Why people select the outpatient clinic of medical centers: a nationwide analysis in Taiwan

Introduction

The National Health Insurance (NHI) program in Taiwan is a single-payer system founded in 1995. The NHI program comprises a hierarchy of medical care facilities consisting of four tiers: medical centers, regional hospitals, local community hospitals, and primary clinics. However, referral systems have not yet been successfully implemented.

Hierarchical medical care means that medical resources can be used the most efficiently through professional division in the medical system. In most countries, primary care physicians act as healthcare “gatekeepers” by providing initial medical interventions and referring patients to additional specialists (Yan, Kung & Lu, 2019). Excluding situations of major illnesses and the urgent requirement of treatment at a medical center, people should first consult a family doctor or a nearby primary clinic regarding an illness. After diagnosis and treatment, patients can be referred to other specialty clinics or hospitals.

In contrast with other countries, patients in Taiwan have full and unrestricted access to all medical care facilities. Patients in Taiwan’s NHI program can freely select specialists and the tier of medical care facility directly without a referral (Lynn et al., 2015). The design of global budget payments and the fee for services result in patients favoring treatment at large hospitals, even for mild diseases, and medical centers are more likely to use advanced instruments and pharmaceuticals (Kuo, Chen & Lin, 2019; Lee et al., 2018). Numerous patients in Taiwan consult several physicians with different specialties and at different health care facilities and switch physicians and facilities rapidly (Wang & Lin, 2010). This phenomenon has been suggested as a source of inefficiency in healthcare use and has resulted in high medical expenditures and costs of outpatient visits.

Studies have reported that people in developed countries visit a doctor 5–6 times a year, whereas in Taiwan, the average frequency of visits is 13. More than 30,000 insured residents in Taiwan seek hospital inpatient and outpatient services over 100 times a year (Lynn et al., 2015). In certain large medical centers in northern Taiwan, the number of outpatients per day often exceeds 10,000. Furthermore, physicians frequently see over 50 patients in a morning, spending only 5 min or less for each consultation (Wu, Majeed & Kuo, 2010). These short consultations can cause misinformation and misunderstanding between healthcare providers and patients because of the time to build rapport. The freedom to have multiple hospital return visits results in high use of outpatient hospital visits, drug prescriptions, and other health services (Wang & Lin, 2010; Yip et al., 2019).

Excessive use of health services is a critical and persistent problem in Taiwan. To moderate these rising costs, a graded medical system was implemented in the NHI program and increased the copayment for high-tier facilities for outpatient visits in 2002, 2005, and 2017. Patients without a referral are charged an additional copayment ranging from 240 to 420 NTD (approximately 8 to 14 USD) for every visit to a high-tier medical facility. Although changes to the NHI copayment policies have mildly reduced the use of high-tier medical care facilities, studies have indicated that the effect of medical prices on people’s medical behavior is very limited (Lee et al., 2018). The implementation of the copayment system exerted little effect on encouraging the population visit primary clinics first (Yang, Tsai & Tien, 2019).

Factors affecting patients’ selection of high-tier medical care facilities have not been fully identified. Cheng et al. reported that patients tend to base their judgment of hospital quality on medical equipment (Cheng, 2015). The main purpose of this study was to evaluate the factors contributing to the patients’ selection of the outpatient clinic of medical centers without a referral. Understanding motivations underlying the public’s choices would enable the implementation of a successful graded medical system in Taiwan.

Materials and Methods

Results

During the survey period, 5,060 people browsed the online survey, and 1,003 responded and completed the online questionnaires. Therefore, the response rate was 19.8%. We excluded 16 participants because of duplication (the same age, occupation, and answer options). Table 1 provides a comparison of the demographic characteristics of the patients who favor different institutions for outpatient visits.

