The Evaluation of Professional Divisions of Traditional Chinese Medicine in Taiwan through Patient Visit Records of 2012

For decades, professional divisions have been represented as the main structural divisions in Western medicine throughout the world. In Taiwan, medical policymakers are also interested in designing professional divisions of traditional Chinese medicine (TCM). Therefore, this study evaluated the current status and potentiality of professional divisions of TCM in Taiwan using data from the year 2012 obtained from the National Health Insurance Research Database; the database provides information regarding age and gender of TCM physicians (TCMPs); total visit counts; contracted medical institution codes; groupings of diseases classified under International Classification of Diseases, Ninth Revision, Clinical Modification codes; numbers of children and female patients seeking treatment; and claim disposition codes used by each TCMP. The results indicated that there were 5522 TCMPs in 2012, and 4876 (90.3%) TCMPs practiced in primary clinics. The proportions of pediatric visits to these TCMPs were mostly below 0.2, and acupuncture or traumatology-related visit proportions were below 0.5. Only a few of the studied Taiwan-based TCMPs practiced gynecology and pediatrics, but most of them performed “internal medicine”, or “acupuncture” or “traumatology” treatments. Thus, the number of TCM specialists practicing gynecology or pediatrics is insufficient, indicating that a policy that forms professional divisions of TCM practitioners in Taiwan should be reconsidered.


Introduction
Although Western medicine has been classified into four main professional specialties and many subdivisions, the classification of traditional Chinese medicine (TCM) can be divided into only two categories: internal herbal medicine, and external procedures (acupuncture, moxibustion, manipulative therapy, etc.). The official classification of TCM was first introduced in 624 AD. The Imperial Medical Bureau of Tang dynasty classified TCM into four main subjects: "medicine", "acupuncture", "massage (which encompasses orthopedics)", and "charms and incantations", and practitioners were of the population, but copayment and registration fees must be paid by patients [18]. The NHI does not cover TCM services, such as prescription for raw herbs, cupping, Gua sha, and bloodletting, and does not cover inpatient stays. The NHI Research Database (NHIRD) has been operational for 22 years. It contains data from each year and is used for many research topics, such as clinical studies, biomedical sciences, and medical-economic sciences [19]. An increasing number of research papers that are pertinent to TCM have been published based on data from the NHIRD, and many have been included in influential journals.
Most TCMPs in Taiwan are general practitioners, and they provide TCM services at primary clinics in communities [20]. During the years 1996 to 2001 in Taiwan, 82.6% of the TCM services provided were at primary clinics, whereas only 12.8% were at private and government hospitals [21]. For health care policymakers, the differentiation of the professional divisions of TCM is required at medical centers and hospitals. Since TCM has been popular in Taiwan, and there are TCMPs with license and college education leading it to move closer to Western medicine. However, many subspecialties exist in Western medicine, but TCMPs have not been able to establish professional divisions. Under such circumstances, comprehensively analyzing the current status of the professional certification of TCMPs in Taiwan is crucial for establishing a professional division system of TCM practitioners, and NHIRD data from the year 2012 were used in this study to achieve this goal.

Database
Taiwan's NHI is government-administered and compulsory for all citizens. In 2012, the NHI covered approximately 23 million people, 99.89% of the total population [22].
In this study, NHIRD data from the year 2012 data were analyzed; these were related to practicing TCMPs and contained information on their age, sex, services provided, total number of outpatient services provided in that year, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes of outpatient services they provided. These data were then analyzed using statistical software to identify trends regarding treatments provided and determine whether professional divisions were evident. The NHI administration made the NHIRD claims data publicly available for researchers from 1996 to 2013. This study was approved by the Institutional Review Board of Taipei Veterans General Hospital (2013-10-001CE).

Research Population
A descriptive and cross-sectional analysis on the 2012 data was conducted. Of the 5524 certified TCMPs in Taiwan, two records were incomplete and excluded, resulting in 5522 TCMPs being studied. The following data were analyzed: the age and sex of each TCMP, total visit count each TCMP registered with the NHI, contracted medical institution codes, the ICD-9-CM codes used by each TCMP for health insurance claims, number of children seeking treatment, number of female patients seeking treatment, and the claim codes used by each TCMP. The analysis determined the ratios of children, female patients, patients seeking acupuncture treatment, patients seeking traumatology treatment, and patients with various diseases (as classified under the ICD-9-CM codes) seeking TCM treatment.
Contracted medical care institutions in this study, as defined by the NHI, comprised four types: "academic medical centers", "metropolitan hospitals", "local community hospitals", and "physician clinics (known as primary clinics)".

