Comprehensive Policies

Abstract

With the sharply escalating medical expenses, the National Health Insurance Administration (NHIA) has implemented a number of programs to contain expenditure, deliver patient-centered health care, and meet the medical needs of the super-aged society that Taiwan will face in the future.

Taiwan has followed the steps of many advanced countries to separate medicine and pharmacy to promote medication safety. In this chapter, we describe various obstacles and contingent approaches to implementing a policy that is quite against the social norm. The outcome was analyzed to evaluate the effect of this controversial policy. To connect long-term care seamlessly after hospital discharge, discharge planning and follow-up management fees are covered by the National Health Insurance (NHI). The NHIA has also endeavored to encourage two-way referrals in the tiered medical care structure since 2017, hoping to improve the efficiency of the overall healthcare system through the redistribution of workload and the continuity of health care. Therefore, in addition to increasing the reimbursement for hospitalization and emergency treatment, differences in co-payment for referral visits from different levels of hospitals were applied to encourage better healthcare-seeking behavior. We also discuss the decision-making process of the on-going co-payment adjustment at the end of the chapter.

Introduction

The National Health Insurance (NHI) is the most important cornerstone of social security, and the National Health Insurance Administration (NHIA) is always committed to providing comprehensive and continuous services for the insured. With the sharply escalating medical expenses, expenditure reduction and high-value health care is the only answer to protecting patients’ medical rights with the limited resources that we have in hand. The NHIA has also implemented a number of programs for the medical needs of the super-aged society that Taiwan will face in the future.

Taiwan followed the steps of many advanced countries in separating medicine and pharmacy to realize pharmacists’ role of integrating and reviewing prescriptions issued by physicians. The NHIA has endeavored to promote two-way referrals in the tiered medical care structure since 2017. We hope to improve the efficiency of the overall healthcare system by the redistribution of the workload and cooperation between hospitals at different levels. Therefore, in addition to a reimbursement increase for hospitalization and emergency treatment, differences in co-payment for referral visit from a different level of hospital was applied to encourage better healthcare-seeking behavior. Recently, co-payment adjustment was proposed to raise the public’s cost awareness and address overuse.

Implementation of the Separation of Medicine and Pharmacy from a National Health Insurance Perspective

Taiwan Bar Journal.

Since the inception of the NHI in March 1995, improved access to the contracted medical institutions facilitated a great opportunity to implement an independent pharmaceutical service through the NHI system. Therefore, the pharmacist association advocated for the enactment of Article 102, Item 2 of the Pharmaceutical Affairs Act, to separate drug prescribing and dispensing. The clause mandated that after 2 years of implementation of the NHI, physicians can dispense drugs by themselves based on their own prescriptions only in the remote areas where practicing pharmaceutical personnel are not available or in the case of urgent need for medical treatment services. It became the legal basis for the independent pharmaceutical service.

The medical profession is quite dissatisfied with the amendment, feeling deprived of their right to dispense, so physicians and pharmacists hit the street separately to protest against the new policy. The separation of prescribing and dispensing not only eliminates the medical institutions’ benefits derived from drug price differences but also causes hidden worries such as license leasing, fewer medicines than the hospitals, dispensing alternative drugs, and modifying prescriptions.

Because of the stalemate between medical and pharmaceutical professionals over the issue of separating medicine and pharmacy, the former Department of Health, Executive Yuan, adjusted the original single-track system¹ to a dual-track system. In this way, the physicians in the medical institutions can release prescriptions, or hire pharmacists to dispense the prescription in-house. In this controversial adjustment, clinical pharmacists become employees hired by physicians to dispense drugs. As there is an employment relationship, the intention of holding pharmacists accountable for the supervision and professional review of the prescription by separating medicine and pharmacy is easily weakened or even disappears. Owing to the implementation of the dual-track system, instead of practicing completely separately, most of the time medical and pharmaceutical professionals only cooperate to share the workload.

The NHIA was tasked to establish a system that incentivizes physicians to release prescriptions. Therefore, the NHIA paid an additional 25 relative value units (RVUs) for the prescription released by clinics and provided pharmacies with higher dispensing and drug fees, so that the pharmacy could earn an extra 51 RVUs² on each prescription on average. But the payment incentive results in the peculiar phenomenon of “front-door pharmacy,” which triggered the NHIA to monitor “unreasonable prescription release patterns from clinics”: the NHIA would refuse to reimburse additional diagnosis fees for clinics that release more than 900 prescriptions or over 70% of its prescriptions to a designated pharmacy, and this pharmacy dispenses more than 70% of the prescriptions released from one clinic at the same time. However, the phenomenon of registering an individual pharmacy within the proximity of the clinics was not fully curbed until the NHIA completely canceled the payment for releasing prescriptions in July 2006 and simultaneously increased the payment for drug dispensing from 21 to 28 RVUs provided by the physician-hired pharmacist.

The Meaning of Separating Medicine and Pharmacy

The purpose of separating medicine and pharmacy is not only to pursue the division of labor between physicians and pharmacists but also to realize pharmacists’ role as patient-centered family pharmacists, who integrate and review prescriptions issued by physicians, dispense independently, prevent patients from duplicated medication or drug interactions, and provide medication consultation.

To ensure pharmacists’ right to dispense independently, most countries³ that have implemented a medicine and pharmacy separation system restrict physicians with prescription rights from operating pharmacies. It is hoped that by structurally excluding physician’s intervention, pharmacists could have independent space to practice.

One of the main arguments of the pharmacists to strive for in the independent pharmaceutical service is to follow the practices of advanced Western countries. But this argument over-simplifies the purpose of this important policy. What is the problem with not separating medicine and pharmacy? Is the separation a suitable strategy to tackle these problems? Will new problems produce the strategy? All of these questions have to be assessed objectively so that the medical profession and the pharmaceutical personnel will not fall into a dispute caused by personal feelings. Because of the space limitation, this article only discusses from the viewpoint of the NHI.

The Effectiveness of Separating Medicine and Pharmacy

The result of separating medicine and pharmacy since the implementation of Article 102 of the Pharmaceutical Affairs Act can be observed from the following data:

• 1. Drug fee:

  Two of the reasons⁴ for separating medicine and pharmacy are to avoid drug abuse and reduce drug fees. However, NHI outpatient drug fees increased annually between 2010 and 2017 and the average drug fee per claim also showed a general increase⁵, which did not support the assumption empirically.

