Background
A nationwide health insurance system improves the quality of life and promotes the health of residents, especially when the insurance tax is low, and when many medical facilities are provided. A study evaluating medical utilization based on the Taiwan NHI system in 2002 revealed that on average, a person had 13.4 physician consultations and consulted 3.4 specialties, 5.2 physicians, and 3.9 healthcare facilities in a year; 17.3% of the studied cohort had visited different healthcare facilities on the same day; and 23.5% had visited physicians of the same specialty at different healthcare facilities within 7 days [
1]. To decrease inappropriate use and overuse of medical facilities, a co-payment method had been introduced into Taiwan’s healthcare system, which adds an economic load that increases proportionally with the use of medical services. However, this could pose great difficulty for those with specific diseases or those of a low socio-economic level. The policy of listing NHI-defined catastrophic illnesses exempts some vulnerable populations from the co-payment economic burden and protects their human rights with regards to access to necessary medical care. There is some debate regarding equity and adequacy issues, as NHI-defined catastrophic illness may not necessarily cause high medical costs, whereas some expensive diseases or treatments may not be included in such an official list. A study analyzing the correlation between NHI-defined catastrophic illness and high medical expenditure revealed that those with catastrophic illness tended to be socio-economically vulnerable and usually had a high medical expenditure [
2].
In Taiwan, the aging society has become an important issue. Owing to progress in the economy as well as in preventive medicine, the life span of Taiwanese people has increased markedly in recent years. This phenomenon has been combined with an unprecedented decline in the overall fertility rate to create a rapidly aging society. As a result, some chronic medical conditions have become major public health problems. Promoting health among the elderly is an important medical issue; in fact, the elderly population has been identified as one of the target populations in the "Healthy People 2020 in Taiwan" program [
3]. Therefore, after the 10-year long-term care project was proposed by the Taiwan government, the supply of health care services and the long-term demands for the elderly or those with a catastrophic illness are important for future Taiwanese society [
4].
To understand the effect of catastrophic illness certification on the use of medical services and the sequence of public health in Taiwan, a simple descriptive, sampled population-based survey maybe is valuable and can be processed as a pilot of a series of studies. Designed as a cross-sectional, randomly-sampled study, the present study was focused on emergency department (ED) visits and aimed to compare medical utilization and various diagnostic categories at EDs between the elderly with an identified catastrophic illness and the elderly without.
Discussions
In Taiwan, patients with a catastrophic illness certificate who receive care for the illness or related conditions within the certificate’s validity period do not need to pay copayments for outpatient or inpatient care. Catastrophic illness patients must still follow normal treatment and payment procedures when seeking care for unrelated conditions [
10]. However, the policy of catastrophic illness certificates, meaning freedom from economic load, indeed benefits these patients with the listed disorders and changes the epidemiological presentation of these diseases in Taiwan. For example, an epidemiologic study of both pediatric and adult systemic lupus erythematosus (SLE) in Taiwan, based on the National Health Insurance Research Database (NHIRD), showed that Taiwan’s incidence and prevalence were higher than those reported in most studies on white populations, and the prevalence increased steadily during the study period, from 42.2/100,000 in 2000 to 67.4/100,000 in 2007 [
11]. Another study revealed that the prevalence and incidence of chronic kidney disease (CKD) in Taiwan are relatively high as compared with other countries, and the incidence of end-stage renal disease (ESRD) in Taiwan is the highest in the world [
12].
Through analysis of Taiwan’s NHI data, the cumulative prevalence of schizophrenia was found to have increased from 3.34 per 1000 to 6.42 per 1000 from 1996 to 2001, and the annual incidence density decreased from 0.95 per 1000/year to 0.45 per 1000/year from 1997 to 2001. According to the trends of cumulative prevalence and incidence density, the treated prevalence and incidence rate will be approximate to community rates. This means that most people with schizophrenia had received treatment in Taiwan after the NHI program was implemented [
13]. Compared with enrollees with a minor psychiatric disorder, those with a major psychiatric disorder have a higher use and a greater cost of mental health care services [
14]. Based on the NHI data and the catastrophic illness register data, the co-morbidity of malignancy with other diseases listed as catastrophic illnesses has also been studied in Taiwan [
15‐
17]. Furthermore, many Taiwanese cancer patients could potentially benefit from hospice care; the rate of hospice utilization during their final year of life was calculated, and was shown to have grown substantially from 5.5% to 15.4% from 2000 to 2004 [
18].
