza vaccination: percentage of CHCG members older than 65 years receiving the annual influenza shot versus percentage in non-members. iFOBT: percentage of CHCG members aged over 50 years receiving the stool iFOBT for colon cancer screening versus percentage in non-members. Discussion Increasing health care cost, growing inpatient utilization, expanding rural–urban disparity and fragmented care are all known to be the major issues confronting the medical care systems in developed countries like Taiwan (6). Therefore, Taiwan government has launched the FPICP to enhance the cooperation between community clinics and regional hospitals via the establishment of PCCNs since March 2003. Implemented for over 10 years, the FPICP in Taiwan has gained support from both primary care physicians and public in the community as evidenced by the growing number of CHCGs and the high levels of satisfaction of enrolled members. Most importantly, it has enabled family physicians to provide preventive health services to improve patients’ health with greater effectiveness and efficiency. The connection and cooperation—both horizontal and vertical—within an individual PCCN appears to be close and effective. As indicated in Lin’s study on PCCN in the early years of its development, CHCG physicians demonstrated an active involvement in the governance and information infrastructures within an individual PCCN (9). It has also been suggested that the main reasons prompting CHCG physicians to end or change their partnership with a PCCN include organization/participant factors (extra working time spent and facility competency), network factors (partner collaboration) and community factors (health policy design incompatibility, patient–physician relationship and effectiveness) (13). One of the key factors affecting the FPICP performance, as identified by Li and Hwang, lies in the joint administrative management centre (JAMC) in a CHCG. The JAMC functions to integrate the resources of a CHCG and its backup hospital(s) so as to improve efficiency, enhance performance and to extend the network to form further strategic alliances for strengthening both the capability and the capacity of a PCCN (14) . The FPICP emerged from the studies of Lin and Lang, Pan et al. and Lin and Huang to be effective in promoting preventive health care and regulating hospitalization, although it exerts no significant influence on outpatient health care utilization and costs initially due to increased utilization of preventive health services. Also pointed out in their studies is that doctor shopping remains quite common because of the equal and easy access to health care made possible with the NHI system (9,15,16). A CHCG carries with it two main functions: (i) in close partnership with its backup hospital(s), a CHCG provides its household members with general and preventive health care services; and (ii) it works as a competent unit offering comprehensive, easily accessible, updated, coordinated and responsible health care, thereby allowing both family physicians and primary care professionals to optimize their roles and functions. Cementing the relationship between CHCGs and their collaborating hospitals helps strengthen the partnership among PCCNs and instilling in the public the concept of family physicians as gatekeepers renders the development and implementation of well-organized national health policies easier and the integration of health care providers more effective (17). The FPICP in Taiwan is in sync with the global health care goals, including ‘Health for all’ first promulgated in the 1978 ‘Alma-Ata Declaration’; ‘Improving chronic illness care’ advocated in the 1996 ‘Chronic Care Model’; ‘Towards Unity for Health’ adopted as the new title of the WHO newsletter since 2000; ‘Primary care as a hub of coordination’ introduced in the 2008 World Health Report on Primary Health Care; and the most recent ‘Integrated person-centered health service’ (IPCHS) proposed by WHO in 2015 (18–23). The FPICP matches the contemporary global trend of the patient-centred integrated care (19). Education, training and research are crucial for the effective implementation and operation of an accountable family doctor system. Further development should concentrate not only on the ongoing establishment of more CHCGs but also on the expanding participation of allied health professionals; meanwhile, each individual CHCG should share and promote its success story as a role model for attracting more primary physicians as greater and more active participation helps minimize health inequality and improve primary care quality. Nevertheless, it is still necessary to evaluate the long-term effect of the FPICP on health care utilization and expenditure in the future. There are several issues that need to be raised for attention. Not all physicians or clinics participate in the FPICP because of the limited budget. It is strongly suggested that the government should invest more financial resources on the effective operation of the accountable family doctor system, continuous promotion of the CHCG, enhancement of the horizontal and vertical collaboration, and the development of information technology and health education to help people become more responsible for their health and to ensure the sustainable development of the integrated health care system in Taiwan. The FPICP model is an excellent example of primary care team as a hub of coordination as promoted by the World Health Organization (21). An integrated health care delivery system with primary care