• 2. Drug fee claimed by the pharmacies:

  Among the NHI drug fees mentioned above, physician-released prescriptions claimed by the contracted pharmacies also increased annually from 2010 to 2017⁶. Although most hospitals had hired their own pharmacists, the number of prescriptions released from the hospitals and its proportion in the total amount of drug fees claimed by the pharmacies both increased from 2010 to 2017⁷. As most of the medical flow of hospital outpatient visits involves filling prescriptions at the in-hospital pharmacy after making a payment, it can be assumed that the possibility of patients voluntarily requesting the release of prescriptions increases and their autonomy is relatively improved. The number of prescriptions released by Western medical clinics has also grown year by year⁸, which is in line with the assumption mentioned above.

• 3. Number of the NHI-contracted pharmacies:

  In 2004, there were only 3898 NHI-contracted pharmacies, and the number grew annually to 5037 in 2011 and 6203 in 2017. The increase in hospital-released prescriptions expanded the drug-dispensing market for contracted pharmacies, and the number of the contracted pharmacies increased subsequently.

Available data demonstrate that although the separation of medicine and pharmacy does not have the function of regulating overall drug fees, the number of prescriptions that hospitals issue increases in contracted pharmacies. It shows that over the past 20 years, the policy has gradually affected the habits of patients, so that they are now willing to have prescriptions filled in community pharmacies.

Ownership of Dispensing Rights from a Legal Perspective

Regarding whether the physician or the pharmacist is more eligible to the dispense drugs, both parties have their own legal right according to the current law:

• 1. Physicians:

  • A. Article 66 of the Medical Care Act: when dispensing medications to patients, a hospital or clinic shall clearly indicate the patient’s name, sex, dosage, quantity, method of administration, actions or indications, warnings or side effects of the medication, the name and location of the medical institution, the name of the dispenser and the date of dispensation on the container or package.

  • B. Article 13 of the Physicians Act: when issuing prescriptions, physicians shall clearly state the following on the signed or sealed prescription slip: physician’s full name, patient name, age, name of medication, dosage, amount, use and year, month and day on which the prescription was issued.

  • C. Article 14 of the Physicians Act: when delivering medicines to patients, physicians have the same obligation to include necessary information such as states in Article 66 of the Medical Care Act.

• 2. Pharmacists:

  • A. Article 37 of the Pharmaceutical Affairs Act: dispensation of drugs shall not be performed unless it follows established operational procedures; the operational guidelines shall be established by the central competent health authority. (Item 1) The aforesaid dispensation of drugs shall be performed by a pharmacist. … (Item 2) Article 102: any physician having dispensation facilities as specified in this Act may, for the purpose of medical treatment, dispense drugs by himself/herself based on his/her own prescriptions (Item 1). After 2 years of the implementation of the National Health Insurance, the provision of the preceding Paragraph shall be enforceable only in remote areas, where practicing pharmaceutical personnel are not available as announced by the central or municipal competent health authorities or in the case of urgent need of medical treatment services (Item 2).

  • B. Article 50 of the Pharmaceutical Affairs Act Enforcement Rules: “Urgent need of medical treatment services,” as used in Article 102, Paragraph 2 of the Act, means circumstances in which a physician at a medical care institution, owing to an urgent need for medical care measures, must immediately use a drug.

  • C. Articles 12, 15 to 20, and 20–21 of the Pharmacists Act specify the pharmacist’s obligations to dispense medications, precautions, regulations to comply with when dispensing medication, and their right to administer dispensation business, etc.

  • D. Good dispensing practice specifies the personnel (pharmacists, assistant pharmacists), procedures and equipment required for drug dispensation.

Judging from the Medical Care Act and the Physicians Act above, physicians have the right to issue prescriptions. Although none of the laws mentioned whether physicians have the right to dispense prescriptions, they have the obligation to deliver prescriptions. Actions including preparation, compounding, and confirmation of the drugs that must be completed before drug deliveries are defined as being within the scope of “dispensation”⁹. Therefore, physicians should complete a series of procedures including prescribing, preparing, compounding, and confirming drugs and delivering them to patients. Moreover, the scope of the physician’s dispensation is limited to prescriptions prescribed by himself or herself. That means, even with statutory equipment, physicians are not allowed to dispense drugs for other physicians.

Of course, objections have been voiced that the Physicians Act and the Medical Care Act only regulate the delivery of drugs by physicians, which is only one part of the dispensation; therefore, physicians are not allowed to conduct other parts of the dispensation¹⁰. The pharmaceutical professionals argue that, in accordance with Article 102, Item 2 of the Pharmaceutical Affairs Act (announced on 5 February 1993), 2 years after the implementation of the NHI, physicians have no right to dispensation, except for in remote areas or medical emergencies. This is the principle that the later law has priority over the earlier law [1]. However, Article 14 of the Physicians Act stated in 1967 that physicians should properly label the medication when they deliver the drugs and the revision of the Article in 2002 did not delete this regulation. Instead, to protect the patient’s right to know, the scope of information that physicians should label was expanded. The same principle was applied in the amendment of Article 66 of the Medical Care Act in 2004, and the abovementioned regulation was added. If the later law has priority over the earlier law, it is hard to recognize the Pharmaceutical Affairs Act as the later one. In addition, comparing Article 102 of the Pharmaceutical Affairs Act with the relevant regulation in the Physicians Act and the Medical Care Act, it is difficult to conclude that Article 102 of the Pharmaceutical Affairs Law is a special law that should be applied first. There are indeed unresolved conflicts regarding the ownership of the dispensation rights in the provisions of the above regulations.

The judicial community also has different opinions on whether physicians can dispense the prescription in general after the implementation of Article 102 of the Pharmacists Act. There is a case involving a clinic that did not hire pharmaceutical personnel, and the drugs were delivered by the physician in charge. The health bureau of the competent authority fined the physician for violation of the provisions of the Pharmaceutical Affairs Act. The Taichung High Administrative Court ruled that the plaintiff’s physician won the case. There are three reasons:

• 1. Whether the physician delivers the drugs belongs to the scope of dispensation. The so-called dispensation is only defined in Article 2 of “Good Dispensing Practice” based on the Pharmaceutical Affairs Act Enforcement Rules¹¹ at the time of the action, not authorized by law. The definition of dispensation in Article 37 of the Pharmaceutical Affairs Act, which is only an administrative rule issued by administrative agencies in order to enforce the rules, violates the principle of clarity of authorization.