The implementation of Taiwan's NHI has significantly increased the utilization of both outpatient and inpatient care among the elderly, and such effects are more salient for people in the low- or middle-income groups [
19]. A study of 519,003 visits to adult EDs in 12 Taiwanese medical centers sampled in 2000 showed that the elderly accounted for 28.5% of all adult ED visits, and elderly patients accounted for 40.8% of the total adult ED cost. Compared with younger patients, a greater proportion of elderly patients have chronic diseases, are major cases, and are higher-level emergency cases [
20]. Different evaluations of the requirement for medical services for the elderly in Taiwan, including the Survey of Health and Living Status of the Elderly in Taiwan (SHLSET) and the National Health Interview Survey in Taiwan (NHIS), have shown that a worsening health status is associated with an increased likelihood of subsequent institutional care use, and the high-comorbidity group tended to utilize more ambulatory care services [
21,
22].
In the US, a large cohort of persons with SLE who underwent annual structured interviews showed that in those with SLE, a greater disease activity and Medicaid insurance are associated with more frequent ED use [
23]. Another study estimated that the average total yearly expense per patient for rheumatoid arthritis increased from 1,155 United States Dollars (USD) in 2000 to 1,821 USD in 2007 [
24]. That meant that great physical and economic burdens are suffered by these chronic illness patients, and their medical behavior may be influenced by the conditions of their insurance. In Taiwan, those with any of the listed catastrophic illnesses receive full and free medical care provided by the nationwide healthcare system that could contribute to their family support and the social security, especially for the elderly. For example, a study to examine the effects of chronic kidney disease (CKD) severity and aging on medical utilization in the Taiwanese elderly population revealed that compared with the reference group, increases in medical utilization and expenses were demonstrated in elderly CKD subjects, especially those with late-stage CKD [
25].
Based on randomly-sampled cases from Taiwan’s NHI data, the direct medical cost of one ED visit in Taiwan averaged NT$1,792 (US$54.3) for insurers in 2004, and the annual increase of expenditure for emergency medicine was estimated to be 4.9% (
p < 0.001). In addition, the average treatment-associated expenditure and drug-associated expenditure in Taiwan EDs were 64.5% and 10.6% of the total ED-associated cost, respectively. In particular, treatment-associated cost markedly increased with age (8% per year,
p < 0.001) [
26]. Compared with the present study, it is apparent that the elderly have a much greater medical expenditure at EDs, and, in Taiwan, more than 70% of the total ED medical cost, either for catastrophic illness or not, is treatment-associated, which could possibly be due to the complexity of the medical problems in the elderly.
Otherwise, the frequency of major medical problems diagnosed at ED visits varied by age: the subjects aged 65 years or older had the highest percentage of multiple diagnoses (43%), and the most common diagnostic category among this elderly subgroup was ill-defined symptoms/signs (32.2%), which was noted in 55.9% of cases with multiple diagnoses [
26]. In the present study, it was found that the highest proportion for any diagnostic category was about 22% and 30% for the catastrophic illness subgroup and the other subgroup, respectively, both of which were ill-defined symptoms/signs. With the exception of ill-defined symptoms/signs, the four most frequent diagnoses for the normal population aged 65 years or older in Taiwan were found to be diseases of the circulation system, diseases of the respiratory system, injury/poisoning and diseases of the digestive system [
26]. This was similar to the distribution of the identified diagnostic categories in the elderly with catastrophic illnesses at EDs found in the present study.
The present study is a descriptive epidemiological survey to evaluate the ED utilization of the elderly Taiwanese population, and some limitations exist. Possible sources of uncontrolled confounding in the present study, for example, social-economic influences, family support, complex co-morbidity or pharmacological management strategies, were not evaluated. Further investigations using data from a community-based interview survey will be performed.
Some limitations exist in the present study. First, a certificate of any catastrophic illness was confirmed based on the definitions announced by the Taiwan’s Health authority but according to the patients’ application. A misclassification bias could be happen when analyzing the present data because some lowly socio-ecological leveled or educated people didn’t know and use the welfare of the health insurance system. Second, the resent study was a cross-sectional study merely to describe the differences in EDs utilization and direct medical expenditure between the catastrophic and non-catastrophic illnesses. Much more interesting comparisons between the two groups, such as consequent lifespan, quality of life et al., could not be obtained. That needs other prospective surveys in future.
Competing interests
All authors declare that they have no conflicts of interest, including directorships, stock holding or contracts.
Authors’ contributions
The study was designed by NPY and YHL; data were gathered and analyzed by CYC and JCH; the initial draft of the manuscript was written by NPY and ILY; and the accuracy of the data and analyses was assured by NTC and CLC. All authors participated in the preparation of the manuscript and approved the final version.