providers as its gatekeepers is needed to solicit more active participation from more primary care professionals (Fig. 4). In the face of a rapidly aging society, it is urgent to equip every community with a well-functioning shared care network in which local clinics work with collaborating hospitals to provide residents with patient-centred, easily accessible, well-coordinated and accountable health care. Therefore, TAFM has announced the TAIWAN Action Plan at its 2016 annual conference to bring Taiwan into the world paradigm of ‘Every Family, a Family Doctor’ by 2020 (24). Currently, the percentage of FPICP-enrolled members in Taiwan’s total population reads a modest 10.5%. TAFM will make every effort to raise the percentage to 100% by 2020 with its TAIWAN Action Plan: (i) developing a uniquely Taiwanese accountable family doctor system fully capable of delivering quality, person-centred, family-based and community-oriented health care services; (ii) enhancing accountability of care and empowering citizens to enhance self-care; (iii) providing integrated person-centred health services and enforcing bi-directional referral to ensure coordination and continuity between the three tiers of health care; (iv) providing family physicians with payment incentives to support reasonable increase in national health expenditure, thereby building up a world-leading model of sustainability; (v) upgrading the ability of family physicians in providing preventive health care to reinforce assurance of quality care; and finally (vi) constructing networks of community health support by recruiting and training volunteers for health education and self-care. Figure 4. View largeDownload slide The blueprint of a well-developed, healthy community. Figure 4. View largeDownload slide The blueprint of a well-developed, healthy community. Conclusions Taiwan’s experience of building PCCNs through the FPICP presents a very good example in response to WHO’s call for primary health care and people-centred and integrated health services. In practice for over a decade, its CHCGs prove to be capable of delivering person-centred, vertically and horizontally integrated care to safeguard the health of community residents. We urge our colleagues in the field of family medicine and the medical community to unite with government agencies, medical centres, community hospitals, local public health centres and clinics in a joint effort to build for every community an integrated health care system practising mutual referral, thereby realizing the vision of ‘Every Family, A Family Doctor’. Disclosures Funding: No. Ethical approval: No. Conflict of interest: none. 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Master thesis. http://handle.ncl.edu.tw/11296/ndltd/58430078249546737871 (accessed on 14 August 2017 ). 15. Lin YS , Lang HC. The Effect of the “National Health Insurance Family Doctors Integrated Care” Program on Patients’ Health Care Utilization . 2008 . Master thesis. http://handle.ncl.edu.tw/11296/ndltd/ 72000058785734214144 (accessed on 14 August 2017 ). 16. Lin CT , Huang N. A long-term evaluation of patients continued to participate in family physician integrated care plan on healthcare utilization . 2016 . Master thesis. http://handle.ncl.edu.tw/11296/ndltd/24568583377593648532 (accessed on 14 August 2017 ). 17. Lee MC . Integrated care and training in family medicine in the 21st century: Taiwan as an example . J Fam Med Community Health 2016 ; 4 : 57 – 9 . Google Scholar CrossRef Search ADS 18. Wagner EH , Austin BT , Von Korff M . Organizing care for patients with chronic illness . Milbank Q 1996 ; 74 : 511 – 44 . Google Scholar CrossRef Search ADS PubMed 19. Bodenheimer T , Wagner EH , Grumbach K . Improving primary care for patients with chronic illness: the chronic care model, Part 2 . JAMA 2002 ; 288 : 1909 – 14 . Google Scholar CrossRef Search ADS PubMed 20. WHO . Framework on integrated people-centered health services . 2015 . http://www.who.int/servicedeliverysafety/areas/people-centred-care/en/ (accessed on 13 March 2017 ). 21. WHO . Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 . http://www.who.int/publications/almaata_declaration_en.pdf (accessed on 14 March 2017 ). 22. WHO . The World Health Report 2008 - Primary Health Care (Now More Than Ever) . http://www.who.int/whr/2008/en/ (accessed on 14 March 2017 ). 23. WHO . Towards unity for health: challenges and opportunities for partnership in health development: a working paper . http://www.who.int/hrh/documents/en/TUFH_challenges.pdf (accessed on 14 March 2017 ). 24. Taiwan Association of Family Medicine (TAFM) . 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A 10-year review of health care reform on Family Practice Integrated Care Project—Taiwan experience

Family Practice , Volume Advance Article (4) – Nov 29, 2017

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Abstract

