Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach

Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.

Impact and cost-effectiveness evaluation of nutritional supplementation and complementary interventions for tuberculosis treatment outcomes under mukti pay-for-performance model in Madhya Pradesh, India: A study protocol

Background

A.

"pay-for-performance" (P4P) intervention model for improved tuberculosis (TB) outcomes, called "Mukti," has been implemented in an underdeveloped tribal area of central India. The target of this project is to improve nutritional status, quality of life (QoL), and treatment outcomes of 1000 TB patients through four interventions: food baskets, personal counseling, peer-to-peer learning and facilitation for linkage to government schemes. The current study aims to assess the success of this model by evaluating its impact and cost-effectiveness using a quasi-experimental approach.

Methods

Data for impact assessment have been collected from 1000 intervention and control patients. Study outcomes such as treatment completion, sputum negativity, weight gain, and health-related QoL will be compared between matched samples. Micro costing approach will be used for assessing the cost of routine TB services provision under the national program and the incremental cost of implementing our interventions. A decision and Markov hybrid model will estimate long-term costs and health outcomes associated with the use of study interventions. Measures of health outcomes will be mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per quality-adjusted life-years gained and cost per unit increase in patient weight in intervention versus control groups.

Results

The evidence generated from the present study in terms of impact and cost-effectiveness estimates will thus help to identify not only the effectiveness of these interventions but also the optimal mode of financing such measures. Our estimates on scale-up costs for these interventions will also help the state and the national government to consider scale-up of such interventions in the entire state or country.

Discussion

The study will generate important evidence on the impact of nutritional supplementation and other complementary interventions for TB treatment outcomes delivered through P4P financing models and on the cost of scaling up these to the state and national level in India.

Shorter antibiotic regimens impact the control efforts in high tuberculosis burden regions of Taiwan

OBJECTIVES

To assess the potential epidemiological impact and cost-effectiveness of shorter antibiotic regimens in high tuberculosis (TB) burden regions of Taiwan.

METHODS

This study combined the TB population dynamic model and cost-effectiveness analysis with local data to simulate the disease burdens, effectiveness and costs of hypothetical 4-month, 2-month and 7-day regimens compared with the standard regimen.

RESULTS

The main outcomes were the potential of shorter regimens for averted incidence, mortality and disability-adjusted life years, incremental cost-effectiveness ratio and net monetary benefit. Shorter regimens would lower incidence rates and mortality cases in a high TB burden region by an average of 19-33% and 27-41%, respectively, with the potential for cost-effectiveness or cost-saving. The 2-month and 7-day regimens would be more cost-effective than the 4-month regimen. The threshold daily drug prices for achieving cost-effectiveness and cost-saving for 4-month, 2-month and 7-day regimens were $US1, $US2 and $US70, respectively. Such cost-effectiveness would remain, even if the willingness-to-pay threshold was less than one gross domestic product per capita.

CONCLUSIONS

The findings support the inclusion of shorter regimens in global guidelines and regional-scale TB control strategies, which would improve disease control, particularly in settings with high rates of incidence and poor treatment outcomes.

Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002-2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002-2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.

Effect of pulmonary tuberculosis on clinical outcomes of long-term dialysis patients: Pre- and post-DOTS implementation in Taiwan

BACKGROUND AND OBJECTIVE

The link between tuberculosis (TB) and dialysis is known; however, the impact of TB on the clinical outcomes remains to be elucidated. This study aims to determine the clinical consequences of pulmonary TB among patients under long-term dialysis.

METHODS

A retrospective propensity-scores matched (1:4) cohort study was conducted by retrieving patient data for pulmonary TB after long-term dialysis commencement from the Taiwan National Health Insurance Research Database between 1999 and 2013. Patients with TB (n = 1993) or without TB (n = 7972) were compared for 3-year morbidity and mortality. The effect of Directly Observed Treatment, Short-Course (DOTS) implementation was also evaluated. Cox proportional hazards models were used to determine adjusted hazard ratios (HRs).

RESULTS

TB patients had a significantly higher risk of mortality than non-TB patients even after multivariate adjustment (HR: 1.48; 95% CI: 1.36-1.60; P < 0.001). DOTS implementation reduced the risk of some morbidities such as pneumonia, hospitalization and intensive care unit stay >7 days, but not inotropic agent usage, ventilator therapy >21 days and mortality in TB patients. In pulmonary TB patients with treatment duration ≥180 days, DOTS implementation also lowered the risk of TB relapse (HR: 0.33; 95% CI: 0.19-0.55; P < 0.001), irrespective of treatment duration (180-224 or ≥225 days).