• 2. Article 14 of the Physicians Act, an act that was amended and announced later, is still part of the physician’s obligation to deliver drugs to patients. Therefore, delivering drugs to patients by physicians is permitted by the law. The competent authority’s restriction on physicians’ right to dispense in urgent situations only in Article 14 of the Physicians Act is a limited interpretation. However, Article 14 and all the provisions of the Physicians Act are difficult to serve as the basis of the limited interpretation.

• 3. The physician’s dispensation is not equivalent to dispensation made by the medical layman. Article 37, Item 2 of the Pharmaceutical Affairs Act stipulates that the dispensation of drugs should be carried out by pharmacists. However, the Act is also stipulated in Item 1, Article 102 that physicians may dispense drugs, subject to the restrictions specified in Item 2. This could not be seen in the same way as the possible risk and harm to patient’s health caused by drugs dispensed by the medical layman. It is questionable whether the intention of the legislation is betrayed when the competent authority recognizes both of the situations violated in Article 37, Item 2 of the Pharmaceutical Affairs Act.

After the appeal of this case, the competent authority won a reversal. The Supreme Administrative Court’s Judgment No. 971 in 2005 held that:

• 1. Both physicians and pharmacists have professional licenses, and each has its own scope of practice. The process of a physician treating patients starts from diagnosis and ends in providing medication. The dispensing of medication, which involves the pharmacist’s expertise, includes the preparation and the delivery of drugs. However, the preparation and delivery of drugs according to the needs of patients are necessary for medical behaviors and are also covered by the physician’s profession. Therefore, it is not unreasonable for physicians to take care of it. Based on above reasons, physicians have the right to dispense drugs when treating patients. However, after the amendment of the Pharmaceutical Affairs Act in 1993, physicians’ right to dispense drugs was restricted to remote areas or under an medical emergency with the purpose of treating patients.

• 2. Dispensation is a professional term for pharmaceutical affairs. As the definition of dispensation is not clearly documented by law at the time of the action and does not specifically define the scope of its concept, it can be determined by the profession of pharmaceutical affairs without authorization.

• 3. According to Article 102 of the Pharmaceutical Affairs Act, in remote areas and medical emergencies, physicians can dispense drugs, including delivery drugs. In addition, in accordance with Article 14 of the Physicians Act, a physician is eligible to deliver drugs by hiring pharmacists in-house to dispense drugs. The delivery of drugs is part of the dispensing procedure, and the drugs delivered by physicians must be dispensed by the pharmacist. This does not mean that the physicians have the right to dispense drugs in accordance with Article 14 of the Physicians Act; otherwise, it will impact the separation of medicine and pharmacy.

After the Supreme Administrative Court made the above judgment, more judgments such as the Miaoli District Court’s Judgment No. 28 in 2014 and the Taipei District Court’s Judgment No. 195 in 2017 reflected the same opinions as those of the Supreme Administrative Court.

Although the Supreme Administrative Court agrees that Article 102 of the Pharmaceutical Affairs Act restricts the physician’s right to dispense, it also pointed out that “according to the needs of patients, the preparation and delivery of drugs are necessary for medical behaviors, and they are also covered by the physician’s profession. It is not unreasonable for the physician to take care of it.” Therefore, it is not quite reasonable for the competent authority to equate “physician’s dispensation” with “layman’s dispensation.”

The Person in Charge of Medical Services in the National Health Insurance System

Physicians and pharmacists are professional and technical personnel, and they must pass exams in order to practice. The state requests that certain jobs must be performed by individuals with qualifications because of the content and nature of the work involving important public welfare and a high level of proficiency; thus, the corresponding performer must possess professional knowledge and experience. At the same time, in order to protect the public welfare and the rights and interests of the professional personnel, the state will also impose penalties on those without qualification and execute the scope of practice.

The right to dispense was regarded as the core practice of pharmacists at the beginning of the legislation of the Pharmacists Act. Judging those who have pharmaceutical expertise from their professional competence and scope of professional practice, pharmacists are most qualified and authorized to determine the best medication and usage for patients and take responsibility. Those who advocate for the separation of medicine and pharmacy assert that pharmacists can confirm and supervise the prescriptions from physicians; however, this conflict is within the scope of practice and responsibilities of physicians.

The healthcare service in our country is characterized by the strong bond between patients and physicians, and patients are highly dependent on physicians. Therefore, there is no doubt that physicians bear the ultimate and almost full responsibility for the treatment of patients. Once the health outcome is not satisfactory, the physicians are always the subject of prosecution¹². When managing contracted medical institutions, the NHIA also holds medical personnel who are in charge of the institution accountable. Exceptions occur when there are medical personnel who are responsible for specific violations; then, the punishment will be imposed simultaneously. Except for the contracted pharmacies, the person in charge of the contracted medical institution is always a physician.

After diagnosing and issuing a prescription, the physician still has to track and adjust the prescription according to the effect of treatment and medication. If the prescription has been integrated, replaced, increased, or decreased by pharmacists, obstacles and blind spots will inevitably arise. When the physician follows up on the condition of the disease and adjusts treatment methods accordingly, the risk of medical disputes and legal liabilities thereby increases. Therefore, the NHIA established the NHI MediCloud System to share pharmacists’ responsibility of integrating medicines and avoiding duplication by checking patient’s medication records from different medical facilities in the past few months. The system automatically alters the physicians if the drugs they are going to prescribe duplicate or interact with the patient’s current medicine to effectively reduce the probability of such problems.

Article 17 of the Pharmaceutical Affairs Act stipulates that the pharmacist should dispense the drugs according to the prescription. If the medicine is not available or is lacking, the pharmacist should inform the physician who prescribed the medicine regarding a replacement instead of omitting or substituting medicines arbitrarily. The clause echoes the physician’s right to prescribe and the fact that the physician is responsible for the medical process. If the pharmacist has to follow the physician’s prescription completely, according to the above provisions, the pharmacist can only discuss and give opinions to the physician at most. The physician still has the right to decide whether to change the prescription or not. Then, in a system in which drug prescribing and dispensing are separate, the “review, supervision, check and balance” function of a pharmacist when they are “evaluating the physician’s diagnosis, verifying whether duplication exists, interaction, individual contraindications, potential side effects, and rationality of medications, and others” is very limited. Besides the pharmacists, other medical personnel also have to “follow the physician’s orders” when providing medical services at all times, so there is limited room for independent business execution.