Abstract Objective Taiwan has launched a Family Practice Integrated Care Project (FPICP) to develop an accountable family doctor system since March 2003. We aim to report the effectiveness of this nationwide demonstration programme over a 10-year period. Methods Papers and reports related to the FPICP published both in English and in Chinese from 2003 to 2015 were collected systematically based on keywords including ‘family doctor’, ‘primary care’, ‘integrated care’ and ‘Taiwan’. Also collected and reviewed were national health insurance administration annual reports and related publications from Taiwan Association of Family Medicine. Quality care indicators including structure, process and outcome for programme monitoring were reported. Results Up to June 2015, the project had enrolled a total of 10.5% of Taiwan’s population. Approximately 24.9% of primary care physicians and 29.7% of community clinics joined the project to serve the members of 426 community health care groups (CHCGs). Compared to non-members, CHCG members received more preventive care services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (43% versus 31%) (P < 0.01). Members showed a markedly high level of satisfaction (>95%), especially in overall satisfaction, provision of health consultation and information, and improvement in understanding personal health condition. Conclusions In the future, through the support of family physicians and CHCGs, a person-centred integrated health care delivery system can be an effective solution to the current barriers in the medical care system. Continuity of care, family, integrated health care systems, physician, primary care Introduction Taiwan has implemented a compulsory national health insurance (NHI) programme that provides universal health care coverage to all of its residents since 1995. Aside from providing equal access to health care, the NHI system is equipped with tools to manage the increase in health expenditure, curtail financial risk and initiate payment reform (1). Taiwan’s NHI system has continued to deliver affordable modern health care met with high levels of public satisfaction ever since its implementation. However, there are still challenges, notably balancing the system’s budget, improving the quality of health care and achieving greater cost-effectiveness, that the NHI has to overcome in the face of a rapidly aging population that has triggered an unprecedented increase in medical demands and cost (2). Hospitals, as well as primary care clinics, in Taiwan have undergone a large-scale M-shaped development during the past two decades (3), while overemphasis on the division of medical specialties has led to the deficiency of family physicians, which in turn has weakened the strength of community care in Taiwan. As indicated in the literature, the health of a country’s population is related to the strength of its primary care system (4–6). Though without abundant resources, family doctors can play a vital role in re-vitalizing a country’s health care system by providing comprehensive care for patients and facilitating coordination between clinics and hospitals. In Taiwan, with the awareness of the need to reinforce primary care heightened by the disastrous 921 earthquake and the SARS outbreak, the Bureau of NHI (now NHI Administration, the Ministry of Health and Welfare) implemented in March 2003 the Family Practice Integrated Care Project (FPICP) to promote community health care group (CHCG)-based practice in the primary care sector after the preliminary success of five pilot programmes launched in northern, central and southern Taiwan (7,8). In brief, with the implementation of the FPICP, the NHI administration (NHIA) strives to recruit more primary care practitioners to join force in establishing primary community care networks (PCCNs) islandwide in Taiwan. About 5 to 10 clinics in a community form a primary care team called a CHCG as the basic unit of a PCCN. More than half of the physicians in a CHCG are specialized in family medicine, internal medicine, surgery, obstetrics and gynaecology, and paediatrics. To obtain CHCG certification, physicians are required to take part in the CHCG family doctor training programme incorporating administration and education courses (4 hours for family medicine, 12 hours for internal medicine, surgery, obstetrics and gynaecology and 20 hours for other specialties). Each CHCG needs to build and maintain collaboration with at least one community hospital or medical centre in the same region for backup and mutual referral. The CHCG and its backup hospital(s) work together to form a PCCN (9). Prior to 2009, citizens were free to decide whether they would like to utilize CHCG services. Later, NHIA started to enrol citizens as CHCG ‘members’ based on their annual utilization frequency and other related NHI data. Therefore, the majority of CHCG members in Taiwan are those reporting high utilization rates of medical care due to chronic or serious diseases. In regard to their major tasks, CHCG family doctors are responsible for building up family-oriented medical profiles, establishing a mutual referral information system and providing members with 24-hour helpline consultation. Moreover, to improve quality of care, they have to take vigorous parts in shared care activities, working with colleagues and collaborating hospital(s) in matters concerning medical care plan, shared care clinic, continuing medical education, case discussion, home visit and promotion of community-oriented primary care (Figs. 1 and 2). Aside from medical service that is based on the current fee-for-service payment system, NHIA subsidizes these additional activities with an annual expense reaching NTD 1 billion (USD30 million) for the FPICP. Figure 1. View largeDownload slide The five major tasks of community health care groups to build a healthy community. Figure 1. View largeDownload slide The five major tasks of community health care groups to build a healthy community. Figure 2. View largeDownload slide The community health care groups and collaborating hospitals work together to improve the health of community residents. Figure 2. View largeDownload slide The community health care groups and