Including the Frail Elderly In the National Health Insurance Hospice Benefits Program-Policy Steps Towards Meeting the Complete Needs of Palliative Care for People in Taiwan

Faced with the trend of an aging population, Taiwan's hospice and palliative care movement is becoming more diversified and comprehensive. As of June 1, 2022, in addition to the eight major categories of cancer and non-cancer patients, four more categories have been added, including terminally debilitated elderly, in the hope of bringing more complete care to the frail elderly through policy support.

It is estimated that in 2025, Taiwan will enter a super-aged society. Faced with the increasing demand for long-term care and desire for a good death for the elderly, the government and the medical system are gearing up and making advanced preparations. Taiwan's palliative care targets are currently limited to so-called patients, but that excludes elderly who do not have major diseases of specific organs and are simply considered frail due to old age. These frail elderly individuals are often lost in the healthcare system as their illness trajectory is difficult to assess. 

Frailty is not just a problem of degeneration caused by age, but also accompanied by disability and a decline in the quality of life. However, due to policies and medical conditions, it is difficult for these frail elderly to accurately connect with palliative care services when their frailty enters the terminal stage. In order to seamlessly align the frail elderly to medical care and life care services, the National Health Insurance Administration has collected opinions from various units and after deliberation and approval, announced the inclusion of frail elderly people as new beneficiaries of hospice benefits, starting from June 1, 2022.

Step by step, opening the door to hospice care

Ying-Wei Wang, former director of the Health Promotion Administration and currently the director of the Palliative Medicine Center at Hualien Tzu Chi Hospital, said that Taiwan’s first wave of hospice palliative care movement started in 1983 when the concept of hospice care was introduced to Taiwan. At that time, cancer patients at different stages had been the main focus, and hospice wards, shared care, and home hospice were developed.

The second wave of the movement promoted hospice services for non-cancer patients. During Ying-Wei Wang’s tenure as director, he was more active in connecting with the third wave, which emphasized hospice care for the elderly, children and newborn, as well as early cancer palliative care, community and long-term hospice care, the introduction of new technology to palliative care, the Patient Right to Autonomy Act, and compassionate communities/cities, etc.

At the same time, it promoted rich and diverse content, which had been developed over many years. Recalling the time when he was the deputy director of the Health Promotion Administration more than ten years ago, Ying-Wei Wang had an opportunity to study Empowerment for Patient and Family in the Community by Allan Kellehear. He said, "The author viewed palliative care from a public health perspective and included the terminal care stage in health promotion."

Ying-Wei Wang often tells students that if one English word is to be used to represent health promotion, it is undoubtedly the word empowerment, which is increasing one’s ability and giving power to individuals. He taught, "Health promotion should be done from birth to death, and people should have enough ability to take care of their own health.”

In 2017, Ying-Wei Wang went to the Vatican to sign the "World Declaration on Hospice Care for the Elderly," and the seeds of caring for the elderly in his heart also had the opportunity to germinate. At that time, hospice experts from all over the world gathered to discuss the care of the elderly through four aspects: clinical practice, patients and their families, human rights, and spirituality and religion.

"Back then, Taiwan's care for the elderly was still centered on the care of chronic diseases," analyzed Ying-Wei Wang. Furthermore, because most elderly had multiple chronic illnesses, doctors tend to treat each symptom individually without considering the overall picture, leading to issues such as overmedication. End-of-life care also became a gray area among different medical specialties.

"Actually, 'frailty' itself is a type of disease."

The Health Promotion Administration entrusted the Taiwan Academy of Hospice Palliative Medicine to compile the Guidelines for Palliative Care for the Frail Elderly. The medical community also affirmed its importance, and Ying-Wei Wang was pleased to see that the frail elderly were included in the hospice benefits. He expressed his satisfaction, saying, “When frailty is recognized by the health insurance system as one of the factors that can cause death, it is possible to look at the medical needs of the frail elderly more holistically.”

Full commitment from National Health Insurance to support the launch of care for the frail elderly

"In the past, many people believed that it was difficult to see significant results in the medical care of the frail elderly," said Po-Chang Lee, Director-General of the National Health Insurance Administration, who has been in the medical field for many years and has seen in clinical practice many regrets caused by inadequate medical care. Although not many people have the same awareness as him, they have come together as a force. Lee noted, "Hospice experts, groups or some medical care have also begun to notice that the frail elderly have their needs for hospice palliative care." Sometimes under the close cooperation of medical care and life care, the frail elderly can return to a relatively healthy state because they enjoy a better quality of life.

