Despite the Patient Autonomy Act being in effect for five years, the signing rate for advance care directives remains below one percent. Criticism has been directed towards the requirement for individuals to pay around NT$3,000 for counseling before establishing medical decisions in advance, leading to a lack of willingness among the public to sign. In early 2024, the National Health Insurance Administration (NHIA) released benefits for four categories of individuals to receive free counseling. On the 22nd, discussions were held to expand the definition of "terminal patients" in the four categories, including allowing hospitalized patients over the age of 65 with major illnesses to also receive free counseling, benefiting around 55,000 people. The new policy is expected to take effect as early as June.
The original four categories planned by the NHIA are terminal patients, mild dementia (Clinical Dementia Rating: below one point), publicly announced incurable diseases, and recipients of home integrated care plan services, who are to enjoy one free advance care planning counseling service.
Director of the NHIA, Chung-Liang Shih, mentioned during recent expert meetings on the actual benefits of providing advance care planning counseling through health insurance that there was a desire to broaden the definition of terminal patients to include hospitalized patients over the age of 65 with major illnesses. This time, only hospitalized patients were discussed for inclusion, mainly because the Department of Health's Medical Affairs Bureau has allocated a budget to subsidize patients with publicly announced incurable diseases, covering outpatient patients, while the NHIA will provide support for hospitalized patients.
If the definition of terminal patients is expanded to include an additional 55,000 people, the total number of eligible individuals from the four categories will be over 81,000. With a subsidy of NT$3,000 each time, NHIA estimates the expenditure to be around NT$2.45 billion. However, Stone Chung-Liang stated that according to current discussions, those who qualify for advance care planning counseling but ultimately do not sign an advance care directive after counseling will still need to pay out of pocket, as health insurance will not cover this.
A member of the NHIA's expert meetings mentioned that the NHIA is currently adding counseling for hospitalized patients over the age of 65 with major illnesses to the insurance coverage. Plans are already underway, and in the next phase, counseling services will be made available to individuals over the age of 80, all free of charge.
Dr. You-Kang Chang, a physician specializing in advance care planning counseling at Taipei Tzu Chi Hospital, stated that while the NHIA's intentions are commendable, attention should be paid to the target population for free counseling. It is advised not to include multiple categories of individuals all at once, as the current counseling capacity may not be able to handle the load. It is suggested that in the future, the age threshold could gradually decrease from 80, and incentives such as increasing hospital fees could encourage the establishment of advance care planning counseling clinics to enhance counseling capacity.
Stone Chung-Liang pointed out that many people may feel that advance care planning is distant from their current situation, as they are still in good health and believe that death is far in the future, resulting in few people actually willing to sign. The Ministry of Health and Welfare's goal is to increase the overall signing rate. Since advance care planning counseling has been criticized for its high cost, becoming a major barrier to signing, the NHIA aims to alleviate the burden on the public by providing subsidies. Additionally, for hospitalized patients who are more likely to contemplate end-of-life issues, counseling can be conveniently conducted within the hospital. The proposal will be discussed at the joint meeting next month for final approval, with the possibility of implementation as early as June.
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