Besides physicians and pharmacists, other professionals have an overlapping scope of practice. For example, bookkeepers and accountants have their own scope of practice, but both can execute tax business¹³.

One of the purposes of separating medicine and pharmacy is to promote the pharmacists’ independent practice and to serve patients better. However, under the current conditions, physicians are the leaders of planning medical services and almost the only people who are responsible. Therefore, the failure to achieve the goal of separating medicine and pharmacy in one step is a reality that requires understanding.

The Strategy to Promote Separation of Medicine and Pharmacy—Discussion and Conclusions

Before the implementation of the separation of medicine and pharmacy, these two parts of the services were intertwined in the Western medical healthcare process in Taiwan [3]. The scope of practice of physicians includes diagnosis, treatment, prescriptions, and dispensation, covering most of the medical services. In addition, medical economic research also pointed out that medical service is obviously characterized by monopolistic competition and information asymmetry, leading to patients’ limited ability in seeking alternative services. Consequently, the bonding between patients and physicians continuously strengthens throughout the medical process, and the relationship between patients, nurses, pharmacists, medical technologists, and other medical personnel remains relatively weak. If the physicians do not actively release the prescriptions, patients usually will not request this; most people’s decision-making process for choosing pharmacies is directed by the physician’s instructions [2]. This is also the reason why the front-door pharmacies were so popular when the policy was just implemented.

Therefore, considering the historical factors, research results, and empirical situation of medicine and pharmacy development, society highly relies on physicians in the whole medical process, and it is not easy to change the habits of the whole of society simply by separating medicine and pharmacy. The pharmaceutical professionals actively advocate the single-track separation of medicine and pharmacy and appeal to impose legal enforcement. Embedding important policy into law is certainly one of the more feasible methods. However, concerning the habituation of society, and the separation of medicine and pharmacy, specific arguments coupled with positive policy incentives can gradually cultivate a social environment conducive to the implementation of the policy. The proliferation of front-door pharmacies that has been attributed to the increasing RVUs of prescription releases highlights that such results may be difficult to achieve with regulations alone. Only legal systems constructed under a mature social environment, which can promote policies, act as a stitch in time saves nine.

Sociologists point out that in addition to the economic benefits it brings, workload division also meets the needs of society. Besides establishing the relationship between different professions, we also have to invigorate individual professions and the “spontaneous division of labor” can form [2] only in this way. The same goes for the separation of medicine and pharmacy. The professionals should demonstrate their specialization by increasing drug safety and additional new values to the publics. When the public recognize the value of independent pharmaceutical service, they would become active collaborators rather than passive recipients and transform the separation of medicine and pharmacy into a social demand. Demand will guide services, and differentiated medical services will follow the trend.

There is no doubt that the NHI shapes the medical environment in Taiwan. To promote the established policy of separating medicine and pharmacy, the NHI will fully utilize the system and promote the core values of pharmacists to accelerate transformation of healthcare-seeking behavior. Before the ideal single-track division is realized, pharmacists can still seize the chance to show their expertise in the current medical environment dominated by physicians. As our society ages, the demand for home and community medical care is rising and people need not only family physicians but also family pharmacists who may be closer to their lives. In addition to performing core responsibilities such as guaranteeing drug safety, pharmacists could also transform pharmacies into important bases of the care system that exert multifaceted functions, creating more value and contributions.

Patient-Centered Integrated Care Plans

201903 Public Governance Quarterly.

Taiwan officially became an “aged society” when the proportion of the population aged 65 and above reached 14% of the total population in March 2018. In addition, we have only 8 years left to reach the “super-aged society” (the population aged 65 and above makes up more than 20% of the total population), which further reflects the severity of ageing in our country. The NHIA has planned a number of policies in recent years to prepare for the medical needs of the super-aged society that Taiwan will face in the future. The elderly often take multiple medications, have comorbidities, and exhibit characteristics of “geriatric syndrome” such as physical and mental deterioration and disability. Therefore, the NHIA proactively implements various integrated medical service plans to construct a patient-centered healthcare system.

National Health Insurance Big Data Reflect the Ageing Population

With an ageing population, technology advancement, and medical progress, the average life expectancy of Taiwanese people increases continuously, and the most prevalent type of disease has gradually changed from acute disease caused by bacterial and virus infection to a chronic disease caused by lifestyle. However, the treatment of chronic disease is different from that of acute disease whereas most of the time the treatments only stabilized the condition rather than curing the disease. Therefore, as the number of patients with chronic diseases increases, their follow-up medical care poses challenges to the NHI.

According to the analysis of the NHI big data, the number of patients with chronic diseases and medical expenses in Taiwan has been on the rise. In 2017, medical expenses for chronic diseases have reached New Taiwan dollars (NTD) 231.8 billion, accounting for about 30% of the total, and an increase of 23% from 2013 (Fig. 4.1). The number of chronic disease patients in 2017 has exceeded 6 million, which equates to a quarter of the total population and represents a 13% increase from 2013.

Fig. 4.1

Medical expenses for chronic diseases and their proportion in total medical expenses. (Source: National Health Insurance Administration)

In addition, the outpatient medical expenses per person for the 65-and-older population reveals that the expenditure for chronic disease drugs is around NTD 33 billion, and the medical expenses are more than NTD 60 billion, both are much higher than the expenses for those aged between 19 and 64 years old (NTD 9.3 billion and NTD 16.5 billion respectively), the working age population. In view of this, as the working age population gradually becomes the elderly in the future, the medical expenditures of the NHI will be more substantial.

Statistics from the NHIA show that the number of chronic disease patients is 6.29 million in 2017, among them, 3.86 million are people aged 65 and above, accounting for about 60%. When we further analyze the data by the number of chronic diseases they have, there are 2.13 million people suffering from one kind of chronic disease, accounting for about 34%, and the remaining 66% suffer from more than two kinds of chronic diseases. In addition, nearly 60% of people who are aged 65 years or older have multiple chronic diseases (Table 4.1). This shows that the number of people suffering from chronic diseases in the country is increasing year by year, and patients with chronic disease who visit doctors in different hospitals or departments are likely to have duplicate prescriptions. These duplicate prescriptions do not just waste medical resources. Medications exceeding their safe dosages or interacting with medications prescribed by other physicians pose risks to patient health.