Po-Chang Lee affirmed that the power of public voices is indispensable, and the National Health Insurance Administration is also optimistic about its potential. Therefore, it has actively deployed and collected opinions from all parties. On October 7, 2021, the "Discussion Conference on Revision of Hospice Care Payment Standards" was held. Among others, hospice-related societies, Taiwan Medical Association, and Taiwan Hospital Association were invited to discuss the revision of the admission conditions. And on March 10 of the following year, it proposed discussion in the "Medical Service Benefit and Reimbursement Scheme Joint Committee." The proposal was approved to add four types of beneficiaries, including the terminally debilitated elderly, terminal myelodysplastic syndrome, patients who meet the conditions of Article 14, Item 1, subparagraphs 2 to 5 of the Patient Right to Autonomy Act, and rare diseases or other estimated life-limited persons.

Among them, given the common multiple comorbidities of the frail elderly, the unpredictable speed of functional decline and survival period, and the possibility of long-term home stay or admission to nursing institutions due to chronic disability, the palliative medical care for the frail elderly was implemented on June 1, 2022.

In addition to the original institutions in the hospice home care field, on March 1, 2022, a new residential long-term care institution and the veterans’ homes of Veteran Affairs Council were added. In order to meet the emergency care needs of residents, institutions that provide hospice care are required to provide 24-hour telephone consultation. Also, after the frail elderly were included in the coverage of hospice health insurance in June, the additional payments for emergency visits by doctors and nurses also increased, so as to encourage the provision of more timely and comprehensive care.

Years of planning have laid the foundation to accelerate progress. Although the care policy for the frail elderly has been gradually improved, Po-Chang Lee admitted that it is still challenging even though there are assessment tools such as the Supportive & Palliative Care Indicators Tool (SPICT) to help doctors diagnose the frail elderly. He stated, "It tests the doctor's sensitivity to detect the patient's weakness."

Nevertheless, Po-Chang Lee remains optimistic, stating that at present, the National Health Insurance Administration and the medical community are actively trying to avoid unnecessary examinations and waste of medicines. It is attempting to adjust portions of the financial burden, so that resources can be allocated more reasonably, especially in the hospice payment. "As long as the country has a well-established system, sufficient resources, and the solidarity of the people, Taiwan is confident that it can do well in this regard.”

The unity of the people that Po-Chang Lee mentioned is not merely a slogan, but a social movement that has started in recent years.

For example, from 2017 to 2019, the Health Promotion Administration entrusted Taiwan Academy of Hospice Palliative Medicine to implement the "Geriatric Palliative Training and Promotion Program." Not only was extensive foreign literature studied, but they also invited domestic and foreign experts to hold discussions and meetings along with symposiums in various places in Taiwan. In the symposiums, in order to accurately describe the localized context of care for the frail elderly, many were invited, including clinical doctors, hospital palliative teams, staffs from social work, psychology, physical therapy, occupational therapy, and community long-term care backgrounds. As a result, they were able to have lengthy dialogues and exchanges, and together analyze foreign practices and domestic challenges.

In addition, Hsien-Cheng Chang, director of the Department of Family Medicine at Lotung Poh-Ai Hospital, expressed strong agreement with the Department of Medical Affairs of the Ministry of Health and Welfare in appointing eight hospitals in 2018 to guide community-based institutions and promote the Hospice Palliative Community Care Model Project. He said, "Although the project lasted only eight months, it has cultivated many primary care clinics and home care centers that are willing and able to engage in home-based palliative care.”

Hsien-Cheng Chang said that even after the project ended, some of the actions were still enthusiastically supported. According to the local statistics of Lotung Poh-Ai Hospital, currently as many as 70% of the patients in the local clinics that currently provide home-based palliative care in the local area are non-cancer patients, and the vast majority qualify as frail elderly.

With the increase of the elderly population, the traditional model end-of-life care provided solely by palliative care professionals or in hospitals is gradually becoming insufficient to meet the demand. Po-Chang Lee also stated that the compassionate communities advocated by Allan Kellehear is particularly important: "The empowerment and participation of the people in the community will enable more frail elderly to be properly cared for."

In the future, the National Health Insurance Administration will regularly invite relevant experts and groups to jointly review the admission conditions and related norms of palliative care, which will continue to improve the quality of palliative care.

As the frail elderly are being taken seriously, Ying-Wei Wang also expects to gradually move towards the fourth wave movement under the concerted efforts of the government and the people, which is: Don’t leave anyone behind, “for example, people with cognitive disabilities, mental and physical disabilities, and homeless people and prisoners.” He continues, “In facing these healthcare vulnerabilities, as the development of hospice and palliative care in Taiwan gradually matures, we must also start thinking about ensuring that every citizen can enjoy adequate care.”