Black Money Haunts the White Tower

Black Money Haunts the White Tower
United Daily News editorial (Taipei, Taiwan, ROC)
A Translation
March 30, 2011

More procurement scandals have broken out in public hospitals. The Taoyuan District Court has taken four suspects into custody. They include Department of Health officials, the DOH Hospital Chief, and manufacturers. Others are out on bail and under house arrest. No one who knows anything about the medical community on Taiwan is surprised. Their reactions will be the same as former Director of Health Yang Chi-liang.

In the past, "black money," i.e., bribe money, was rampant in the larger public hospitals on Taiwan. This included implicit or explicit appeals to patients for "red envelopes," to drug manufacturers for kickbacks, to procurement personnel for commissions. It even included compulsory contributions for activities inside and outside the hospital. Fortunately, people are becoming more enlightened. Hospital management systems are gradually straightening out their act. The NHI payment system and joint procurement of drugs have made red envelopes and drug kickbacks increasingly rare. Every now and then however, prosecutors will uncover a hospital procurement scandal involving huge sums, that shock the medical community and society as a whole.

Times have changed. New medical devices swiftly become obsolete. The higher the procurement price, the more exorbitant the commissions. This presents a powerful temptation for anyone. Physicians often find themselves in control of large sums of procurement funds. Vendors lobby them day and night, assuring them they will never be found out. Such temptations are hard to resist. Therefore to those in the know, the procurement scandals that have surfaced so far are merely the tip of the iceberg.

in some large public hospitals, rumors of black money have never ended. Because both parties usually refuse to admit guilt, investigating such cases is not easy. But among some large medical equipment providers, the whispers have never stopped. One key factor is that within medical circles on Taiwan, doctors have long been king, Those in charge of large-scale procurements are usually docotrs. As a result, doctors are usually the ones caught during procurement scandals.

Over the past two years the Department of Health has increased restrictions on the outsourcing of medical operations. This may have improved the situation in some public hospitals, reducing procurement abuses. But it has not solved the problem completely. Will halting the outsourcing of medical operations prevent procurement scandals? No one would dare make such a guarantee. In fact, many hospitals benefit greatly from outsourcing. Medical expenses are reduced while income is increased. Many of these are public hospitals. But when the same measures are introduced in DOH hospitals, they paradoxically become a major source of scandals.

The cause of procurement scandals has nothing to do with outsourcing. It has everything to do with the procurement system itself. The public health care system has long opposed laymen being charged with procuring medical devices. But turning total control over to doctors unwittingly increased the opportunities for dirty money. That is why Chang Gung Memorial Hospital has long separated the requisitioners from the purchasers. The administrative staff forms a group responsible for procurement and bargaining. This makes it impossible for merchants to offer bribes. This model merits consideration.

For physicians to actively refuse bribes requires certain conditions. One way is to ensure that doctors are paid enough to keep them honest. But health insurance benefits continue to shrink. Public hospitals find it hard to make ends meet. Leave aside increases in staff salaries. Young doctors must economize on everything from food to clothing. They must work hard to succeed. When large sums of money pass through their hands, how many can resist? How many are not tempted to take something off the top?

Public hospitals want to reduce disputes over black money. They should consider the hospital's position. Public hospitals are subject to human limitations and to the procurement laws. They must be self-financing. They are non-profit public health providers. Clearly the pressure on them is too great. If public hospitals accept government subsidies, they can remain non-profit. They can avoid becoming profit-oriented. This will naturally reduce the phenomenon of black money. But this means government must underwrite their losses.

If the government is unwilling to underwite such losses, or cannot underwrite such losses, it may wish to transform them. They could be privately managed but publicly owned. Their operations could be cut back. Tainan Municipal Hospital has been privately manageed but publicly owned for 20 years. It remains one of Tainan's important medical institutions, and is very well known. There is no reason DOH hospitals could not change their operating model. Meanwhile, some Department of Health hospitals are located in resource-intensive areas. They have no particular raison d'etre. They long ago lost whatever signficance they had when they were founded. Why not phase them out, consolidate, or transform them? DOH hospitals must separate the wheat from the chaff. This will improve their overall quality.

The scandal has undermined the reputation of the medical community. The medical community must share in the shame. It must feel deep remorse. But hospitals continue to develop, and the temptation of money remains. To avoid deleterious results, they must stress medical ethics. They must also consider more fundamental factors. They must cure the disease at its root, and not merely suppress its symptoms. Only then can they eliminate this chronic illness.

