2025-05-15

Innovative Patient Support Model Addresses the Challenge of Out-of-Pocket Medical Expenses in Taiwan

Taiwan’s total healthcare expenditure has consistently remained around 6.8% of its Gross Domestic Product (GDP), significantly lower than the OECD average of approximately 9.7% and neighboring South Korea’s 9.3%. In recent years, thanks to government efforts and the inclusion of long-term care expenses, this share has gradually increased. However, the continuous emergence of innovative and high-cost medical technologies, coupled with the complexity of benefit assessments for inclusion in the NHI and limitations of the global budgeting system, has led to growing demand in the self-pay (non-reimbursed) healthcare market. Unlike many developed countries where out-of-pocket payments are primarily driven by high co-payment models, Taiwan does not implement a co-payment system, making its situation notably different.

The main factors contributing to the rise in out-of-pocket medication expenses in Taiwan may include:

Coverage gap for new drugs and technologies: Due to the annual global budget constraints of the NHI, many innovative therapies or medications—despite demonstrating strong clinical efficacy—fail to pass health technology assessments for cost-effectiveness. While these treatments may offer significant value to specific patients, they often fall short of demonstrating sufficient public health benefit to warrant reimbursement.
Increase in balance billing and fully out-of-pocket items：Patients who opt for more advanced and higher-priced medical devices are required to pay the price difference themselves. In the case of new medications, where balance billing is not applicable, patients must cover the full cost out of pocket.
Limitations or exclusions in NHI coverage：Due to global budget constraints and overall financial considerations, NHI reimbursement often comes with strict eligibility criteria or limited coverage scopes. As a result, some patients who fall outside these conditions are still required to pay out of pocket for necessary treatments.

As Taiwan faces the dual pressures of an aging population and rapidly advancing—yet increasingly costly—medical technologies, the relatively low proportion of healthcare spending as a share of GDP suggests that the burden of out-of-pocket expenses will likely intensify. Can international experience offer solutions? The recent ACCESS USA 2025 conference held in Philadelphia brought together global experts in patient assistance, market access, and care for complex conditions. The topics and emerging trends discussed at the event offer valuable insights for Taiwan’s evolving healthcare landscape.

Global Trends from ACCESS USA 2025: Insights for Taiwan

ACCESS USA 2025 revealed a rapidly evolving patient support landscape, driven primarily by policy pressures—such as the U.S. Inflation Reduction Act (IRA)—funding challenges, and technological innovation. Several key themes may offer valuable insights for Taiwan’s situation:

Matrix Support Programs: Going Beyond Traditional Financial Assistance

Facing the uncertainties of future medical and market developments, one promising approach is the emergence of “Matrix Support Programs”—a comprehensive model that addresses multiple patient needs simultaneously. Unlike traditional Patient Assistance Programs (PAPs) that primarily focus on drug cost-sharing (co-pay) relief, these integrated programs combine:

Product access assistance (financial support)
Support for medical procedure coverage
Treatment journey navigation
Patient treatment outcomes and adherence programs

For Taiwan, although the NHI covers most new medications, gaps remain in timing and access for specialized treatments. Adopting a matrix support model could significantly improve patient outcomes. By integrating support throughout the entire treatment journey, these programs can help Taiwanese patients overcome not only financial barriers but also better navigate the complexities of the healthcare system itself.

A matrix approach in Taiwan might involve coordinated support from pharmaceutical companies, hospital systems, and patient advocacy organizations—creating a safety net that complements the NHI framework while addressing its limitations in high-cost therapies.

Evolution and Sustainability of Patient Assistance Programs (PAPs):

Traditionally, Patient Assistance Programs (PAPs) have served as a safety net for the uninsured or those with insufficient insurance coverage. The conference emphasized that PAPs must continuously evolve to ensure their sustainability and effectiveness. A hot topic was the U.S. phenomenon of Alternative Funding Programs (AFPs)—which controversially direct insured patients to PAPs to reduce employer costs. Although the operational mechanisms differ from Taiwan’s system, this reflects market innovation that holds valuable lessons.

Any assistance mechanism, including Taiwan’s gradually developing PAPs and PSPs, requires rigorous design, clear eligibility criteria, and effective oversight to prevent resource misuse and ensure aid reaches those truly in need. At the same time, incentive structures for participating companies must be carefully considered to address the support interests of specific patient groups.