collaborating hospitals work together to improve the health of community residents. Several performance indicators including structure, process and outcome components are used for programme monitoring. The quality indicators include emergency visit rate, hospitalization rate, number of visit to CHCG family doctors, questionnaire-based patient satisfaction survey, adult preventive care examination rate, Pap smear rate, utilization of flu shot for the elderly and immuno-faecal occult blood test for colon cancer screening, case management including shared care activities, outpatient/hospitalization referral rates by CHCGs and, most importantly, utilization of the 24-hour helpline service. It should be noted that these are mainly structure and process indicators, rather than indicators measuring health income. After presenting a general picture of the FPICP, the article proceeds to share the experience of Taiwan in building an accountable family doctor system in the past decade with the hope to help develop a bright future for the family physician-based integrated care model. Method FPICP-related papers and reports published both in English and in Chinese from 2003 to 2015 were systematically collected from PubMed, the National Digital Library of Theses and Dissertations in Taiwan and the Airiti Library, a leading databank of Chinese academic e-journals based on searching for the following keywords: ‘family Doctor’ or ‘family physician’, ‘primary care’, ‘integrated care’ and ‘Taiwan’. Also collected were NHIA reports and publications of the Taiwan Association of Family Medicine (TAFM). Managing Taiwan’s single-payer universal health care system, NHIA as the legal proprietor of FPCIP data analyses the data to assess the effectiveness of the CHCG programme. NHIA reports the outcome data of quality indicators at the end of every year as the basis to make payment to individual CHCGs and consults TAFM for project implement adjustment through a FPICP committee on an annual basis. The focus of this study was directed to report on performance indicators and health care utilization. The main outcomes of NHIA data on the preventive care services between CHCG members and non-members were compared. For measuring satisfaction of CHCG members, NHIA conducted telephone interviews using cluster sampling by area and asking members to indicate their overall satisfaction and their feedback to individual services such as the provision of health and related education information, general and 24-hour helpline health consultation, and assistance in understanding personal health condition. Results According to the 2015 NHIA statistics, the FPICP had enrolled 10.5% of Taiwan’s population (2.48 million people) and organized a total of 426 CHCGs composed of 24.9% of the primary care physicians and 29.7% of the community clinics in Taiwan (Table 1). The CHCGs in central Taiwan accounted for nearly one-third of the total number of CHCGs (10). Table 1. The Taiwan Family Practice Integrated Care Project data (2003–2015) (data source: National Health Insurance Administration, Ministry of Health and Welfare, Taiwan) Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 CHCG, community health care group. View Large Table 1. The Taiwan Family Practice Integrated Care Project data (2003–2015) (data source: National Health Insurance Administration, Ministry of Health and Welfare, Taiwan) Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 Calendar year CHCG group no. Clinic Physicians Population n % n % n % 2003 24 144 1.68 154 1.39 60 331 2.73 2004 269 1576 18.41 1811 16.36 620 294 2.81 2005 258 1533 17.05 1766 14.74 1 186 997 5.11 2006 303 1801 19.68 2050 16.80 1 535 740 5.28 2007 305 1736 18.76 1981 16.00 1 371 362 6.84 2008 324 1871 19.85 2269 17.72 1 569 133 6.61 2009 318 1789 18.74 2026 15.48 1 610 276 6.99 2010 356 2183 21.46 2478 18.59 1 311 460 5.77 2011 373 2257 22.86 2499 17.92 1 444 835 6.23 2012 367 2361 23.79 2749 19.65 2 110 866 9.11 2013 374 2785 27.73 3343 23.29 2 053 499 8.75 2014 389 2890 28.54 3527 24.09 2 235 088 9.55 2015 426 3035 29.69 3709 24.87 2 484 646 10.54 CHCG, community health care group. View Large The concise systematic review by Chang et al. in 2011 summarized the effectiveness of the FPICP in the initial years of its implementation: First of all, the FPICP was estimated to help reduce medical expenditure by 5.4%–8.0% for outpatient visits and 7.5–20% for hospitalization. Secondly, the FPICP was met with high level of overall satisfaction (80%) from the participating members, and over 90% of the enrolled members preferred to consult their CHCG family doctors first and go to a hospital for further examination or treatment when a referral was issued. The review further found the FPICP capable of encouraging members to better utilize preventive health services. For example, the utilization rates of adult health examination and Pap smear were higher in CHCG members than in the general population (51.9% versus 34.9% and 33.7% versus 28.5%, respectively). Moreover, the FPICP could improve the quality of health care through observing the performance indicators developed by NHIA (11). Pan et al. used the difference-in-difference estimation approach, propensity score method and multivariate regression models to evaluate the FPICP effects on health care utilization and outcome based on 2004–2011 NHIA data. Their results also indicated an increase in utilization of adult preventive health services; although no significant impact was observed in other aspects (12). NHIA reports in 2016 showed a