白色巨塔中的黑錢糾葛
【聯合報╱社論】 2011.03.30

公立醫院又發生採購弊案，桃園地院羈押了衛生署官員、署立醫院院長及廠商共四人，另有多人交保並限制住居。只要是對台灣醫界生態稍有認識的人，反應大概都會和前衛生署長楊志良一樣：一點都不意外。

過去，台灣大型公立醫院中的黑錢橫行，包括暗示或明示病人送紅包、藥商給回扣、採購給佣金，甚至醫院內外各種活動的不樂之捐等，不一而足；幸而隨著民智漸開、醫院管理制度漸上軌道，加以全民健保給付制度及藥品實施聯合採購等，已使紅包及藥品回扣的新聞近年來漸不多見。取而代之的，檢調單位每隔一陣子總會揭發一樁醫院採購弊案，涉及數額龐大，震驚了醫界與整個社會。

隨著時代進步，醫療儀器快速推陳出新，採購單價越來越高，佣金也相對的更為驚人，這對任何人都可能形成極大誘惑；定力不夠的醫師一旦有機會掌控金額鉅大的採購案時，在廠商夜以繼日的遊說與安全保證下，難保不心動。因此在有識者眼中，浮出檯面的採購弊案極可能只是冰山一角。

事實上，在一些大型公立醫院中，涉嫌收受黑錢的傳聞不斷，只是因為施受雙方通常堅不承認，查緝並不容易；但在一些大型醫療器材商之間，類似的耳語從未間斷。其間一個重要的關鍵是，在台灣的醫療生態圈中，醫師一向獨大，醫院中提出大型採購案的主要是醫師，採購案的管理者通常也是醫師，因此在醫療採購弊案中醫師往往身陷其間。

也因此，衛生署近兩年推動的限制醫療外包作業，或許部分改善了公立醫院的一些弊病，減少採購弊端，卻很難徹底解決這個問題。醫療作業不外包就不會發生採購弊案了嗎？恐怕沒有人敢做這樣的保證。其實，不少醫院因實施醫療外包作業而大受其惠，非但醫療支出減省了，收入也增加了，而其中不乏公立醫院；但同樣的措施引進署立醫院以後，何以反而成了弊案的源頭之一？

採購弊案的關鍵，其實不在外包與否，而在採購制度本身。公立醫療體系素來反對由外行人負責醫療器械的議價與採購，但在醫師全程主導下，無形中增加了收受黑錢的機會；在這方面，長庚醫院始終堅持申購人與採購人分離，由行政人員組成採購小組負責詢價、議價的做法，令廠商根本無從行賄，值得參考。

要求醫師主動拒絕廠商的賄賂，一個主觀條件是，也許要讓醫師覺得能獲得足以「養廉」的待遇。但在目前，全民健保不斷的緊縮給付，使多數公立醫院的經營喘不過氣來，遑論增加醫護人員的薪酬。從節衣縮食中苦熬出頭的年輕醫師，一旦遇到鉅額金錢過手，還有多少人能把持得住，不想從中撈點油水？

公立醫院要想減少與黑錢的糾葛，現階段更應考量醫院的定位問題：公立醫院都受到人力員額及採購法的限制，需自負盈虧，又得承辦不賺錢的公共衛生業務，顯然經營壓力過大；公立醫院如能接受政府預算補貼，不以營利為目標，更避免以利潤為導向，自然可以減少黑錢流竄的現象。只不過，如此一來，政府必須承擔公立醫院的虧損。

如果政府不願或沒有能力負擔公立醫院的虧損，則不妨考量讓它們轉型，譬如公辦民營，或者減量經營。台南市立醫院公辦民營廿多年來，現已成為台南地區重要的醫療院所，而且頗負盛名，各地署立醫院沒有理由不能改變經營形態。同時，部分署立醫院位在醫療資源密集地區，又不具特色，早已失去當初設立的時代意義，為什麼不及早廢除、整併或轉型呢？署立醫院去蕪存菁後，對提升整體的服務效能應更有助益。

本案使醫界名譽再受重創，這是醫界應同感恥辱並深刻反省的時刻。但是，在醫院發展的過程中，金錢誘惑無時無刻不在，要杜絕可能因而產生的弊端，除了強調醫師要有醫德之外，尤應考量更根本的原因，做標本兼治之計，才能徹底解決多年來久治不癒的沉?。