For several decades, Taiwan's pharmacists have been urging the government to adopt a health care system with a clear division of responsibilities between pharmacists and physicians. Pharmacists have long argued that such a system, if similar to what is found in most Western countries, would cut the waste of medical resources and better protect the health, rights, and finances of patients. But the government's recent promise to institute such a system has run into heavy opposition from doctors and health officials, who claim that it will increase medical care costs as well as lower its quality.
At present, most patients opt for one-stop health care. They see a doctor, receive prescriptions, and purchase medication at one of the many private clinics and small hospitals, which are often under the supervision of a single doctor. Unlike in Western countries, the physician's office and the pharmacy are not separate operations. Pharmacists charge that while the law allows doctors to prepare prescriptions, the actual work at most private clinics and hospitals is actually being undertaken by persons who have scant pharmaceutical knowledge, such as the doctors' spouses.
On the other hand, the pharmacies at most major hospitals are manned by registered pharmacists, who contend that their specialized knowledge gives them the capability to check the safety and efficacy of the medicines that doctors prescribe. Without this added safety check, pharmacists argue, patients do not receive adequate protection. For example, in cases of malpractice in the small private clinics, it is difficult for the victims to collect compensation because doctors can easily avoid responsibility by concealing or forging prescriptions.
The doctors' near monopoly on prescription medicine also allows them to maximize their profits by arbitrarily in creasing prices or prescribing unnecessary medications. In addition, doctors can often collect handsome kickbacks from drug manufacturers for using their products. It is abuses such as these that pharmacists hope to eliminate by restructuring the health care system.
But doctors counter such accusations by charging that many pharmacists are not qualified to fill prescriptions. They cite a Department of Health test conducted in 1986, in which a majority of the 450 pharmacists tested failed to handle sample prescriptions properly. Another statistic lends further credence to this claim: Of the 13,700 pharmacies operating at the end of 1990, only 45.3 percent were operated by registered pharmacists. The others were run by amateurs who were renting licenses from registered pharmacists and operating the drugstores under these pharmacists' names.
Chang Hung, chairman of the National Association of Pharmacists, attributes the poor performance on the government-sponsored test to insufficient practical experience because of the existing system. He is quite confident that once the new system is in place, pharmacists will have more business and become more proficient. He also hopes to see pharmacists given additional training by the association or by some government agency.
Physicians are also interested in up grading the island's overall health system. "Doctors don't oppose a division of responsibilities between physicians and pharmacists," says Chan Hung-tai, supervisor of the Taipei Association of Doctors. "But the implementation of such a system should be contingent upon pharmacists improving their ability to fill prescriptions, an adjustment of physicians' rates, and public acceptance of the system."
The current system has discouraged both an increase in registered pharmacists and an improvement in their professional quality. Pharmacists had hoped that the government's expansion of the social insurance program would improve their situation. But they were soon disappointed. For example, only one month after the farmers' insurance program was implemented in July 1989, incorporating 1 million farmers into the public medical insurance program, business at rural drugstores dropped by 30 percent. The reason? Enrollees in the new program could not claim insurance coverage on prescriptions filled at pharmacies.
The implementation of Taiwan's new health care system, which is slated to institute a comprehensive medical insurance for the island's 20 million people by 1994, is already behind schedule. Originally expected to begin on a trial basis in July 1991, it was postponed because the revisions to the Labor Insurance Act, which would have permitted pharmacies to collect insurance payments, had yet to be passed by the Legislative Yuan. Unless the necessary revisions are made, pharmacists see their very survival threatened.
Dim prospects for the future have already prompted many pharmacists to abandon their careers. But others have vigorously stepped up their efforts to encourage the early adoption of the Western-style health care system by lobbying, filing petitions, and organizing demonstrations. The Department of Health expects the Legislative Yuan to approve the necessary revisions to the Labor Insurance Act before the end of 1991.
Over the next four years, the government will also implement a three-stage program that is expected to bring about a clearer division of labor between pharmacists and physicians. In the first year, it will draft a plan for instituting the new system. In the second year, it will choose a number of areas to test the system. And during the following two years the system will be extended to the rest of the island. For now, the government is asking pharmacists to be patient.
But there is still a lack of consensus among government agencies on how to proceed. Government officials, including some in the Department of Health, are having second thoughts about the desirability of the new health care system. For example, Chang Po-ya, director-general of the Department of Health, while speaking at a press conference in May, suggested that the new health care system as now envisioned might not be the best choice. To bolster her argument, she cited a remark made by a Canadian congressman during a recent visit to Taipei concerning the amount of waste in the Canadian health care system—a system quite similar to what pharmacists hope to see introduced here. Her remarks instantly touched off an uproar among pharmacists. In response, Chang denied that the government intended to retreat from its commitment to instituting the new system. But she also said that the system will be put into place only after her department has completed plans for its implementation and determined when conditions are appropriate.