The mean age of the respondents was 43.6 years (SD, minimum, and maximum were 10.6, 19, and 85 years, respectively). Men accounted for 43.8% and women accounted for 56.2% of the 987 respondents included; 509 (51.6%) respondents favored visiting a primary clinic, 308 (31.2%) favored visiting the general hospital, and 170 (17.2%) favored visiting the medical center without a referral. Table 1 provides a comparison of demographic characteristics and preferred institutions for outpatient visits. Gender, marital status, and education level were not statistically related to the choice of outpatient visits. In univariate analysis, the choice of medical treatment facility was statistically related to income (p = 0.026). Patients with a monthly income of NTD 50,001–70,000 favored outpatient clinics of medical centers. People living in urban areas accounted for 65.8% of respondents. A larger number of people living in urban areas favored medical centers than patients living in other areas (p < 0.001). Approximately 51.5% of the respondents had regular family doctors. Significantly more patients who favor primary clinics for outpatient visits had regular family doctors than patients who prefer medical centers (61.9% vs 41.2%, p < 0.001). Approximately 67.6% of the respondents were satisfied with their previous medical experience in primary care. Furthermore, patients who favored primary clinics for outpatient visits exhibited significantly higher satisfaction rates than patients who favored medical centers (75.2% vs 52.9%, p < 0.001).

Table 2 summarizes the average rating of respondents on the importance of each factor when selecting an outpatient facility and their preferred outpatient institution. “Physicians were highly reputable”, “physicians explained in detail”, and ”physicians have a good medical practice” were the rated most important factors to consider when selecting the outpatient institution. The low copayment was the least important factor for outpatient medical choice among all patients (Likert scale rating of 3.08 ± 1.16).

In univariate analysis, six factors were significantly more important among the respondents who chose to visit a medical center (p < 0.001). These factors were “physicians are highly reputable”, “physicians have a good medical practice”, “the institution has advanced equipment”, “the institution has high-quality drugs”, “the institution has diverse specialties”, and ”the institutions has a good reputation”. In this study, we conducted exploratory factor analysis to understand the potential common characteristics among factors and clarify the influencing factors. We used principal component analysis to extract data using a correlation matrix and oblimin rotation method. We removed six items because of cross-loading or because the factor load was too low (<0.4). Factors with eigenvalues greater than 1, cumulative percentages of variance explained above 71.2%, KMO value reaching of 0.868, and p value less then 0.001 were excluded. Three main factors were retained in the final extraction (Table 3), namely “physician factor”, “image and reputation factor”, and “facility and medication factor”. We subsequently converted the scores to three factors into a multivariable analysis model.

Table 4 illustrates three models of logistic regression for predicting “visits to the outpatient clinic of the medical center for an illness.” Age was a crucial predictor in all the models. The likelihood of choosing to visit a medical center when ill increased by 2.7%–3.1% for every additional year of age (95% CI [1.4%–4.3%]) when other variables were controlled.

In Model 1, when age, gender, “have a regular family physician,” and “consider that copayment is important” were adjusted, patients who were previously satisfied with the medical experience of primary clinics had a 0.5 lower likelihood of visiting the outpatient clinic of a medical center for an illness (95% CI [0.429–0.584]).

Model 2 was then also adjusted for the extracted factors I to III, which revealed that patients who reported that hospital facilities, high-quality drugs, and diverse specialties were very important had a 2.218 higher likelihood of selecting the outpatient clinic of the medical center (OR = 2.218, 95% CI [1.514–3.249]). Patients who were previously satisfied with the medical experience of primary clinics had a 0.509 lower likelihood of choosing a medical center to visit when ill (95% CI [0.435–0.595]). Patients who rated copayment as important were 0.525 times as likely to select a medical center to visit when ill (95% CI [0.354–0.781]). People with a regular family doctor were 0.676 times less likely to select a medical center (95% CI [0.471–0.969]). Patients who rated physician factors as very important were less likely to select an outpatient clinic in a medical center (OR = 0.717, 95% CI [0.523–0.984]). The gender of the patient and the image and reputation of the hospital and physicians were not significantly related to inpatient hospital choice.

In Model 3, when the possible sociodemographic confounding variables were added, the step Wald chi-square statistic was insignificant (Wald chi-square difference = 13.581, df = 8, p = 0.093). The residential area, income, and education level did not appear to be related to the selection of an outpatient clinic. Therefore, we decided to adopt model 2 as the result of our analysis.