steady annual progress in FPICP performance from 2013 to 2015. Compared to non-members, CHCG members made better use of preventive health services, especially in adult health examination (49% versus 19%), Pap smear (29% versus 22%), elderly influenza vaccination (42% versus 28%) and immunochemical faecal occult blood test (iFOBT; 43% versus 31%; P < 0.01) (Fig. 3) (10). CHCG members slightly outran non-members (51.0% versus 48.0%) in terms of the fixed doctors’ rate but reported no significant difference from non-members in either emergency rate or admission rate. With regard to 24-hour helpline consultation, 73.2–81.2% of members were satisfied with the service provided by CHCGs. Members reported an impressive overall satisfaction rate (98.0%%) and responded well to the CHCG provision of health consultation, health information and assistance in understanding personal health condition. For the cost of outpatient visits, approximately NTD 700 million (USD 21 million) and NTD 1.7 billion (USD51 million) were saved in 2013 and 2014, respectively. Figure 3. View largeDownload slide The performance indicators comparison between community health care group members (black bar) and non-members (grey bar). Fixed doctors: percentage of CHCG members visiting family doctors in the same CHCG group versus percentage in non-members. Adult health examination: percentage of CHCG members aged over 40 years utilizing adult health examination service versus percentage in non-members. Pap smear: percentage of sexually active female CHCG members older than 30 years receiving Pap smear service for cervical cancer screening versus percentage in non-members. Elderly influenza vaccination: percentage of CHCG members older than 65 years receiving the annual influenza shot versus percentage in non-members. iFOBT: percentage of CHCG members aged over 50 years receiving the stool iFOBT for colon cancer screening versus percentage in non-members. Figure 3. View largeDownload slide The performance indicators comparison between community health care group members (black bar) and non-members (grey bar). Fixed doctors: percentage of CHCG members visiting family doctors in the same CHCG group versus percentage in non-members. Adult health examination: percentage of CHCG members aged over 40 years utilizing adult health examination service versus percentage in non-members. Pap smear: percentage of sexually active female CHCG members older than 30 years receiving Pap smear service for cervical cancer screening versus percentage in non-members. Elderly influenza vaccination: percentage of CHCG members older than 65 years receiving the annual influenza shot versus percentage in non-members. iFOBT: percentage of CHCG members aged over 50 years receiving the stool iFOBT for colon cancer screening versus percentage in non-members. Discussion Increasing health care cost, growing inpatient utilization, expanding rural–urban disparity and fragmented care are all known to be the major issues confronting the medical care systems in developed countries like Taiwan (6). Therefore, Taiwan government has launched the FPICP to enhance the cooperation between community clinics and regional hospitals via the establishment of PCCNs since March 2003. Implemented for over 10 years, the FPICP in Taiwan has gained support from both primary care physicians and public in the community as evidenced by the growing number of CHCGs and the high levels of satisfaction of enrolled members. Most importantly, it has enabled family physicians to provide preventive health services to improve patients’ health with greater effectiveness and efficiency. The connection and cooperation—both horizontal and vertical—within an individual PCCN appears to be close and effective. As indicated in Lin’s study on PCCN in the early years of its development, CHCG physicians demonstrated an active involvement in the governance and information infrastructures within an individual PCCN (9). It has also been suggested that the main reasons prompting CHCG physicians to end or change their partnership with a PCCN include organization/participant factors (extra working time spent and facility competency), network factors (partner collaboration) and community factors (health policy design incompatibility, patient–physician relationship and effectiveness) (13). One of the key factors affecting the FPICP performance, as identified by Li and Hwang, lies in the joint administrative management centre (JAMC) in a CHCG. The JAMC functions to integrate the resources of a CHCG and its backup hospital(s) so as to improve efficiency, enhance performance and to extend the network to form further strategic alliances for strengthening both the capability and the capacity of a PCCN (14) . The FPICP emerged from the studies of Lin and Lang, Pan et al. and Lin and Huang to be effective in promoting preventive health care and regulating hospitalization, although it exerts no significant influence on outpatient health care utilization and costs initially due to increased utilization of preventive health services. Also pointed out in their studies is that doctor shopping remains quite common because of the equal and easy access to health care made possible with the NHI system (9,15,16). A CHCG carries with it two main functions: (i) in close partnership with its backup hospital(s), a CHCG provides its household members with general and preventive health care services; and (ii) it works as a competent unit offering comprehensive, easily accessible, updated, coordinated and responsible health