Innovative patient support models to tackle Taiwan's out-of-pocket healthcare spending challenge

The main drivers of rising out-of-pocket drug spending in Taiwan may include:

1. Coverage gaps for new drugs and technologies: Constrained by the NHI's annual global budget, many innovative therapies and drugs with strong clinical results but high price tags fail the health technology assessment of economic benefit—they may hold value for specific patients, yet cannot demonstrate public benefit.
2. More balance-billing and fully self-paid items: Patients who choose more advanced, higher-priced medical devices must pay the difference themselves. For new drugs, where no balance-billing option exists, the full cost must be self-paid.
3. NHI coverage limits or exclusions: Constrained by the global budget and fiscal considerations, NHI attaches many restrictions and scope limits to its coverage conditions, leaving a share of patients no choice but to pay out of pocket.

As Taiwan faces the twin pressures of an aging population and rapidly advancing (and costly) medical technology—while overall health insurance spending remains low as a share of GDP—out-of-pocket pressure is bound to intensify. Can international experience offer solutions? The recent ACCESS USA 2025 conference in Philadelphia gathered global experts in patient assistance, market access, and specialty disease care, and the issues and trends it explored hold real reference value for Taiwan.

Global trends from ACCESS USA 2025: lessons for Taiwan

ACCESS USA 2025 revealed a patient support field in rapid transformation, driven chiefly by policy pressure (such as the US Inflation Reduction Act, IRA), funding challenges, and technological innovation. Several core themes speak to Taiwan's situation:

• Matrix support programs: beyond traditional financial assistance

Amid uncertainty about the future of healthcare and market development, one promising development is the emergence of "matrix support programs"—a comprehensive model that addresses patients' needs on multiple fronts at once. Unlike traditional PAPs focused mainly on drug cost-sharing (copays), these integrated programs combine:

• Product access assistance (financial support)
• Medical procedure coverage support
• Treatment journey navigation (Navigator)
• Patient outcomes and adherence programs

For Taiwan, although NHI covers most new drugs, gaps in time and place remain in specialty care, and adopting this matrix support model could significantly improve patient outcomes. By integrating support across the entire treatment journey, these programs can help Taiwanese patients not only overcome the financial side of care but also better navigate the complexity of the healthcare system itself.
A matrix approach for Taiwan might include coordinated support from pharmaceutical manufacturers, hospital systems, and patient advocacy organizations—creating a safety net that complements the NHI structure while addressing its limits on high-cost therapies.

• The evolution and sustainability of Patient Assistance Programs (PAPs):

Traditionally, PAPs have provided a safety net for the uninsured or underinsured. The conference stressed that PAPs must keep evolving to ensure sustainability and effectiveness. The hotly debated US phenomenon of "Alternative Funding Programs" (AFPs)—controversial schemes that steer insured patients toward PAPs to cut employer costs—operates differently from anything in Taiwan, but still offers a market innovation lesson: any assistance mechanism, including Taiwan's gradually developing PAPs/PSPs, needs rigorous design, clear eligibility criteria, and effective oversight to prevent abuse and ensure aid truly reaches those in need—while also weighing corporate incentives and addressing the patient support interests of specific groups.

• AI and digital tools: enabling efficiency and personalization:

Artificial intelligence (AI) was framed as a "must-have" for patient support in 2025, not a future concept. Applications discussed included:

• Boosting operational efficiency: automating administrative work such as benefit verification and prior authorization.
• Personalized engagement: using AI to analyze patient data, predict risks (such as medication adherence or financial hardship), and deliver tailored communication and interventions. The conference gave special mention to "Causal AI" for understanding the "why" behind behavior.
• Proactive support: using predictive analytics and sentiment analysis to identify patients who need help early.
• Patient journey tracking: maintaining a full picture of the patient's status to anticipate needs and provide guidance.

For Taiwan, these technologies hold enormous potential. AI can not only optimize how PAPs operate but could also drive the development of intelligent patient navigation tools. Imagine a system that integrates NHI rules, balance-billing options, hospital fees, eligibility for various PAPs, and charitable resources—helping patients and clinicians identify the most suitable and economical treatment path and resolving today's information asymmetry.

• Policy levers and market dynamics: 

The US debates around the IRA (including the US$2,000 OOP cap, drug price negotiation, and installment payment of Medicare Part D drug costs) and PBM reform highlight the universal challenge of balancing cost control, innovation incentives, and access. The IRA experience—its successes and failures alike—offers Taiwan valuable reference points for shaping HTA policy and deploying MEAs, a reminder that policymaking demands careful weighing of complex trade-offs and potential consequences.

• Optimizing the patient journey:

The conference emphasized that effective support goes beyond financial aid—it must improve the overall patient experience (PX) and adherence. Key strategies include patient-centered design, personalized digital communication, streamlined processes, and, crucially, patient education. US research shows that patients' poor understanding of insurance and assistance programs often delays treatment—echoing the confusion Taiwanese patients feel when facing NHI, balance billing, self-pay options, and PAPs. Government health policy should therefore open market mechanisms further in information services, and support systems must include clear information, easy navigation, and personalized care.

Turning global insight into momentum for Taiwan

The innovative thinking at ACCESS USA 2025 points to concrete directions for Taiwan:

• Strengthening Taiwan's PAP ecosystem:

Taiwan's existing PAPs/PSPs can draw on international practice: raising transparency and ensuring compliance (especially personal data protection). The key is deeper integration among PAPs, hospital systems, and the NHI, so physicians can initiate assistance applications for patients more easily at the point of care—building an integrated "Hub services" model.

• Driving the digital transformation of the NHI system:

AI's potential extends far beyond PAPs. The NHI system could explore applying AI to:

• Support HTA decision-making (analyzing real-world data).
• Predict high-risk populations to optimize resource allocation.
• Improve administrative efficiency (such as automated review).
• Develop intelligent patient navigation tools. This, however, requires sound data infrastructure and governance frameworks to manage privacy and ethical challenges.

• Refining the policy path: 

Drawing on international experience, Taiwan could consider:

• Targeted financial protection: taking inspiration from the IRA's OOP cap, establish stronger safeguards for specific high-priced self-paid items or vulnerable groups.
• Optimizing value assessment: keep refining HTA/MEA processes and make wider use of RWE and outcomes-based payment agreements.
• Addressing "low-value care": create mechanisms to review and potentially retire low-benefit NHI-covered items, redirecting resources toward high-value innovation.
• Improving self-pay market oversight: strengthen information transparency and regulation of balance-billing and fully self-paid items to protect patients' rights.
• Fostering multi-stakeholder collaboration: build platforms for dialogue and cooperation among government, medicine, industry, technology, and patient groups to pursue diverse solutions together.
   

From the evolution of PAPs, the application of AI and digital technology, and the lessons of policy reform, to the emphasis on patient experience, these global insights are highly instructive. The key is translating this vision and thinking into localized solutions suited to Taiwan's unique healthcare environment.
That includes improving the effectiveness of existing patient support programs, using technology to empower the NHI system and service processes, and carefully balancing multiple objectives at the policy level. The potential of AI is enormous, but its adoption must be matched by equal attention to data governance, privacy, and ethics.
Solving the growing out-of-pocket burden will take the combined efforts of all stakeholders—government, the medical community, industry, technology partners, and patient groups. Through open dialogue, pragmatic planning, and innovative practice—drawing on global wisdom to meet local challenges—Taiwan has the opportunity to further strengthen its health protection system, ease the public's burden, improve access to medicine and quality of care, and ultimately move toward a more sustainable, more equitable future that meets the health needs of all.