Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan
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RESEARCH ARTICLE
Open Access
Do patients bypass primary care for common health problems under a freeaccess system? Experience of Taiwan Li-Lin Liang1, Nicole Huang2, Yi-Jung Shen2, Annie Yu-An Chen3,4 and Yiing-Jenq Chou5*
Abstract Background: A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system. Methods: This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000– 2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. Results: The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. Conclusions: Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass. Keywords: Outpatient visits, Referral, Health care delivery, Primary care, Family physicians
Introduction The principles of primary care, namely, first-contact, continuous, coordinated, and comprehensive care, have contributed significantly to population health and health care systems [1, 2]. First-contact care can be achieved by introducing a gatekeeping system in * Correspondence: [email protected] 5 Institute of Public Health, National Yang-Ming University, No.155, Sec. 2, Li-Nong St., Beitou Dist, Taipei 112, Taiwan Full list of author information is available at the end of the article
which access to secondary care is only available through referrals from primary care physicians (PCPs) [3]. Another approach to facilitating first-contact care is increasing the cost for visits to specialists without a referral [4]. When people have to bear additional costs to bypass primary care, the financial incentive may prompt them to visit PCPs first. Compared with
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