Meanwhile, the Council for Economic Planning and Development has decided that the division of the professions is not among their priorities for 1992. And the Labor Insurance Bureau, which manages the labor insurance and farmers' insurance programs, seems to be wavering on its commitment to the new system. At present, the bureau is paying an average of US$7.50 per outpatient visit at local clinics. The cost breakdown is US$3.80 for seeing a doctor, US$0.70 for the prescription preparation fee, and US$3.00 for medicine and other miscellaneous costs. But should a clearer division of labor between physicians and pharmacists be implemented, the bureau expects that doctors will want to double the rates they charge the public insurance program in order to compensate them for substantial revenues lost to pharmacists. At the same time, registered pharmacists are also expected to request an increase in their fees for preparing prescriptions. At present, the fees are negligible.
Officials at the Labor Insurance Bureau are concerned that the increased outlay in the new health care system for physician and pharmacist services may fail to be offset by a reduction in the waste of medical resources. Moreover, because there are no accurate estimates on the amount of waste currently generated, it is impossible to calculate potential savings. But if no savings are realized, consumers can expect that the resultant increases in medical costs will be passed on to them in the form of higher taxes or insurance premiums.
Chang Hung, of the National Association of Pharmacists, resents the government's reluctance to implement the new system. "If the director-general of the Department of Health insists on maintaining the existing system, all pharmacists will have to give up and leave the profession," he says. Chang also feels certain that the Insurance Bureau's fears are unfounded and that the savings garnered from the new system will more than compensate for the rise in physician and pharmacist fees.
Stiff competition for independent pharmacies—the ten pharmacists at Mackay Memorial Hospital fill thousands of prescriptions a day.
Pharmacists are taking a wait-and-see attitude. In the interim, they have begun preparing for a new era in their business. The National Association of Pharmacists is ready to organize the pharmacies in the trial areas during the system's second year of implementation. One plan is to provide around-the-clock service by establishing 24-hour drugstores or by rotating night service so that patients can conveniently fill prescriptions. The association also plans to be more active in promoting the new system in hopes of winning consumer support, which is critical for its success.
One of the biggest hurdles facing pharmacists is how to win the trust and support of the general public. After all, patients will have to accept the inconvenience of making an extra stop at a pharmacy to fill their prescriptions. Public support, at least at the initial stage, is especially critical since patients will have the option of picking up their medication either at clinics or pharmacies.
Experience in other Asian nations is not encouraging. Despite the institution of a Western-style health care system in Japan twenty-six years ago, only 10 percent of the country's patients fill their prescriptions at independent pharmacies. In South Korea, the system has also ended in failure, due in large part to the tactics of physicians who prescribe medicines not easily found at the average pharmacy.
Still, some pharmacists expect to see a dramatic change in their operations. They will have to set up reference files in their stores, a waiting lounge for patients, and on-line connection with hospitals. With the expected increase in customers, pharmacies might even be transformed into American-style drugstores, selling not only medicine, but also health and exercise equipment, cosmetics, health food, and other sundries.
In fact, a number of international drugstore chains already have opened in Taiwan, aiming to secure a handsome share of a market estimated at US$2 billion a year. They bring with them years of experience and sophisticated organizational structures. Such chain stores can attract customers with low prices, high-quality service, and brand name uniformity. For example, Medicine Shoppe International Inc., which has nine hundred drugstores in the U.S., just signed an agreement in July authorizing Taiwan's Pro Healthcare International Co. to set up a chain of pharmacies on a franchise basis. With the first pilot store scheduled to open within the year, Pro Healthcare plans to expand the number of franchises to fifty next year and to four hundred by 1994. Local pharmacy chains are also growing. Yes Pharmaceutical Marketing Co., for example, already has forty franchises, and Nine Yang Pharmacy Chain has a hundred.
While the future may appear bleak to many pharmacists, chain store owners are optimistic. They are convinced that their high-quality service will win over consumers. "The uniform procurement, personnel training, logo, and good service will help the chains win customer confidence," says Li Cheng-chia, chairman of Pro Healthcare. Li adds that the chains not only have the ability to withstand the adversities of the market under the present health care system, they can even expand. Chain stores may also play an important role in upgrading professional standards. To win the trust of the public, as well as maintain their international reputations, the chain stores are expected to hire only the most qualified applicants.
Although the implementation of the new health system is now only a matter of time, an important issue remains unresolved: how best to regulate the system to ensure quality. For example, the licenses granted to pharmacies need to be more strictly regulated. Prescriptions should be filled by registered pharmacists, not by amateurs. And registered pharmacists would benefit by further education and training to help them keep abreast of the huge number of new drugs and medications on the market. Furthermore, internships or a period of residency should be mandatory for all graduating pharmacy students, and they should be tested by a more rigorous standardized examination before being allowed to enter the profession on their own.
Some steps are already being taken in these areas. The Department of Health plans to have large hospitals train more pharmacists, and there are signs that the Association of Pharmacists may become more energetic in policing their own ranks to help raise professional standards. But in the end, it is the consumers who will decide where to fill their prescriptions. —Philip Liu (劉柏登) is editor-in-chief of Business Taiwan, an economic weekly newspaper published in Taipei .