Discussion

Several factors significantly affected the selection of a medical center, including older age, the physician factors, advanced equipment, high-quality drugs, past experience in primary clinics and the copayment. Most of the Taiwanese population agree with the principle of a hierarchical medical system and a medical referral system. However, many people still disagree with changes to their health care-seeking choices because of policy promotion (Yan, Kung & Lu, 2019). A survey determined that age, residence, education, and monthly family income were significantly related to inpatient hospital choice (Kamra, Singh & De, 2016). Some results were consistent with ours. However, in our study, income did not have an obvious effect on outpatient choice. This may be because of the exemption for low-income people in Taiwan’s health insurance. Low-income residents do not pay any component when visiting a medical center without a referral (Yang, Tsai & Tien, 2019).

Family physicians were introduced over 20 years ago in Taiwan. However, only 51.5% of the respondents had regular family doctors. In this study, patients with regular family doctors, who were satisfied with their medical experience in primary care, who rated the physician factor as important, and who rated copayment as important, were less likely to select a medical center when ill. These results indicated that the implementing a family physician system, whereby the public generally has a trusted family doctor, would help reduce the number of patients electing to go directly to the medical centers without a referral.

Gender, marital status, and education level did not affect the choice of outpatient visits. The univariate analysis indicated that the choice of the outpatient institution was only slightly related to income levels, and income levels were not related to the outpatient choice, after controlling for other variables in regression analysis. Low copayment was the least important factor for outpatient medical choice among all patients. This result may be caused by the low copayment amount in Taiwan’s NHI system. Furthermore, in the NHI program, most of the cost of medical treatment is waived for low-income households and catastrophic illness patients in Taiwan. Thus, the financial burden is rarely a consideration in the patients’ choice of outpatient institution (Chen & Fan, 2015). The current copayment of outpatient medicines is a fixed fee, and the out of pocket maximum is only NTD$200 (approximately USD$6.7). Although the NHI copayment reforms had mildly reduced the probability that patients with minor ailments would choose to visit high-tier medical facilities, several studies have indicated that the effect of medical prices on people’s medical behavior is limited.

In the present research, a similar phenomenon was also observed. Low copayment had the lowest average rating on the Likert scale when considering the importance of outpatient medical choices among all patients. Changes to the health insurance system (e.g., changing the copayment to a fixed-rate coinsurance) may be the only method to eliminate unnecessary testing and medical waste (Victor et al., 2018).

Ideally, every older adult should have trusted primary care physicians who can provide outpatient services. However, in this study, older people had a greater likelihood to visit the medical center for outpatient visits. In 2012, Liu et al. indicated that the different health profiles of elderly people significantly affected the likelihood of use and expenditure on health care services. The high comorbidity group tended to use more ambulatory care services, and the frail group had higher health care expenditures (Liu, Tian & Yao, 2012). Our research results did not accord with these findings. Further research is needed to understand whether the primary clinics in Taiwan satisfy the needs of elderly people.

This study has several limitations that may affect the findings. First, participants were recruited over the Internet because of the web-based survey design, thus the low response rate warrants further exploration. Although the online survey represents a wide age range and geographic distribution, the sample was younger and more highly educated than the general public (Tengilimoglu et al., 2017). Hsieh et al. determined that Internet use in Taiwan was significantly associated with more outpatient clinic visits among people with chronic diseases in Taiwan (Hsieh et al., 2016); therefore , caution should be exercised when generalizing these results. Second, the variance explained by the logistic regression model suggests that other significant factors may determine outpatient clinic decisions (Cheng, 2015; Yip et al., 2019).

Despite these limitations, this study is the first to investigate how the public chooses outpatient institutions in Taiwan. Further research should explore the influencing factors among the older group.

Conclusions

A good primary medical experience and a regular family physician significantly reduces people’s likelihood of visiting the medical center without a referral. The results of this study support that the key to establishing graded medical care is prioritizing the strengthening of the primary medical system.

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