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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
Raymond NC Kuo
(1)
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
“No relationships to disclose”
Background
National health insurance in Taiwan
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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
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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
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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
Pathology staging
Year of survival
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
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Difference of performance between care for
P4P Initiatives enrollees or none enrollees?
If better performance could reflect in better
survival?
Methods
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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
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Measure performance of breast cancer care
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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))
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composite scores :
(counts of measures the case complies with)
—————————————————————
(counts of total measures applicable to the case)
Methods – breast Cancer core
measure indicators
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2 Pre-treatment indicators
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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. )
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9 Treatment indicators
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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. )
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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
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Data
Combine with
 National Health Insurance database (NHID)
 Taiwan cancer registry
 National death registry
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Exclusion
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not treated at the reporting hospital
not applicable with the performance composite score
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lack of tumor size reported in cancer registry
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Methods
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Cox Proportional Hazard Modeling
Control for
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Age
cancer staging
hospital service volume
Results
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4,273 (79.3%) cases are included
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792 cases are P4P treatment-complete enrollees (18.6%)
P4P-claimed patients
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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%)
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Have higher mean of composite scores (0.62 vs. 0.49,
p<0.001)
Results
Age
Stage
0
I
II
III
IV
Cases reported by joined hospital
Reported by other Hospitals
(n=1,257)
(n=2,993)
P4P (a)
None P4P (b)
None P4P (c)
Mean
S.D.
Mean
S.D.
Mean
S.D.
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
%
16
168
391
173
44
2.02
21.21
49.37
21.84
5.56
93
138
152
68
14
20.00
29.68
32.69
14.62
3.01
n
%
256
8.55
820
27.40
1384
46.24
430
14.37
103
3.44
2
(x =171.970, p>0.001)
Results: Cox’s PH Model (a)
Exp(B)
Age
Stage (stage 0 as control)
I
II
III
IV
Service volume
Score of performance
P4P enroll.
1.018
1.801
3.940
14.436
64.058
1.000
0.633
0.741
All hospitals (n=4,273)
95.0% CI for Exp(B)
Upper
Lower
1.011
1.024
0.969
2.203
8.065
35.313
1.000
0.481
0.599
3.347
7.048
25.841
116.204
1.001
0.832
0.917
p-value
<0.001
0.063
<0.001
<0.001
<0.001
0.203
0.001
0.006
Results: Cox’s PH Model (b)
Joined hospital (n=1,257)
Exp(B) 95.0% CI for Exp(B) p-value
Upper
Lower
1.012
1.000
1.024 0.048
Age
Stage (stage 0 as control)
I
1.050
0.328
II
2.966
1.055
III
13.643
4.935
IV
68.616
24.191
Score of performance 0.830
P4P enroll.
0.661
0.568
0.480
3.362
8.340
37.712
194.625
0.934
0.039
<0.001
<0.001
1.212 0.334
0.910 0.011
Conclusion and Discussion
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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:
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same goals for bonus
rewards hospitals that already performed better?