Data Processing
Data were processed using Perl software (version 5.20.2) and descriptive statistics was generated using Microsoft Excel 2013. The results are presented in the figures provided in this paper. We expressed the proportions of specific patient types, diagnoses, or treatment methods (e.g., acupuncture) of a particular TCMP as a ratio labeled as a proportion (e.g., acupuncture proportion) of the total visit counts, and we used this to determine if that TCMP could be characterized according to visitation trends. For example, by dividing the number of reported pediatric visits by the total visit count, we obtained the proportion of pediatric visits (pediatric visits/total visits = pediatric visit proportion) of a particular TCMP. A high pediatric visitation ratio indicates that a considerable proportion of a particular TCMP's patients were children. The same principle was applied to female patients. However, not all female patients visited physicians for gynecological treatments. Hence, female patients with ICD-9-CM codes corresponding to "diseases of female genital organs" (614-629) were further segregated and expressed as a ratio of total visit counts to obtain the proportion of women who went for gynecological treatments. A similar segmentation approach was used for patients with claim codes corresponding to acupuncture or traumatology treatment. Finally, the same method was used to determine and analyze the visitation ratios for various groupings of diseases classified under ICD-9-CM codes (see Table 1 for the systemization of ICD-9-CM codes).

Results
A total of 5522 practicing TCMPs in 2012 were selected for the analysis. Of them, 1531 were women. The studied TCMPs were aged between 25 and 95 years ( Figure 1). As displayed in the figure, for those between 35 and 75 years old, the ratio of male to female physicians was large, at 3.51:1 (3481:1003); however, for those between 25 and 35 years old, the ratio was closer to 1:1 (463:426), indicating an increase in the number of young female TCMPs. As shown in the distribution chart ( Figure 2), 4985 TCMPs (90.3%) provided services in primary clinics. Most of the TCMPs (78.9%) had a total visit count lower than 10,000, and 87.5% of TCMPs had a total visit count lower than 12,000; and the peak range for total visit count was 4001-6000 visits. The TCMPs that mostly provided services in academic medical centers had visit counts below 2000 (89 physicians, 46.6%). For the 106 TCMPs with total visit counts above 20,000, 90.6% worked in primary clinics. Most TCMPs had a pediatric visitation ratio lower than 0.2 ( Figure 3), and only five TCMPs had a pediatric visitation ratio above 0.5, indicating that one in every two patients that visited the TCMPs was a child. Most TCMPs had a female patient ratio of 0.4-0.8 ( Figure 4). However, the ratio of gynecology-related visitations of TCMPs was lower than 0.2 ( Figure 5), indicating that most female patients did not visit TCMPs for gynecological treatments. As shown in the distribution chart ( Figure 2), 4985 TCMPs (90.3%) provided services in primary clinics. Most of the TCMPs (78.9%) had a total visit count lower than 10,000, and 87.5% of TCMPs had a total visit count lower than 12,000; and the peak range for total visit count was 4001-6000 visits. The TCMPs that mostly provided services in academic medical centers had visit counts below 2000 (89 physicians, 46.6%). For the 106 TCMPs with total visit counts above 20,000, 90.6% worked in primary clinics. As shown in the distribution chart ( Figure 2), 4985 TCMPs (90.3%) provided services in primary clinics. Most of the TCMPs (78.9%) had a total visit count lower than 10,000, and 87.5% of TCMPs had a total visit count lower than 12,000; and the peak range for total visit count was 4001-6000 visits. The TCMPs that mostly provided services in academic medical centers had visit counts below 2000 (89 physicians, 46.6%). For