care, thereby allowing both family physicians and primary care professionals to optimize their roles and functions. Cementing the relationship between CHCGs and their collaborating hospitals helps strengthen the partnership among PCCNs and instilling in the public the concept of family physicians as gatekeepers renders the development and implementation of well-organized national health policies easier and the integration of health care providers more effective (17). The FPICP in Taiwan is in sync with the global health care goals, including ‘Health for all’ first promulgated in the 1978 ‘Alma-Ata Declaration’; ‘Improving chronic illness care’ advocated in the 1996 ‘Chronic Care Model’; ‘Towards Unity for Health’ adopted as the new title of the WHO newsletter since 2000; ‘Primary care as a hub of coordination’ introduced in the 2008 World Health Report on Primary Health Care; and the most recent ‘Integrated person-centered health service’ (IPCHS) proposed by WHO in 2015 (18–23). The FPICP matches the contemporary global trend of the patient-centred integrated care (19). Education, training and research are crucial for the effective implementation and operation of an accountable family doctor system. Further development should concentrate not only on the ongoing establishment of more CHCGs but also on the expanding participation of allied health professionals; meanwhile, each individual CHCG should share and promote its success story as a role model for attracting more primary physicians as greater and more active participation helps minimize health inequality and improve primary care quality. Nevertheless, it is still necessary to evaluate the long-term effect of the FPICP on health care utilization and expenditure in the future. There are several issues that need to be raised for attention. Not all physicians or clinics participate in the FPICP because of the limited budget. It is strongly suggested that the government should invest more financial resources on the effective operation of the accountable family doctor system, continuous promotion of the CHCG, enhancement of the horizontal and vertical collaboration, and the development of information technology and health education to help people become more responsible for their health and to ensure the sustainable development of the integrated health care system in Taiwan. The FPICP model is an excellent example of primary care team as a hub of coordination as promoted by the World Health Organization (21). An integrated health care delivery system with primary care providers as its gatekeepers is needed to solicit more active participation from more primary care professionals (Fig. 4). In the face of a rapidly aging society, it is urgent to equip every community with a well-functioning shared care network in which local clinics work with collaborating hospitals to provide residents with patient-centred, easily accessible, well-coordinated and accountable health care. Therefore, TAFM has announced the TAIWAN Action Plan at its 2016 annual conference to bring Taiwan into the world paradigm of ‘Every Family, a Family Doctor’ by 2020 (24). Currently, the percentage of FPICP-enrolled members in Taiwan’s total population reads a modest 10.5%. TAFM will make every effort to raise the percentage to 100% by 2020 with its TAIWAN Action Plan: (i) developing a uniquely Taiwanese accountable family doctor system fully capable of delivering quality, person-centred, family-based and community-oriented health care services; (ii) enhancing accountability of care and empowering citizens to enhance self-care; (iii) providing integrated person-centred health services and enforcing bi-directional referral to ensure coordination and continuity between the three tiers of health care; (iv) providing family physicians with payment incentives to support reasonable increase in national health expenditure, thereby building up a world-leading model of sustainability; (v) upgrading the ability of family physicians in providing preventive health care to reinforce assurance of quality care; and finally (vi) constructing networks of community health support by recruiting and training volunteers for health education and self-care. Figure 4. View largeDownload slide The blueprint of a well-developed, healthy community. Figure 4. View largeDownload slide The blueprint of a well-developed, healthy community. Conclusions Taiwan’s experience of building PCCNs through the FPICP presents a very good example in response to WHO’s call for primary health care and people-centred and integrated health services. In practice for over a decade, its CHCGs prove to be capable of delivering person-centred, vertically and horizontally integrated care to safeguard the health of community residents. We urge our colleagues in the field of family medicine and the medical community to unite with government agencies, medical centres, community hospitals, local public health centres and clinics in a joint effort to build for every community an integrated health care system practising mutual referral, thereby realizing the vision of ‘Every Family, A Family Doctor’. Disclosures Funding: No. Ethical approval: No. Conflict of interest: none. 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TAIWAN Action Plan . Declaration at 2016 annual conference . Taipei, Taiwan . © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

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Family PracticeOxford University Press

Published: Nov 29, 2017

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