Table 4.1 Analysis of the number of patients with chronic diseases in 2017

The Family Doctor Integrated Care Program

Because of the abundance of medical resources in the domestic metropolitan area and the low co-payment required in the NHI system, many people visit doctors but still fail to obtain a proper diagnosis and treatment. Therefore, The NHIA implemented the “Family Doctor Integrated Care Program” in 2003 to encourage at least five clinics in the same area to form a “community healthcare group” with partner hospitals. It is hoped that through the implementation of the Family Doctor Integrated Care Program, people will develop correct healthcare-seeking behavior. The public will receive primary care provided by primary clinics on a regular basis and get referred to the hospital for medical treatment when further diagnosis and treatment is necessary, integrating medical resources in hospitals and primary clinics.

Under the “Family Doctor Integrated Care Program,” primary clinics cooperate with contracted hospitals to provide more comprehensive health care, including the 24-h consultation hotline services for members of this plan. The aim is to reduce emergency room and unnecessary visits by providing appropriate health education and value-added services. The NHIA also established a comprehensive referral mechanism to improve the continuity and coordination of patient care by implementing the two-way referral and collaborative care. We evaluate the service provision, healthcare quality, satisfaction, preventive care, and link the performance to the NHI payment system to ensure the smooth operation of the plan.

A total of 526 community medical groups in Taiwan participated in the “Family Doctor Integrated Care Program” by the end of 2017. There were 4063 primary clinics participating, an increase of 1006 from 3057 in 2016. Approximately 2.5 million people received health care in this plan in 2015, and the number increased to 4.1 million in 2017, showing a 1.6-fold increase in 3 years. Medical expenses of 2015 and 2017 were NTD 1.2 billion and 2 billion respectively, representing a 1.7-fold increase during this period (Table 4.2).

Table 4.2 Number of cases and medical utilization of the “Family Doctor Integrated Care Program” from 2015 to 2017

Providing a New Model of Integration and Interdisciplinary Services

The NHIA provides integrated medical services for patients with multiple chronic diseases, hoping that the comprehensive, coordinated, and continuous medical care helps to improve safety and avoid duplication as well as improper medication and treatment. In addition, the NHIA offers additional integrated medical services in different levels of medical institutions to cater to the healthcare-seeking behavior of the public. If patients are accustomed to visiting hospitals, they can participate in the “Patient-Centered Integrated Outpatient Care Program in Hospitals”; if patients are used to seeking treatment in the clinics, they can join the “Family Doctor Integrated Care Program.” Patients with impaired mobility for whom it is not convenient to obtain medical treatment in hospitals or clinics can participate in the “Integrated Home Health Care Program.”

Since 2009, the NHIA has implemented the “Patient-Centered Integrated Outpatient Care Program in Hospitals” to foster proper integration of various specialties in the hospital and encourage hospitals not only to think about treatment strategies from the scope of a single medical department, but to provide integrated outpatient care services. The hospitals integrate medical teams by providing medical services from multiple specialized physicians. Each consultation accounts for at least 3 h, or by providing a one-stop consultation service for patients with dementia, major injuries or rare diseases, multiple chronic conditions of the elderly, chronic conditions (such as high blood pressure, high blood lipids, and high blood glucose), and other diseases. In addition to the general consultation fee for each visit, an additional outpatient integration fee will be awarded. As for an integrated outpatient clinic that is provided by multidisciplinary doctors, an additional fee will be awarded; for patients with dementia, 300–500 RVUs are paid for family consultation. Through economic incentives, The NHIA provides integrated care service to patients with multiple chronic conditions, hoping to improve the quality of care, so that the public can feel more at ease while seeing a doctor when the quality of healthcare is guaranteed.

According to the statistics, 189 hospitals participated in the “Patient-Centered Integrated Outpatient Care Program in Hospitals” in 2017. The number of cases increased from 360,000 to 520,000 from 2015 to 2017, and the number has increased by 1.4 times in 3 years. Medical expenses increased from about NTD 110 million in 2015 to about NTD 230 million in 2017, and the cost has doubled (Table 4.3).

Table 4.3 Number of cases and medical utilization of the “Patient-Centered Integrated Outpatient Care Program in Hospitals” from 2015 to 2017

Incorporating the Labor Power of Home Care into Integrated Care

To further serve patients with impaired mobility, the NHIA has been seeking funding to promote the “Integrated Home Health Care Program” since 2016. For elderly and disabled persons with impaired mobility, the care team in community evaluates and integrates care resources before long-term care staff provide life care services, and medical personnel can provide home medical care for them. The service extends to home hospice and palliative care as the patients’ conditions shift, to care for them at the end of life in a patient-centered manner.

The “Integrated Home Health Care Program” comprises general home care, home respiratory care, home hospice care, and the home medical care plan that was trialed in 2015. Through the cooperation of care teams and the case management mechanism, the NHIA provides patients with complete medical services. The continuity of home medical care is therefore enhanced when patients do not have to change the care team when their health conditions change.

A total of 195 teams and 2024 hospitals participated in 2017, covering all 50 medical sub-regions, and more than 90% were primary clinics and home care, which can provide care nearby. The cumulative number of participants in 2017 was 32,759. Among them, 85.4% are over 65 years old, and this is 4.3 times higher than the 7675 people receiving service between March and December in 2016. Medical expenses have increased by seven times, from NTD 60 million in 2016 to NTD 470 million in 2017 (Table 4.4).

Table 4.4 Number of cases and medical utilization of the “Integrated Home Health Care Program” from 2016 to 2017

Starting from 2019, the “Integrated Home Health Care Program” has expanded its scope and started to include services provided by dentists, Chinese medicine physicians, and pharmacists. At the same time, the responsibility of home care doctors has been further emphasized. The home care doctor is responsible for evaluating a patient’s overall needs for home care, and requesting services provided by other medical personnel, such as dentists, Chinese medicine physicians, nurses, and respiratory therapists, when necessary. Patients are required to cooperate with home care doctors in medication reconciliation and comprehensive home care. If the patient cannot cooperate with the doctor, he or she shall return to receive medicine during outpatient sessions, so that the limited number of home care service providers can take care of physically impaired patients with actual needs.

Promoting the Vertical Integration of Hospitals and Clinics

The implementation of the “Family Doctor Integrated Care Program,” the “Patient-Centered Integrated Outpatient Care Program in Hospitals,” the “Integrated Home Health Care Program,” and various programs of the NHI is aimed at improving medical accessibility and quality to construct a patient-centered medical care system, by providing patients with safe, appropriate, and continuous integrated medical services according to their needs, and to reduce the waste of medical resources.

