Practice of Electrophysiology in Taiwan

Abstract

Taiwan is an island country with a population of 21.5 millions and an area of 361.8 million square kilometers. The per capita income is US$ 13,747 per year. A universal health insurance system was implemented by the government in March 1995. This insurance system covers citizens and their families who have registered and resided in this country for longer than four months. It also provides coverage to aliens who have legally registered in this country and have been allowed a resident status and working permission. Services provided by physicians or hospitals are paid on a fee-for-service basis by the government insurance of~ce. However, there is a uni~ed payment system for each itemized service and there are limitations. For example, implantation of a coronary artery stent or an intracardiac de~brillator is not reimbursed. There are four levels of medical services. Most physicians are general practitioners. They are non-hospital-based, clinic-oriented, solo practitioners, taking care of general problems. There are also plenty of small-sized hospitals of about 100 beds with less than 10 physicians. These hospitals provide services similar to the community hospitals in the States. The third level service includes 47 regional hospitals of about 500 beds and 100 physicians, which are funded by private groups, churches or government. The fourth level of medical care includes 12 private or government medical centers of 1000–3000 beds and 500–1000 physicians. The practice in the regional hospitals and medical centers are highly specialized. The hospital wards and clinics are arranged according to subspecialties and the patients are triaged accordingly. The annual cost of this universal health insurance system in tthe ~rst year was US$ 13.3 billions (5.21% of GDP). Practice of subspecialty in this country requires board certi~cation. Eligibility for cardiology board requires board certi~cation in internal medicine and a two-year fellowship training in cardiology. A three-year residency training is required for internal medicine. Although there is no further certi~cation for interventional electrophysiology or pacemaker implantation, one is required to complete 100 cases of catheter ablation and 30 cases of pacemaker implantation under the supervision of a quali~ed proctor before conducting such procedures independently. Albeit there are up to 100 quali~ed cardiologists or cardiovascular surgeons capable of implanting pacemakers in Taiwan, most pacemaker implantations are conducted in medical centers. In 1996, approximately 1200 pacemakers were implanted in this country. Eighteen hospitals with 40 electrophysiologists are currently conducting electrophysiologic studies and catheter ablation. A total of 1928 ablations were done in 1996; however, 80% of ablations were done in 7 hospitals which had a volume of more than 100 ablations per year. There is no solid referral system in Taiwan. Most patients have their own private physician (usually a general practitioner) for minor medical problems. When they have a problem requiring special care, they select a specialist by the advice of their private physician, relatives or friends and refer themselves to the specialist. Patients’ appointments, billings and paper work are all managed by the hospital administration and, therefore, a patient may be able to see any physician as desired in this country. Thus, it is not uncommon to have patients with panic disorder, thyrotoxicosis or chronic obstructive lung disease in a cardiology clinic. In other words, an electrophysiologist will have to pick up patients with Wolff-Parkinson-White syndrome, ventricular tachycardia or heart block among a group of patients with general cardiac or medical problems. A specialist in Taiwan is not only an expert in his specialty but also a physician in general medicine.