Chinese Medicine in the Taiwanese Healthcare System
by Eric Brand
Chinese medicine enjoys broad coverage in the Taiwanese national insurance system, which covers all Taiwanese citizens as well as foreign students and workers. During my internship at Chang Gung Hospital in Taiwan, I was on a work-study visa that allowed me to have health insurance coverage for an astonishingly low $18/month (the insurance cost is related to one’s income). The insurance card itself is a smart card with a chip inside that can be read by computers in all hospitals and clinics, and the coverage includes biomedical care, dental care, and Chinese medical care. While there are naturally still some imperfections in the Taiwanese healthcare system, Taiwan nonetheless has one of the best healthcare systems in the world when it comes to comprehensive benefits, preventative care, and universal coverage.
In Taiwan, most large hospitals have a Chinese medicine division. This division is generally subdivided into different specialized departments, such as gynecology, internal medicine, tui na, pediatrics, acupuncture, and traumatology (傷科shang ke). Smaller private Chinese medicine clinics also abound throughout Taiwan. While smaller clinics lack departments like large hospitals, they are often designed around the specialty of the chief doctor. Thus, we find smaller clinics specializing in tui na, internal medicine, gynecology, etc. Taiwan is not without general practitioners who see a bit of everything, but there is a greater overall tendency towards specialization than we see in the U.S.
Within a large hospital, the Chinese medical gynecology, internal medicine, and pediatric departments are exclusively herbal. The doctor sits behind a desk, asks questions, takes tongue and pulse, and types the formula into a computer that is linked to a centralized pharmacy. The patient then picks up their prescription from the hospital pharmacy.
Granules are covered by the national health insurance, but raw herbs are not. Thus, most patients opt to use granules, though wealthier patients or patients with serious and acute conditions sometimes choose to pay out of pocket for raw herbs. Granules can be prescribed for up to one month on a single patient visit, and the co-pay for the patient is usually about $5 US. By contrast, raw herbs cost the patient about $2-5 per day, so raw herbs are a much more expensive choice for Taiwanese patients. When raw herbs are chosen, hospitals can often decoct the herbs for the patient in a Korean extraction machine, but this further increases the price. While most Taiwanese doctors believe that raw herbs have a faster and stronger effect than granules, the general consensus is that granules are quite effective for managing most common complaints.
Acupuncture is primarily used in only two departments, the acupuncture department and the traumatology department (herbs can be prescribed in these departments as well). The traumatology department, sometimes called the bone and trauma department (骨傷科gu shang ke), is the most diverse department in terms of modalities because acupuncture, tui na, internal herbs, and external applications are all used. It should also be noted that the field of tui na in Asia is far more advanced than what we associate with tui na in the U.S.; Taiwanese tui na doctors study for seven years and they use bone manipulation and other techniques in addition to massage.
In Taiwan, doctors that treat patients using insurance make very little per patient visit (about $4), but they tend to treat a high volume of patients. This makes Chinese medicine a relatively stressful profession because the patient load is high and the time with each patient is often relatively brief. However, Chinese medicine is very affordable to patients, so it is widely used. Naturally, there is a trade-off here; care in Taiwan is inexpensive and accessible, while Chinese medical care in the U.S. is quite expensive by comparison. In the U.S., our high cost of individual treatments gives us the luxury of spending more time with our patients and giving them more personalized attention. We are better situated to act like therapists, we have time to listen to our patient’s personal stories and we tend to give a lot of time and care to each patient. By contrast, the patients in Taiwan have shorter patient visits, but their cost of treatment is much lower and they see doctors that have much more cumulative experience as a result of the high patient loads.
Interestingly, there is a slight shortage of Chinese medical practitioners in Taiwan. Biomedical doctors outnumber traditional doctors ten to one, and some biomedical practitioners actually come into the field of traditional medicine because there are better opportunities and more jobs available in Chinese medicine than in biomedicine.
When I studied at Chang Gung, I was surrounded by young resident doctors who were completing extended study. These doctors were generally working for around $2000 US per month, but they could easily make double that by working in an outside clinic. While jobs are plentiful for Chinese medical doctors in Taiwan, the resident doctors at Chang Gung generally chose to be there because they wanted more experience studying with senior doctors. In order to have the opportunity to study more and move up in the ranks at Chang Gung, they were willing to accept a salary that was basically half what they stood to earn outside. As an interesting aside, the opportunities for promotions within the hospital often depend on producing publications in SCI-rated journals. Thus, much of the research that is undertaken has a biomedical slant to fit into these scientific journals.
The Taiwanese health care system provides an excellent model of integrative care. For those interested in assessing the health care costs of preventative medicine and traditional medical care, the data from Taiwan’s healthcare system is probably one of the best sources of such information. Additionally, there is a high degree of integration between biomedicine and traditional medicine in Taiwan, because most doctors of Chinese medicine are also MDs. Tracking records between biomedical departments and traditional medical departments is easy because of the paperless smart card system, and the general openness of practitioners promotes widespread referrals between biomedical practitioners and Chinese medical practitioners.
I’d highly recommend Taiwan as a destination for studying Chinese medicine in its native environment. However, Chinese language skills are generally necessary to study in Taiwan, because the medical system is anything but strapped for cash. In mainland China, it is easy to pay a hospital and hire a translator, but in Taiwan it is virtually impossible to pay to study. One needs Chinese language ability and relationships with teachers in order to get into a good study opportunity, so Taiwan really isn’t a good place to show up and expect to get in just because one can pay. In a sense, Taiwan is the best place for advanced study and the worst place for advanced study- there are nearly unlimited (and free) opportunities for Chinese speakers but virtually no opportunities for people that don’t speak the language. In some ways, this is a shame because I have several monolingual friends that would love to study here but cannot; on the other hand, a Taiwanese doctor can’t show up in NY and expect doctors to speak to them in Chinese, so it is totally natural that one should expect speaking the native language to be a basic requirement for advanced study anywhere in the world. Perhaps Taiwan is the ideal place to motivate one to learn the Chinese language, because once we develop language skills, all the doors seem to open here.
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