The tiered medical care system and two-way referral, which NHIA has proactively promoted since 2017, have received enthusiastic responses from the majority of medical centers and regional hospitals. They have come forward to take the leading role by forming alliances with community hospitals and clinics actively in their areas. As of mid-November 2018, there was a total of 78 “vertical integration” strategic alliance groups of institutes in Taiwan. The NHIA encourages people to seek medical care from their trusted family doctors nearby when they are not feeling well. As the primary clinics have medical centers as their medical backup, referrals can be arranged through the “Electronic Referral Platform” established by the NHIA when necessary. The division of workload and cooperation between clinics and hospitals not only provides continuous care for patients, but also reduces their cost and time spent traveling to and waiting in big hospitals.

Healthcare Digital Transformation Brings Win–Win–Win for Physicians, Patients, and National Health Insurance

With limited NHI resources, the NHIA and the medical profession must reach a consensus on how to design incentives that support the integrated care services and reward systems that pay according to the service quality. Some representatives of the medical profession complained that under the current division of medical specialties, it is difficult to provide integrated care services from physicians with different expertise. Some hospitals provide integrated care services, whereas in fact they only integrate the medical information, so patients still have to visit multiple departments. Some patients hope to maintain the freedom of choosing their medical providers. Because of the above-mentioned factors, the medical care system is still facing challenges in fragmentation.

In recent years, the NHIA has been actively integrating various sorts of medical information, such as the establishment of the “NHI PharmaCloud System” in 2016 to ensure the safety of patients’ medications and avoid duplicate medications. It was upgraded to the “NHI MediCloud System” in 2017, providing additional medical information including examination and test records and results. The NHIA established the “Medical Image Sharing and Access” mechanism in 2018 to provide clinicians with real-time cross-hospital access to patients’ digital medical images, and has further set up an online real-time reminder, so that the clinician can immediately review the medication and examination (test) patients received in the last 3–6 months before ordering new ones. If every physician can query the NHI MediCloud System in the clinic thoroughly to avoid duplicate examinations and medications, unnecessary medical expenses can be reduced, and patient safety can also be guaranteed.

In recent years, the NHIA has carried out various medical and expenditure reforms to distribute the medical and NHI resources more effectively, and reduced medical waste by managing its source, hoping to avoid the impact on income of medical staff caused by the RVU fluctuation attributed to the global payment system (Fig. 4.2). In addition, the NHIA improved the mobile phone authentication function of “My Health Bank” in 2018 to support people’s self-health management. The public can download the National Health Insurance Mobile Easy Access mobile application (NHI Express App) to check personal insurance premium payment and medical records, health examinations, preventive health care, and other related information easily. By the end of 2021, the number of downloads had exceeded 7 million. We hope to create a win–win–win situation for physicians, patients, and the NHI so as to meet the challenges of the super-aged society.

Fig. 4.2

The NHIA won the 2020 National Sustainability Award with the theme of “Digitalized Health Network—the NHI MediCloud”

Connection to Long-Term Care After Hospital Discharge

To provide comprehensive and continuous care after hospital discharge, the NHIA continues to support contracted hospitals in improving the quality of the discharge planning service. We look forward to providing high-quality discharge planning through cross-organization cooperation, so that inpatients who have needs for long-term care can receive necessary services in a timely manner.

Covering the Discharge Planning and Follow-Up Management Fee Through National Health Insurance

The NHIA provides patients with needs assessment, health education, and interprofessional communication during their hospitalization. The services also include coordination of information as well as referral arrangement for subsequent medical follow-ups, long-term care and social resources to reduce the possibility of emergency revisit and readmission shortly after their discharge. The “Discharge Planning and Follow-up Management Fee” was added to the NHI fee schedule in April 2016, so that 1500 RVUs are paid per person per time. The NHIA stipulated the subject eligibility and established the specifications and procedures in June 2017 as operational guides that hospitals could follow and properly connect hospital discharge with follow-up care services.

Most hospitals provide discharge planning by their in-house discharge planning team. The case managers customize discharge plans for specific inpatients and conduct at least one interprofessional communication meeting depending on the patients’ condition. Participants of the discharge planning team may include physicians, pharmacists, nurses, dietitians, rehabilitators, respiratory therapists, social workers, etc. When necessary, family meetings that facilitate communication between family members and medical professionals will be held to assess patients’ post-discharge medical care, long-term care, or other social need. The discharge planning team provides the patient and their family members with health education and related information, as well as arranging referral to follow-up care such as community healthcare groups in the NHI Family Doctor Integrated Care Program, various types of home care, the Integrated Home Health Care Program, and long-term care institutions. The service also includes more than one telephone follow-up and telephone consultation within 2 weeks after discharge.

Implementation of Long-Term Care 2.0

Owing to the aging population in Taiwan and the diversified needs for care services, the Ministry of Health and Welfare has established a community-based long-term care service system in response to the need for long-term care for the increasing proportion of the population with disability and dementia. To tackle the challenges of long-term care in our aging society, the “National Ten-Year Long-Term Care Plan 2.0” (referred to as Long-Term Care 2.0) was approved by Executive Yuan in December 2016 and put into effect in January 2017.

In addition to promotion of the Comprehensive Community Care and development of innovative services, the Long-Term Care 2.0 also focuses on the establishment of a community-based healthcare team, and connection to other services such as discharge planning and home medical service.

Connection Between National Health Insurance Discharge Planning and Long-Term Care 2.0

The goal of the “Discharge Planning and Long-Term Care 2.0 Connection Friendly Hospital Reward Program” and the “2020 Discharge Planning Connect to Long-Term Care Plan” is to encourage hospitals to complete a long-term care needs assessment, and referral arrangement to the long-term care facilities before patients leave the hospitals, so that the long-term care services can kick in within 7 days after discharge to avoid care fragmentation. By doing so, we hope to reduce the long waiting time before the initiation of long-term care service caused by the traditional needs assessment process (Fig. 4.3).

Fig. 4.3

Connection process between medical care and Long-Term Care 2.0

From April 2017 to December 2020, there were a total of 508,534 claim cases from 361,708 patients regarding the “Discharge Planning and Follow-up Management Fee.” Among them, 139,034 claim cases were eligible for the Long-Term Care 2.0 and assessed for their Long-Term Care 2.0 needs before or after being discharged from the hospital. Among them, 94,113 cases subsequently received the Long-Term Care 2.0 services, accounting for 68% of the total number assessed. The rate of subsequent transfers to long-term care services is increasing year by year (Table 4.5).

