Taiwan NHI upgrades coverage for pediatric proton therapy

Taipei, Jan. 12 (CNA) The National Health Insurance Administration (NHIA) on Monday announced three reimbursement reforms, highlighted by the introduction of full coverage for proton therapy for pediatric cancer patients starting this month.

The proton therapy measure is expected to benefit about 100 children each year, supported by funding of around NT$105 million (US$3.32 million).

NHIA head Chen Lian-yu (陳亮妤) said in a statement that proton therapy was added to the national health insurance program in January, with priority given to childhood cancers.

Reimbursement is tiered by radiation dose into low, medium and high-level proton radiotherapy, set at about NT$676,000, NT$1.03 million and NT$1.26 million, respectively.

The NHIA estimates around 100 pediatric patients will qualify each year.

Huang Pei-shan (黃珮珊), head of the NHIA's Medical Affairs Division, said the benefit is fully reimbursed but limited to indications with solid evidence of safety and effectiveness, meaning not all childhood cancers are eligible.

Low-dose proton therapy will be covered for conditions including Wilms tumor, Hodgkin lymphoma and neuroblastoma, she said.

Medium-dose coverage applies to pediatric malignant soft tissue sarcomas (excluding osteosarcoma), non-Hodgkin lymphoma and germ cell tumors.

High-dose coverage is designated for patients requiring craniospinal irradiation for central nervous system tumors, certain ocular tumors, and curative-dose treatment for osteosarcoma, she added.

The NHIA second reform raises reimbursements for emergency surgery or procedures for major trauma cases to bolster hospital emergency capacity.

Patients receiving specified imaging, procedures, surgery or anesthesia within two hours of arriving at an emergency department will qualify for a 100 percent payment add-on, while those treated within two to four hours will receive a 60 percent add-on.

The measure is expected to add about NT$154 million in annual funding, according to the NHIA.

The third reform improves reimbursement for hyperlipidemia care. Chen said the NHIA is rolling out a value-based reimbursement program developed with nine domestic medical societies, incorporating atherosclerotic cardiovascular disease (ASCVD) risk classification and a Taiwan-specific lipid management clinical pathway.

Implemented on Jan. 1, the initiative incentivizes medical facilities to follow the pathway in providing follow-up and care for patients at "extremely high" and "very high" risk.

The program offers case-acceptance care fees of about NT$500 to NT$2,000 and a successful referral fee of around NT$1,000, and is expected to benefit about 34,000 people annually with funding of roughly NT$113 million.