AI and Digital Tools: Empowering Efficiency and Personalization：

Artificial intelligence (AI) is regarded as an essential technology for patient support in 2025, rather than a future concept. Applications discussed at the conference include:

Improving operational efficiency: Automating administrative tasks such as reimbursement verification and prior authorization.
Personalized interactions: Using AI to analyze patient data, predict risks (e.g., medication adherence, financial hardship), and deliver tailored communication and interventions. The conference highlighted the use of causal AI to understand the underlying reasons behind behaviors.
Proactive support: Early identification of patients needing assistance through predictive analytics and sentiment analysis.
Patient journey tracking： Comprehensive monitoring of patient status to anticipate needs and provide guidance throughout the treatment process.

For Taiwan, these technologies hold tremendous potential. AI can not only optimize the operations of PAPs but also drive the development of intelligent patient navigation tools. Imagine a system that integrates NHI regulations, balance billing options, hospital fees, eligibility for various PAPs, and charitable resources—helping patients and healthcare providers identify the most suitable and cost-effective treatment pathways, thereby addressing the current problem of information asymmetry.

Policy Levers and Market Dynamics:

Discussions in the U.S. around the Inflation Reduction Act (IRA)—including the \$2,000 out-of-pocket cap, drug price negotiations, and the option for installment payments of certain Medicare Part D drug costs—highlight the global challenge of balancing cost control, innovation encouragement, and access assurance. Regardless of its successes or setbacks, the IRA experience offers valuable reference points for Taiwan when formulating Health Technology Assessment (HTA) policies and implementing Managed Entry Agreements (MEAs), underscoring the need for careful evaluation of complex trade-offs and potential impacts in policymaking.

Optimizing the Patient Journey:

The conference emphasized that effective support goes beyond financial assistance and must improve the overall patient experience (PX) and adherence. Key strategies include patient-centered design, personalized digital communication, streamlined processes, and crucial patient education. Research in the U.S. shows that patients’ lack of understanding about insurance and assistance programs often leads to delayed treatment. This resonates with the confusion Taiwanese patients face regarding NHI, balance billing, out-of-pocket costs, and PAPs. Therefore, the government should adopt a more open market approach in pharmaceutical policies, ensuring support systems provide clear information, easy navigation, and personalized care.

Transforming Global Insights into Momentum for Taiwan

The innovative ideas from ACCESS USA 2025 offer concrete directions for Taiwan to address its challenges:

Strengthening Taiwan’s PAP Ecosystem:

Taiwan’s existing PAPs and PSPs can draw from international best practices by enhancing transparency and ensuring compliance—especially regarding personal data protection. A key focus should be strengthening integration among PAPs, hospital systems, and the NHI framework, enabling physicians to more easily initiate assistance applications at the point of care. This calls for establishing an integrated “hub services” model.

Driving Digital Transformation of the NHI System:

The potential of AI goes far beyond PAPs. The NHI system could explore applying AI in:

Supporting HTA decisions by analyzing real-world data
Predicting high-risk populations to optimize resource allocation
Enhancing administrative efficiency through automation (e.g., automated reviews)
Developing intelligent patient navigation tools
Refining Policy Pathways:

Drawing on international experience, Taiwan could consider:

Targeted financial protection:** Inspired by the IRA’s out-of-pocket (OOP) cap, establish stronger safeguards for specific high-cost out-of-pocket items or vulnerable populations.
Optimizing value assessment:** Continuously improve HTA and MEA processes, expanding the use of real-world evidence (RWE) and outcome-based payment agreements.
Addressing low-value care:** Develop mechanisms to review and potentially discontinue low-benefit NHI-covered services, redirecting resources toward high-value innovations.
Enhancing regulation of the out-of-pocket market:** Strengthen transparency and regulations around balance billing and fully self-paid items to protect patient rights.
Promoting multi-stakeholder collaboration:** Build platforms to facilitate dialogue and cooperation among government, medical community, industry, technology sectors, and patient groups to jointly explore diverse solutions.

From the evolution of PAPs and the application of AI and digital technologies to lessons learned from policy reforms and the emphasis on patient experience, these global insights offer valuable references. The key lies in translating these perspectives and ideas into localized solutions suited to Taiwan’s unique healthcare environment.

This includes enhancing the effectiveness of existing patient support programs, leveraging technology to empower the NHI system and service workflows, and carefully balancing multiple objectives at the policy level. The potential for AI adoption is immense but must be accompanied by equal attention to data governance, privacy, and ethics.

Addressing the growing burden of out-of-pocket costs requires joint efforts from the government, medical community, industry, technology partners, and patient groups. Through open dialogue, pragmatic planning, and innovative practice—drawing on global wisdom to tackle local challenges—Taiwan has the opportunity to further improve its healthcare security system, reduce financial burdens on citizens, enhance accessibility and quality of care, and ultimately move toward a more sustainable, equitable, and comprehensive health future for all.

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Innovative Patient Support Model Addresses the Challenge of Out-of-Pocket Medical Expenses in Taiwan

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