Table 4.5 Situation of the cases of the National Health Insurance (NHI) “Discharge Planning and Follow-up Management Fee” receiving Long-Term Care 2.0 services

To understand if cases are connected to Long-Term Care 2.0 seamlessly, we conducted a subset analysis for 69,336 cases who received a needs assessment prior to discharge. Among them, 28,447 cases received the Long-Term Care 2.0 service within 7 days after discharge, accounting for 41% of the recipients of the Long-Term Care 2.0 needs assessment during their hospital stay and the proportion of this item is showing an increasing trend (Table 4.6).

Table 4.6 Situation of the cases of the National Health Insurance (NHI) “Discharge Planning and Follow-up Management Fee” receiving Long-Term Care 2.0 services—assessment before discharge

Tiered Medical Care System

In Taiwan, the comprehensive coverage provided by NHI allows residents to gain easy access to medical treatment, and can freely choose the institution for medical treatment. Therefore, people tend to swarm to big hospitals regardless of whether they have serious or mild illnesses. The overcrowded situation in big hospitals causes extreme waiting times for patients with acute, severe, and difficult diseases with immediate needs for specialized care. On the other hand, it is difficult for small community hospitals to sustain themselves because of the small number of patients they serve. These two extremes have caused inefficiency in the overall medical care system, and revolutionary policies are urgently needed to improve this situation.

The goal of the tiered medical care system is to encourage the public to seek medical care in the right way by receiving healthcare from the same provider regularly. In this way, their doctors can quickly evaluate their conditions and refer patients to appropriate hospitals for further medical treatment when necessary. Of course, the change of behaviors cannot be accomplished overnight. It must be promoted over a long period and implemented with appropriate supporting measures.

Current Distribution of Hospital Levels

The number of hospitals has shown a decreasing trend in the past 5 years. For example, in 2020, there were 25 medical centers, 82 regional hospitals, and 368 district hospitals. Compared with 2016, the most significant change was that the number of district hospitals decreased by 6. However, the number of wards increased at all hospital levels. The total number of wards increased from about 130,000 to 134,000 over the 5 years (Tables 4.7 and 4.8).

Table 4.7 Statistics of the number of facilities at each hospital level in the past 5 years

Table 4.8 Statistics on the number of wards at each hospital level in the past 5 years

In terms of medical expenses, the total medical expenses claimed by medical centers and regional hospitals are both around 200 billion RVUs each year, whereas that of district hospitals has grown gradually to approximately 100 billion RVUs, and medical expenses of district hospitals have also slightly increased from 16.7% in 2016 to 18.7% in 2020 (Table 4.9). This may be attributed to the downgrading of the two regional hospitals to district hospitals in 2019.

Table 4.9 Statistics on the number of medical expenses claimed by each hospital level in the past 5 years

Encouraging Big Hospitals to Treat Acute, Severe, and Difficult Diseases

The hospitals are divided into three levels in the NHI: medical center, regional hospital, and district hospital. Medical centers and regional hospitals, commonly known as “big hospitals,” are staffed not only by various specialists but even by sub-specialists. Besides that, they have a wide range of examination and test equipment and advanced instruments. Big hospitals are able to provide high-quality medical services for inpatients and patients with acute, severe, and difficult diseases with the highly specialized human resources and equipment they possess. Therefore, the NHI, with a strong backing for big hospitals, is obligated to provide big hospitals with strong support in term of reimbursement.

Because of the difficulty of treatment for acute, severe, and difficult diseases, the big hospitals demand more security in their human resources. Therefore, the NHIA strives to utilize the limited NHI resources to not only increase the reimbursement of diagnosis, treatment, and surgery related to acute, severe, and difficult diseases continuously, but also secure the value of the RVU. Starting from 2021, the NHIA planned to first adopt a fixed RVU value to guarantee the inpatient examination fee, nursing fee, and ward fee of the intensive care ward, and then obtains a budget in the following years to gradually expand the scope of coverage.

Small Hospitals Are the Leaders of Community Medical Care

The most fundamental level of the pyramid of the tiered medical care system is the primary health care from community medical institutions. Community medical care is provided by all primary clinics and small hospitals in the community. Based on 368 million outpatient visits in 2019, about 71 million medical visits were made in big hospitals (medical centers and regional hospitals), which means that 297 million medical visits accounting for 80% of total outpatient visits, occurred in community medical institutes.

To promote the “good doctors in the community” policy, district hospitals, as the big brothers of community medical care, not only cooperate with the promotion of “Holiday Clinics in District Hospital” to share the congestion in emergency departments of big hospitals but also continuously improve the lineup of their doctors. In addition to inviting doctors from big hospitals to support outpatient clinics, the district hospitals also actively join the medical alliance led by big hospitals to fully accomplish the assignment of connecting the services between community medical care and big hospitals.

Supporting policies should also be in place. As for the global budget of 2021, the NHIA planned to use a fixed amount of 500 million NTD to guarantee that holiday and night outpatient visits in district hospitals are reimbursed at a fixed RVU value. The NHIA also explores the possibility of enhancing the capacity of district hospital services by providing measures such as: evaluating the upper limit for the number of support visits in district hospitals made by physicians from medical centers, regional hospitals and primary clinics, and encouraging the establishment of telemedicine models among hospitals of different levels, to strengthen people’s confidence in community medical care.

Consolidate Small Hospitals in Remote Areas to Continuously Protect the Health of Residents

The main purpose of the implementation of NHI is to reduce the barriers to medical care for the disadvantaged; therefore, the NHIA especially focuses on those who reside in remote areas with scarce medical resources. And this is how the policy can intervene to assist hospitals that have established their foothold in remote areas to provide services continuously.

For hospitals established in mountainous areas, offshore islands, and areas with insufficient medical resources, or hospitals that are located in neighboring towns of the aforementioned areas, as long as they meet the requirements of the “Medical Service Improvement Plan for Areas with Insufficient Medical Resources” of the NHI, and provide 24-h emergency and outpatient services in Internal Medicine, Surgery, Obstetrics & Gynecology, and Pediatrics Departments, subsidies up to NTD 15 million each year would be granted to help these hospitals to have better medical delivery capabilities.

