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

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, (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 Data Combine 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

Results: Cox ’ s PH Model (a)

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?