Breast Cancer Reimbursement Policy in Taiwan Mao-Ting Sheen Director Bureau of National Health Insurance Department of Health, Executive Yuan November 10,

Outline Current Status of Breast Cancer in Taiwan Medical Expenditures of Breast Cancer Reimbursement of Target-therapy Drugs The Breast Cancer Pay for Performance Pilot Program 2

Current Status of Breast Cancer in Taiwan The 2008 Cancer Registry Report published by the Department of Health in Taiwan indicated that breast cancer still had the highest incidence rate among all female cancers and appeared a gradually year-by-year rising tendency. The incidence rate and death rate of breast cancer in Taiwan took the 2 nd rank in Asian countries. The prevalence of breast cancer has become a global trend. In recent years, it has an obvious trend that the patient’s age has been dropping in Asian countries.

The Long-term Trend in the Incidence of Female Breast Cancer in Taiwan 4 Source ： Taiwan Cancer Registry

The Age-specific Incidence Rate of Taiwan’s Female Breast Cancer (1981 ~ 2005) Source ： Taiwan Cancer Registry 5

6 Inpatient Medical Expenses of Breast Cancer in Taiwan Source: Medical claims database of BNHI In-patient (million)(%)(million)(%)(million)(%)(million)(%)(million)(%) Total Exp.1, %1, %1, %2, %2, % Drug Fees % % % % % Diagnosis Fees603.8%663.8%753.8%834.0%894.0% Inpatient Surgical Fees % % % % % Ward Fees % % % % % Inpatient Laboratory Fees %1438.2%1668.5%1828.9%2069.3% Inpatient X-ray Fees1177.3%1307.5%1447.4%1627.9%1737.8% Inpatient Therapeutic Procedure Fees & Medical Devices Fees %1277.3%1517.7%1567.6%1627.3% Others1388.7%1458.3% %1678.1%1336.0% Number of patients11,715 12,966 14,388 15,620 16,659 Avg. admissions per patient Avg. length of stay per patient

7 Outpatient Medical Expenses of Breast Cancer in Taiwan Source: Medical claims database of BNHI Out-patient (million)(%)(million)(%)(million)(%)(million)(%)(million)(%) Total Exp. 2, %3, %3, %3, %4, % Drug Fees 1, %1, %1, %1, %2, % Diagnosis Fees %1404.7%1574.5%1764.6%1934.2% Laboratory & Treatment Fees 1, %1, %1, %1, %1, % Others 642.4%90.3%180.5%300.8%481.0% Number of patients 48,394 53,288 58,173 63,680 68,864 Avg. number of visits per patient

8 Outpatient & Inpatient Medical Expenses of Breast Cancer in Taiwan

Reimbursement of Target-therapy Drugs for Breast Cancer  Trastuzumab ( Ex: Herceptin ) coverage 2002/4/1 covered by NHI - used for metastatic breast cancer (MBC) patients – Use alone ： HER2 excessive expression(IHC 3+ 或 FISH+) and received at least one time of chemotherapy(C/T) MBC patients – Use combined with paclitaxel or docetaxel: HER2 excessive expression(IHC 3+ 或 FISH+) and has never received C/T MBC patients – MBC and HER2excessive expression patients who has never used trastuzumab. 2010/1/1 expanded coverage to early breast ca. patients – Post surgery and C/T, early breast ca. patients with HER2 excessive expression (IHC 3+ or FISH+), used as adjuvant therapy, and confined its use for less than one year. 9

Reimbursement of Target-therapy Drugs for Breast Cancer  Lapatinib ( Ex: Tykerb ): not covered yet Reason: due to high uncertainty in the effectiveness of increasing survival rate and the total budget impact, this drug has not been covered till date. 10

The Drug Expenses of Trastuzumab 11 Note: Use rate is defined as the rate of the patients who has ever used trastuzumab among the total number of breast cancer patients. Year Patient who has ever used Trastuzumab Use rate Trastuzumab drug expenses (million) Share of all medical cost Share of all drug cost %2826.7%13.8% %3978.4%16.9% %4818.9%18.5% % %22.1% %1, %39.1%

Pay for Performance Pilot Program 12  Requirement in Process Participation rate of cases Completion rate of disease management for new patients Completion rate of disease management for old patients Annual assessment of disease management completion rate The degree of adherence to the treatment guidelines  Requirement in Outcome Extra payment based on the performance of quality indicators Disease free survival rate, Overall survival rate

Payment Incentives for P4P Program  Payment Incentives: Fee for Service ＋ Performance Bonus Performance Bonus calculation ： 1.The bonus depends on the performance of the disease free survival rates in the stage 0 to 3 and the overall survival rate in the stage 4 in 5 years after treatment as indicated in the table. 2. It is paid annually in percentage of the annual total payment amount calculated based on FFS if the required standard is met. 13 Pathological stageFirst yr.Second yr.Third yr.Fourth yr.Fifth yr. Stage 0(Disease free survival rate) 97%94%93% Stage 1(Disease free survival rate) 97%93%89%88%86% Stage 2(Disease free survival rate) 95%86%80%78%75% Stage 3(Disease free survival rate) 85%70%50%45%40% Stage 4(Overall survival rate) 64%33%23%18%10% Extra bonus on top of FFS 2%3%4%6%7%

Participation of P4P Program Number of cases 5,8526,9278,4389,80710,74311,678 Participation rate 12.09%12.98%13.60%14.64%14.50%14.62% Note: Since the requirement and calculation of performance bonus was quite complicated, hospitals were not willing to partake.

Results of P4P Program 15 Use Kaplan-Meier or life table to calculate survival rate as of 2010 Stage 0Stage 1Stage 2Stage 3Stage 4 99%98%95%87%71%  5-year disease free survival rate

Results of P4P Program 16  Local recurrence rate after breast cancer surgery This indicator is defined as the rate of the number of cases occurred local recurrence (including supraclavicular lymph nodes) among the total number of patients who performed either partial or whole breast mastectomy. According to the results of the hospitals which joined the pilot project, the local recurrence rate was less than 2% annually, and five- year local recurrence rate was less than 10%.

Results of P4P Program 17  Re-treatment rate of breast cancer after surgery This indicator refers to the rate of the number of cases who received repeated chemotherapy or radiation therapy after partial or whole breast mastectomy among the total number of patients who performed either partial or whole breast mastectomy. According to the results of the hospitals which joined the pilot project, the re-treatment rate within 18 months, 24 months and 30 months were less than 10%, 15% and 20%, respectively.

Conclusions 18  The incidence of breast cancer in Taiwan has increased year by year. And there’s a tendency that the patient age has been obviously dropping in recent years.  The government has made promotion and provided funding for early screening.  The National Health Insurance has also put helpful drugs, exams and treatment items into coverage.  Strong activities of private society involved.  I believe with the joint efforts of government, medical providers and private support groups, the prevention and treatment of breast cancer will generate more effective results.

Thank you for your attention! 19