Co-Payment Adjustment

The spirit of the co-payment adjustment is not only to raise the public’s cost awareness and let people cherish medical resources but also to further guide the correct medical behaviors of the insured, implement the tiered medical care system, and promote the separation of medicine and pharmacy. When unnecessary medical treatment is reduced, patients with minor illnesses and stable chronic diseases go to community institutions for medical treatment, and patients with acute and severe illnesses are referred to hospitals for treatment according to medical professions. The total amount of medical services will decrease, and the value of the RVUs will increase. The doctors have more time to take care of patients, and the quality of medical care will naturally improve, creating a win–win medical environment for patients and medical personnel. It promotes the efficiency of medical services, maximizes the benefits of health insurance, and achieves the goal of improving efficiency and quality through doctor–patient communication.

The NHIA refers to the opinions of all parties, analyzes the overall trend of the co-payment and the medical use situation, and proposes the following planning and thinking for reference and discussion. It is hoped that after the advice is widely accepted into the policy, a consensus can be gradually built, so that the public and medical service providers can accept and benefit.

Current Situation Analysis

There are two types of drug prescriptions: general drug prescriptions and continuous prescriptions for chronic diseases. According to the current collection analysis of the co-payments for drugs and examinations (tests), the average drug cost is NTD 381, but 70% of prescribed drugs are less than NTD 100, where the public does not have to bear the co-payments. Taking 2019 as an example, the NHI paid a total of NTD 80.6 billion for continuous prescriptions for chronic diseases, an average drug cost of NTD 985, but the public did not pay for any of them.

For examinations and tests, the average examination (test) cost per item is 1169 RVUs (1719 RVUs for medical centers, 1466 RVUs for regional hospitals, 1184 RVUs for district hospitals, and 435 RVUs for clinics). However, according to the current regulations, the co-payments of the examinations (tests) are not charged.

The Planning, Thinking, and Direction of Outpatient Co-Payments

With aging of the population, and the development of medical technology and new drugs, it is an indisputable fact that medical expenses have increased year by year. The number of RVUs claimed is much higher than the number approved, with the budgets falling into a vicious circle of doing more and getting less, making Taiwan known as a “sweat hospital.” Further analysis shows that among the overall medical expenses, the annual increase in the cost of drugs and the examinations (tests) are the most obvious. Taking drugs as an example, there is no need to pay the co-payments for drugs under NTD 100 currently, and the maximum charges only NTD 200 for the drugs above NTD 1001. Some people took drugs home, but did not take them on time, causing a waste of resources. Furthermore, people do not need to pay extra costs for examinations or tests in hospitals, resulting in a small number of people who may ask doctors for additional examinations or tests.

The NHIA analyzed the suggestions of all parties comprehensively, planned adjustment measures for the co-payments, and focused on increasing the co-payments slightly, implementation of the tiered medical care system, and enhancement of the separation of medicine and pharmacy. The NHIA adopts a fixed-rate system to collect the costs that the people should bear in accordance with the NHIA, and also considers people’s affordability and sets a ceiling price. It is hoped that with the paying part of the medical expenses, the people will think about whether to take more unnecessary drugs and do unnecessary tests, and the doctors should also carry out their responsibilities to inform patients about the necessity of the tests. It is hoped that the cost awareness of the people can be raised, the medical resources can be used appropriately, the insured can be further guided toward the correct behavior for medical care, and the tiered medical care system can be promoted continuously. The planning direction is divided into three parts: drugs, examination (tests), and emergency treatment.

• 1. Adjust the planning direction of co-payment for outpatient drugs:

  • A. The NHIA plans to charge co-payments for outpatient drugs at a statutory rate and set a ceiling price. The plan to collect the co-payment of drugs for continuous prescriptions for chronic diseases is expected to improve the perception that patients with continuous prescriptions for chronic diseases do not cherish drugs because they do not have to bear the co-payment of drugs. However, it is still considered that patients with chronic diseases need long-term regular drugs, and there are concerns about the financial burden. Considering the amount that chronic patients need to bear, the co-payment at different levels of medical institutions and community pharmacies needs to be moderately adjusted.

  • B. The NHIA will also plan to encourage people to go to district hospitals and clinics for medical treatment, and obtain drugs from community pharmacies, so as to implement the tiered medical care system and the separation of medicine and pharmacy.

• 2. The new planning direction of the co-payment for examinations (tests):

  • A. The NHIA plans to charge the co-payments for examinations (tests) at a statutory rate. Considering that the issuance of examinations (tests) involves medical professional judgments, and the additional collecting of the co-payments will cause shocks in all walks of society and be more controversial. Therefore, people who cooperate with the tiered medical care system will be referred by a doctor after diagnosis and charged at a lower rate to the plan. After analysis, the average cost of each examination (test) at each level of medical institution is different, so different ceiling prices will be set according to the level and with or without referral.

  • B. In addition, the NHIA will plan the co-payment mechanism for examinations (tests) toward the direction of encouraging people to go to district hospitals and clinics for medical care. If there are further medical needs, the primary doctors will refer patients to hospitals above the regional levels according to professional recommendations.

• 3. Adjust the planning direction of the co-payment for emergency care:

  When adjusting the co-payments of drugs and examinations (tests), the co-payments at the hospital level will approach or even exceed the quota for emergency care. It may cause people transfer to the emergency department for medical treatment. After investigation, the current emergency department does not collect the co-payments for drugs and examinations (tests), so the co-payments for the emergency department will be fine-tuned in coordination with the overall plan. We hope to advance the emergency medical resources of large hospitals to the tasks and roles of emergency and critical care, prevent mild cases from going to the emergency department of medical centers, and guide people toward behaving correctly in seeking medical care.

Conclusion

Providing a comprehensive and continuous service for people in Taiwan is always the aim of the NHI. With the ageing of the population and the development of medical care, medical expenses have increased year by year. To protect patients’ medical rights with limited resources, expenditure reduction by inhibiting inappropriate use of medical resources is an answer to reduce the pressure of premium increases.

The high or low co-payments affect the rights and interests of most of those insured, because of Taiwan’s medical convenience and the people’s freedom of medical treatment. Our goal is to control the balance of interest conflicts and account for the rights of the insured and basic justice. The NHIA explains the concept and direction of the plans for everyone with reference and discussion. It is hoped that after the advice is widely accepted into the policy, a consensus can be gradually built, so that the public can accept and benefit.