How will "one-day surgery" be compensated? FSC: If 3 conditions are met, inpatient items can be reimbursed

(Central News Agency, Taipei, June 30) Public attention is focused on the reimbursement of "one-day surgery." The Financial Supervisory Commission (FSC) stated today that if one-day surgery simultaneously meets the three conditions for hospitalization stipulated in the policy terms, existing policies can still reimburse inpatient items. If hospitalization procedures are not completed, it will generally be handled according to the outpatient surgery agreement and will not be relaxed for inpatient reimbursement just because it is one-day surgery.

The amendment to the Medical Act was passed on May 8, officially incorporating the three-tier nurse-to-patient ratio system into law, scheduled to be implemented in phases. National Taiwan University Hospital recently proposed that surgery originally requiring a 2.5-day hospital stay might gradually be changed to "one-day surgery." Many past medical insurance policies used hospitalization as a condition for reimbursement. Legislators are concerned whether one-day surgery will affect reimbursement, and the FSC indicated that it would present a research direction within one month.

Regarding existing policies, Tsai Huo-yen, deputy director of the FSC's Insurance Bureau, stated that when life insurance companies design inpatient medical insurance premium rates, they are mostly actuarially calculated based on hospitalization. One-day surgery is a colloquial term, and there is no such term in medical regulations. The actual determination must refer back to the policy terms. If one-day surgery is a "one-day inpatient surgery" and simultaneously meets the three conditions for hospitalization, including the doctor's diagnosis that hospitalization is necessary, completing hospitalization procedures, and actually receiving treatment in the hospital, inpatient surgery benefits will be reimbursed.

Tsai Huo-yen pointed out that if one-day surgery does not involve hospitalization procedures, it will generally be handled according to the policy's "outpatient surgery" agreement. In other words, if it is a one-day outpatient surgery, it depends on whether the policy reimburses outpatient surgery.

In practice, if a surgery performed has a high degree of substitutability between inpatient and outpatient care, the industry has adopted a flexible approach. This means that even if hospitalization procedures are not completed, as long as surgery is performed, reimbursement may still be obtained, with actual determination made on a case-by-case basis.

Regarding whether the current flexible approach will be adjusted, Tsai Huo-yen stated that communication with the industry is ongoing. The industry indicated that it is currently difficult to determine which surgeries can mostly be completed without hospitalization and may require assistance from the Ministry of Health and Welfare (MOHW) for judgment, looking for statistical data to further clarify. Currently, the more common flexible surgery is cataract surgery; others still need clarification.

As for new types of policies, Tsai Huo-yen said that most current medical insurance products categorize surgery into two major types: inpatient surgery and outpatient surgery, with premium rates and policy terms setting reimbursement conditions. If individuals undergo treatment for various major illnesses, including cancer, using drugs not covered by the National Health Insurance that require high out-of-pocket expenses or co-payments, or special medical devices, domestic insurance companies have also launched health insurance products such as cancer insurance, critical illness insurance, and major disease insurance that are not contingent on hospitalization. The FSC continues to encourage companies to develop products that align with medical practice developments.

Tsai Huo-yen also mentioned that insurance companies currently offer cancer insurance to cope with new cancer drugs and novel treatment methods. In addition to providing a one-time large payout upon diagnosis of cancer, such as initial cancer diagnosis benefits, they also offer fixed payments or actual expense reimbursement based on medication use and treatment, including benefits for genetic testing after cancer diagnosis, targeted therapy drug costs, da Vinci surgical costs, and autologous immune cell therapy. These are also not contingent on hospitalization and meet the needs of precision cancer medicine.

The National Health Insurance Administration of the MOHW launched the "Home Acute Care Trial Program" starting in July 2024. The program applies to infectious diseases, including pneumonia, urinary tract infections, and soft tissue infections, for disabled patients who have difficulty leaving home, with medical professionals providing home visits. Medical care is gradually shifting from hospitalization to outpatient care, and even home hospitalization. However, as this type of care is not within the scope of commercial insurance, the MOHW and FSC have held meetings to assess the feasibility of developing new products.

Tsai Huo-yen stated that on June 26, Cathay Life submitted an application for a trial home acute care policy. A total of three companies in the industry, including Cathay Life, have expressed interest in piloting home acute care policies. The FSC will complete the review as soon as possible after receiving the applications. (Editor: Yang Lan-hsuan) 1150630

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