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Reform of NHI Review System to Make Reviewers Identifiable and Ensure Better Review Quality

  • Data Source:Ministry of Health and Welfare
  • Created:2016-07-11
  • Last Updated:2017-01-10

The National Health Insurance scheme has been in operation for 21 years. To ensure reasonable use of medical resources, reviewing, auditing, and denying certain medical expenses have become necessary evils. Although there is an appeal and dispute deliberation system to judge audit and denial results, disputes still arise due to the anonymous review system and different professional opinions. Hence, demand for an identified reviewer system has ensued. In response to this demand, and in an attempt to improve the review quality, the Minister for Health and Welfare, Tzou-Yien Lin, instructed the National Health Insurance Administration to make a thorough examination of the review system based on the principle of “respect for professional dialogue; enhancing medical quality.” After intensive meetings and extensive surveys of opinions from specialist associations and reviewing physicians over the course of a month, a major reform proposal was put forward today. It was proposed that the identified reviewer system is to be given a trial run for some medical specialties. The trial run would start in October 2016 at the earliest. 

Peer reviews of NHI medical expenses are sampled by means of random and purposive sampling. The audit and denial result of the randomly sampled cases will be traced back for proportional cut in the reported expenditure points. For purposive sampling, cases are sampled based on specified criteria, but the audit and denial result will not be traced. Recently, some physicians and the Legislative Yuan have demanded an identified reviewer system in order to make the reviewing physicians more accountable and reduce the percentage of expenditure cuts and their impacts. Thus, the NHI Administration has surveyed the opinions of 25 medical specialist associations, hospital associations, and the three national medical associations for dentistry, Western medicine, and traditional Chinese medicine since early June. Of those surveyed, 55% of them supported the identified reviewer system, and 89% indicated they would continue to refer reviewing physicians even with the identified reviewer system. Meanwhile, the NHI Administration also conducted a survey among the more than 3000 existing reviewers, and found that 31% of them were willing to be identified, involving 35% of the departments under hospital global budget. In addition, the New Taipei City Medical Association’s survey on its members also showed that 93% supported the identified reviewer system, and 42% would serve as an identified reviewer, involving 63% of the departments under hospital global budget. 

Having sought opinions from various sources and conducted careful evaluation, the Ministry of Health and Welfare has planned to carry out a major reform of the NHI review system. Preliminarily, a trial run will be implemented for the review of departments under hospital global budget by having the specialist associations that consent to the identified reviewer system (including the obstetrics and gynecology, pediatrics, ophthalmology, otolaryngology, neurology, psychiatry, and rehabilitation) refer physicians who agree to be identified reviewers. The following supporting measures will also be simultaneously adopted: 

1. Professional autonomy is absolutely respected during the review process, and administrative units will not intervene. This includes having specialist associations refer peer reviewers. 
2. Common reviewing standards for the respective specialties are to be laid down by specialist associations that take part in the trial run and publicly announced. 
3. Denied cases shall come with specific and reasonable explanations of the reason for denial, and shall be confirmed by a second reviewer. Both reviewers shall be identified. 
4. The number of randomly sampled cases shall be reduced to allow sufficient time for peer reviewers to make review, and extreme values and rare cases shall be excluded for the proportional expenditure cut, in order to reduce the impact of expenditure cut. 
5. A virtual private network (VPN) platform shall be constructed for denied physicians to raise objections about expenditure cut, and a mechanism for professional dialogue shall be established, so as to improve the review quality. 
6. In case of special disputes, a case discussion shall be held by the relevant specialist association. 

The above reform proposal will be put into practice after the NHI Administration has finished the relevant internal procedures. Result of the trial run will be assessed, and a full-scale implementation will be executed if the result is favorable. The review of departments under global budget on Western medicine clinics will be further discussed with the Taiwan Medical Association in relation to the approach and feasibility of implementation, because the NHI Administration has already entered into a commissioning contract with the Association. Minister Lin made an appeal to the peer reviewers to maintain a professional spirit for rational dialogue and to work together for the betterment of medical quality.