The influence of Breast Cancer Pay for Performance Initiatives on breast cancer survival and performance measures:a pilot study in Taiwan

Raymond NC Kuo, PhD Candidate; Mei-Shu Lai, PhD;

Kuo-Piao Chung, PhD

Institute of Health Care Organization Administration,College of Public Health,

National Taiwan University

Presenter Disclosures

(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

Raymond NC Kuo

“No relationships to disclose”

Background

National health insurance in Taiwan

National Health Insurance program was established in 1995

Fee-for-service and case payment under the global budget payment scheme

No gate-keeper system for outpatient visits Patients are free to choose care providers for

every visit High satisfaction rate (over 75% satisfied) High service volumes in outpatient department

in most hospitals Closed-staff system for hospitals

Comprehensive benefit package

• Inpatient care• Outpatient care• Laboratory tests (combined within

In/Outpatient care)• Prescription drugs and certain OTC drugs• Dental services• Traditional Chinese medicine• Day care for the mentally illness• Home care

P4P for Breast cancer care Started in 2001 Hospitals with more than 100 incident cases annually

are eligible to participate in Hospitals are ‘voluntary’ to join-in P4p cases are reimbursed on a case-basis

(higher financial incentive than FFS cases) Hospitals which achieved goals on stage-specific

survival rate could earn extra bonus No penalty for low performance

Stage-specific survival rate for

annual bonus Year of survival

Pathology staging 1st 2nd 3rd 4th 5th

0 (disease-free) 97% 94% 93% 93% 93%

I (disease-free) 97% 93% 89% 88% 86%

II (disease-free) 95% 86% 80% 78% 75%

III (disease-free) 85% 70% 50% 45% 40%

IV (overall) 64% 33% 23% 18% 10%

Bonus† 2% 3% 4% 6% 7%

†Percentage of total fee claimed for cases who meet the bonus criteria and received

complete ‘treatment-mix’ as first course of treatment

Objective Difference of performance between care

for P4P Initiatives enrollees or none enrollees?

If better performance could reflect in better survival?

Methods

Study cohort 5,388 breast cancer incident cases

diagnosed in 2002 and 2003 followed to the end of 2007 Data source: population based cancer

registry

Methods

Measure performance of breast cancer care measured by a composite score of performance

measures based on two pre-treatment and nine treatment Core

Measure indicators collected through literature review selected by an expert panel group three stages of modified Delphi technique (Chung, K.P., et al., European Journal of Cancer Care, 2008.

17(1))

composite scores : (counts of measures the case complies with)————————————————————— (counts of total measures applicable to the case)

Methods – breast Cancer core

measure indicators 2 Pre-treatment indicators

PT1: Proportion of women aged over 50 who received bilateral mammography or breast sonography 3 months before surgery

PT2: Proportion of breast cancer patients who have diagnosis in cytology and histology before surgery

Methods – breast Cancer core measure indicators (cont. )

9 Treatment indicators T1: Proportion of breast cancer patients who were

discussed by multi-disciplinary team T2: Proportion of zero-stage breast cancer patients

with ten or more lymph nodes on pathology report T3: Proportion of Stage I and II patients who undergo

Breast Conserving Surgery (BCS) T4: Proportion of breast cancer patients with

pathology report of tumor-size in the medical record after surgery

Methods – breast Cancer core measure indicators (cont. )

T5: Proportion of invasive breast cancer after surgery with ten or more lymph nodes removed on pathology report

T6: Proportion of invasive breast cancer patients with estrogen receptor analysis results in the medical record

T7: Proportion of patients with invasive cancer who receive radiation treatment after BCS

T8: Proportion of breast cancer women aged less than and equal to 50 years (pre-menopausal) with positive lymph node receiving adjuvant chemotherapy

T9: Proportion of breast cancer women aged greater than 50 years (post-menopausal) with positive lymph node receiving adjuvant hormone therapy or chemotherapy

Methods

DataCombine with

National Health Insurance database (NHID) Taiwan cancer registry National death registry

Exclusion not treated at the reporting hospital not applicable with the performance composite score

lack of tumor size reported in cancer registry

Methods

Cox Proportional Hazard Modeling Control for

Age cancer staging hospital service volume

Results

4,273 (79.3%) cases are included 792 cases are P4P treatment-complete enrollees (18.6%)

P4P-claimed patients younger than none-enrollees P4P-claimed patients are with less proportion of early

stage (stage zero and stage one) cases (23.2% vs.

49.7%) Have higher mean of composite scores (0.62 vs. 0.49, p<0.

001)

Results

Cases reported by joined hospital (n=1,257)

Reported by other Hospitals (n=2,993)

P4P (a) None P4P (b) None P4P (c) Mean S.D. Mean S.D. Mean S.D.

Age 48.66 10.49 52.47 12.53 50.73 11.55

(F=17.591, p<0.001; a<b, a<c, b>c)

n % n % n %

Stage

0 16 2.02 93 20.00 256 8.55

I 168 21.21 138 29.68 820 27.40

II 391 49.37 152 32.69 1384 46.24 III 173 21.84 68 14.62 430 14.37

IV 44 5.56 14 3.01 103 3.44

(x2=171.970, p>0.001)

Results: Cox’s PH Model (a)

All hospitals (n=4,273)

Exp(B) 95.0% CI for Exp(B) p-value

Upper Lower

Age 1.018 1.011 1.024 <0.001

Stage (stage 0 as control) I 1.801 0.969 3.347 0.063

II 3.940 2.203 7.048 <0.001

III 14.436 8.065 25.841 <0.001

IV 64.058 35.313 116.204 <0.001

Service volume 1.000 1.000 1.001 0.203

Score of performance 0.633 0.481 0.832 0.001 P4P enroll. 0.741 0.599 0.917 0.006

Joined hospital (n=1,257)

Exp(B) 95.0% CI for Exp(B) p-value Upper Lower

Age 1.012 1.000 1.024 0.048

Stage (stage 0 as control) I 1.050 0.328 3.362 0.934 II 2.966 1.055 8.340 0.039 III 13.643 4.935 37.712 <0.001 IV 68.616 24.191 194.625 <0.001

Score of performance 0.830 0.568 1.212 0.334 P4P enroll. 0.661 0.480 0.910 0.011

Results: Cox’s PH Model (b)

Conclusion and Discussion Breast Cancer P4P Initiatives in Taiwan has some

positive influence on performance of cancer care and survival

P4P enrollees seem to receive care with better performance and have better outcome

design of financial incentive: same goals for bonus rewards hospitals that already performed better?