the 106 TCMPs with total visit counts above 20,000, 90.6% worked in primary clinics. Most TCMPs had a pediatric visitation ratio lower than 0.2 (Figure 3), and only five TCMPs had a pediatric visitation ratio above 0.5, indicating that one in every two patients that visited the TCMPs was a child. Most TCMPs had a female patient ratio of 0.4-0.8 ( Figure 4). However, the ratio of gynecology-related visitations of TCMPs was lower than 0.2 ( Figure 5), indicating that most female patients did not visit TCMPs for gynecological treatments. Most TCMPs had a pediatric visitation ratio lower than 0.2 (Figure 3), and only five TCMPs had a pediatric visitation ratio above 0.5, indicating that one in every two patients that visited the TCMPs was a child. Most TCMPs had a female patient ratio of 0.4-0.8 ( Figure 4). However, the ratio of gynecology-related visitations of TCMPs was lower than 0.2 ( Figure 5), indicating that most female patients did not visit TCMPs for gynecological treatments.     Most of the studied TCMPs had acupuncture treatment ratios smaller than 0.5 ( Figure 6). Of the 359 physicians with acupuncture treatment ratios larger than 0.5 (i.e., more than one in every two patients visited the physician for acupuncture), only one TCMP had a total visit count of over 10,000 (Figure 7). The traumatology treatment proportion is shown in Figure 8. Of the 56 TCMPs with traumatology ratios above 0.5, none had a total visit count exceeding 10,000 ( Figure 9). Additionally, as depicted in Figure 10, most of the ICD-9-CM codes for the TCM patients were categorized under Most of the studied TCMPs had acupuncture treatment ratios smaller than 0.5 ( Figure 6). Of the 359 physicians with acupuncture treatment ratios larger than 0.5 (i.e., more than one in every two patients visited the physician for acupuncture), only one TCMP had a total visit count of over 10,000 ( Figure 7). The traumatology treatment proportion is shown in Figure 8. Of the 56 TCMPs with traumatology ratios above 0.5, none had a total visit count exceeding 10,000 ( Figure 9). Additionally, as depicted in Figure 10, most of the ICD-9-CM codes for the TCM patients were categorized under "Diseases of the Respiratory System", "Diseases of the Digestive System", "Diseases of the Skin and Subcutaneous Tissue", "Diseases of the Musculoskeletal System and Connective Tissue", or "Diseases of the Female Genital Organs" groupings. Proportions of patients with ICD-9-CM codes falling under "Symptoms, Signs, and Ill-Defined Conditions", and the "Injury and Poisoning" grouping were also high. "Infectious and Parasitic Diseases", "Neoplasms", "Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders", "Diseases of the Blood and Blood-Forming Organs", "Mental Disorders", "Diseases of the Nervous System", "Diseases of the Eye and Adnexa", "Diseases of the Ear and Mastoid Process", "Diseases of the Circulatory System", "Diseases of the Urinary System", "Diseases of the Male Genital Organs", "Disorders of Breast", "Complications of Pregnancy, Child Birth, and the Puerperium" and "Diseases of the Skin and Subcutaneous Tissue" groupings were comparatively few. Of the TCMPs with grouping proportions higher than 0.5 ( Figure 11), 199 TCMPs applied the most ICD-9-CM codes from "Injury and Poisoning", 161 from "Symptoms, Signs and Ill-Defined Conditions", 67 from "Diseases of the Musculoskeletal System and Connective Tissue", 61 from "Diseases of the Respiratory System", 12 from "Diseases of Female Genital Organs", 11 from "Diseases of the Circulatory System" and "Diseases of the Digestive System", 8 from "Diseases of the Skin and Subcutaneous Tissue", 4 from "Neoplasms" and "Diseases of the Eye and Adnexa" and 1 from "Endocrine, Nutritional and Metabolic Diseases and Immunity Disorders" and "Diseases of the Nervous System". No other grouping proportions calculated from TCMP-applied ICD-9-CM codes were higher than 0.5.

Discussion
Research findings obtained in 2007 indicate that the TCMP resources in Taiwan were saturated with the natural growth of their supply, and the average number of visits per TCMP decreased annually [23]. In 2003, scholars predicted that the number of TCMPs in 2010 would be 4606 [24]. According to our study, there were 5522 licensed TCMPs in 2012, and 758 (13.7%) exhibited a total visit count of under 2000 per year (Figure 2). Based on the NHI payout records, every patient paid equal fees per visit regardless of consultation and treatment time, indicating that only a higher visit

Discussion
Research findings obtained in 2007 indicate that the TCMP resources in Taiwan were saturated with the natural growth of their supply, and the average number of visits per TCMP decreased annually [23]. In 2003, scholars predicted that the number of TCMPs in 2010 would be 4606 [24]. According to our study, there were 5522 licensed TCMPs in 2012, and 758 (13.7%) exhibited a total visit count of under 2000 per year (Figure 2). Based on the NHI payout records, every patient paid

Discussion
Research findings obtained in 2007 indicate that the TCMP resources in Taiwan were saturated with the natural growth of their supply, and the average number of visits per TCMP decreased annually [23]. In 2003, scholars predicted that the number of TCMPs in 2010 would be 4606 [24]. According to our study, there were 5522 licensed TCMPs in 2012, and 758 (13.7%) exhibited a total visit count of under 2000 per year (Figure 2). Based on the NHI payout records, every patient paid equal fees per visit regardless of consultation and treatment time, indicating that only a higher visit count would increase payout amount. Determining whether the aforementioned physicians with low visit counts had treated self-paying patients to increase their income was difficult because data from the NHI database were used for this study.
Because of the increased education level of women and promotion of gender equality, an increase in the proportion of female TCMPs among those aged under 35 years was observed, with the ratio of male to female physicians approaching 1:1. However, the proportion of male TCMPs was higher for older age groups. More female patients sought TCM treatments than male patients [25][26][27]. Thus, visiting female TCMPs might decrease their anxiety during treatment and avoid related medical conflicts.
According to the aforementioned regulations in Taiwan, various professional divisions of TCM could be registered. However, in this study, from the analysis of claim codes or the categorization of patients into children, women, and women with gynecology-related diagnostic codes, few TCMPs focused on pediatrics or gynecology (Figures 3 and 5). Therefore, the number of qualified teachers promoting TCM gynecology and pediatrics might be insufficient.
Currently, TCM in Taiwan is categorized into three main subspecialties: "internal medicine" (involving pediatrics and gynecology), "acupuncture", and "traumatology". As illustrated in Figures 6 and 7, the TCMPs relevant to acupuncture and traumatology treatments exhibited relatively low total patient visit counts. This might be the reason why these physicians spent longer treating patients. Huang reported that only 8.9% of TCM students would like to practice traumatology after graduation [28] because of the long working hours, difficulty of techniques, high medical risks, and low income levels [29]. If future policies were to promote professional divisions of TCM, attention should be given to acupuncture and traumatology because they may encounter difficulties in recruitment and cause students to change their specialties before completing their training, leading to scarcity of physicians in these fields. In other words, income and cost of risk influence a doctor's choice of professional divisions. Although professional divisions of TCM enable patients to choose a physician who is experienced in the specialty, TCM focuses on holistic concept of a human being, and a patient may express multiple complaints regarding many organs of the body that may not be limited to a single professional division. In these cases, professional divisions of TCM may cause complications during treatment and wastage of medical resources.
Professional divisions of TCM are more feasible in hospitals (academic medical centers, metropolitan hospitals, and local community hospitals) than in primary clinics because critically ill patients will not visit primary clinics. However, 80% of TCM patients visited primary clinics [21], and 90.3% of the TCMPs practiced in such clinics ( Figure 2). In addition, few patients sought TCM treatments in hospitals. Furthermore, TCMPs play a similar role as family doctors of Western medicine, and they are typically at the frontline of general public health care. Therefore, we observed that TCMPs used the ICD-9-CM code grouping "Symptoms, Signs and Ill-Defined Conditions" to a great extent (Figures 10 and 11). Furthermore, diagnoses from TCMPs are also typically unclear, hindering professional divisions of TCM.
Studies have revealed that the most commonly used ICD-9-CM codes for NHI TCM claims were related to the "Diseases of the Respiratory System" [21,30,31]. Most patients who "shop" towards TCMPs seek treatment for respiratory diseases (44.7%), followed by sprains and injuries (44.0%) [32], and these patients also attended otolaryngology clinics (known as ENT clinics) and Western medicine physical therapy clinics [32]. Additionally, published results have detailed information regarding the most commonly used ICD-9-CM codes and prescriptions [33].
Some limitations exist in this study, which are recapitulated in the following points. Firstly, this study used single-year data from the NHIRD, which did not involve self-paid treatment procedures or decoctions. The information extracted from the NHIRD did not represent all TCM treatments in Taiwan. In addition, Taiwanese people can purchase Chinese herbs and remedies from pharmacies without visiting any TCMP; therefore, self-paid Chinese remedies were not been recorded in the NHIRD [31]. Research indicates that more than half of the patients seeking TCM treatment were willing to self-pay for only a few types of services and preferred to claim health insurance for most services, and only one-fourth of the patients interviewed opted for copayment. This was because patients could not judge the quality of medical products, were unsure whether the quality matched the price paid, were worried about the financial burden, or were worried that they might have purchased counterfeit drugs [34]. Therefore, a high proportion of self-pay procedures was deemed as unlikely. Secondly, the NHIRD has several limitations. For example, a short consultation time under the health insurance system results in insufficient recorded details [18]. Thirdly, in addition, similar to research based on observations, results that are not obtained experimentally cannot provide conclusive evidence for causation. However, research data obtained from the analysis of large databases could still be of value to clinical studies because the database contains information from a nationwide population [35], which overcomes the difficulty of obtaining statistically significant results.
Because the NHI covers most diseases and treatments, this study demonstrated the distinct characteristics of TCM outpatients, which are crucial in the medical field. These data can serve as references for future policymakers. This study was also free from selection or recall biases because of the structure of the samples and database. Due to the large sample size, this study achieved high statistical power and precision, and therefore provided a basis for conducting further international studies of medical policies.

Conclusions
This novel study investigated the trends of professional divisions among TCMPs in Taiwan. The 2012 NHIRD data were adopted to analyze the claim codes and ICD-9-CM codes of the patients in addition to other factors for each TCMP, thereby determining whether a tendency existed toward the development of professional divisions of TCMPs. The results implied that TCM in Taiwan is currently categorized in three main specialties: "internal medicine", "acupuncture", and "traumatology." The number of TCMPs specializing in pediatrics and gynecology, which are subspecialties in internal medicine, remains limited, indicating that detailed professional divisions in the future may lack sufficient physicians to treat related patients. These findings provide a reference for TCM for health authorities so that they can plan regulations and policies concerning TCM and satisfy the training requirements of clinical professional divisions.