CONCLUSION

Pulmonary TB increases the risk of morbidity and mortality in dialysis patients; DOTS implementation reduces some morbidities and TB relapse. Continuing DOTS implementation should be encouraged to improve clinical outcomes in dialysis patients.

Financial Incentives to Encourage Value-Based Health Care

This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.

The effectiveness of payment for performance in health care: A meta-analysis and exploration of variation in outcomes

BACKGROUND

Pay for performance (P4P) incentive schemes are increasingly used world-wide to improve health system performance but results of evaluations vary considerably. A systematic analysis of this variation in the effects of P4P schemes is needed.

METHODS

Evaluations of P4P schemes from any country were identified by searching for and updating systematic reviews of P4P schemes in health care in four bibliographic databases. Outcomes using different measures of effect were converted into standardized effect sizes (standardized mean difference, SMD) and each study was categorized as to whether or not it found a positive effect. Subgroup analysis, meta-regression and multilevel logistic regression were used to investigate factors explaining heterogeneity. Random-effects models were used because they take into account heterogeneity likely to be due to differences between studies rather than just chance. Sensitivity analysis was used to test the effect of different assumptions.

FINDINGS

96 primary studies were identified; 37 were included in the meta-analysis and meta-regression and all 96 in the logistic regression. The proportion of observed variation in study results that can be explained by true heterogeneity (I²) was 99.9%. Estimates of effect of P4P schemes were lower in evaluations using randomized controlled trials (SMD=0.08; 95% CI: 0.01-0.15) compared to no controls (0.15; 95% CI: 0.09-0.21), and lower for those measuring outcomes (e.g., smoking cessation) (SMD=0.0; 95% CI: -0.01 to 0.01) compared to process measures (e.g., giving cessation advice) (0.18; 95% CI: 0.06-0.31). Adjusting for other design features and the evaluation method, the odds of showing a positive effect was three times higher for schemes with larger incentives (>5% of salary/usual budget) (OR=3.38; 95% CI: 1.07-10.64). There were non-statistically significant increases in the odds of success if the incentive is paid to individuals (as opposed to groups) (OR=2.0; 95% CI: 0.62-6.56) and if there is a lower perceived risk of not earning the incentive (OR=2.9; 95% CI: 0.78-10.83). Schemes evaluated using less rigorous designs were 24 times more likely to have positive estimates of effect than those using randomized controlled trials (OR=24; 95% CI: 6.3-92.8).

INTERPRETATION

Estimates of the effectiveness of incentive schemes on health outcomes are probably inflated due to poorly designed evaluations and a focus on process measures rather than health outcomes. Larger incentives and reducing the perceived risk of non-payment may increase the effect of these schemes on provider behavior.

The role of GP's compensation schemes in diabetes care: evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

Incidence and outcome of newly-diagnosed tuberculosis in schizophrenics: a 12-year, nationwide, retrospective longitudinal study

Background

To control tuberculosis (TB), it is critical to identify at risk populations. Schizophrenia is recognized as an important risk factor for TB. However, previous studies have been confounded by comorbidities, and reports of TB infection outcomes are rare. Therefore, the current nation-wide study aimed to compare the adjusted incidence and outcome of TB diseases in schizophrenics and the general population.

Method

Using the National Health Insurance Research Database from 1998 to 2009, this retrospective longitudinal study included 60,409 schizophrenics and general population matched for age, Charlson’s score, and comorbidities. Diagnosis of TB was based on the international classification of disease, ninth revision and use of anti-TB drugs. Unfavorable outcome for TB was defined as death, loss to follow-up, or use of anti-TB treatment for more than 9 months.

Results

The adjusted incidence of TB in schizophrenics was significantly higher than in the general population [hazard ratio, 1.52; 95% confidence interval (CI), 1.29-1.79; p < 0.001; Kaplan-Meier log-rank test, p < 0.001]. Cox regression revealed age and male gender as risk factors for newly-diagnosed TB. The outcome of TB was comparable in schizophrenics and the general population [odds ratio (OR), 0.78; 95% CI, 0.55-1.09; p =0.144]. Logistic regression revealed a statistical trend for diabetes mellitus to predict poor outcome in schizophrenics with TB (OR, 2.30; 95% CI, 0.96-5.74; p = 0.062).

Conclusions

Schizophrenics are at increased risk for TB, and screening may be warranted for those living in areas with high prevalence of TB.

Effectiveness of a government-organized and hospital-initiated treatment for multidrug-resistant tuberculosis patients--a retrospective cohort study

BACKGROUND

In contrast to the conventional model of hospital-treated and government directly observed treatment (DOT) for multidrug-resistant tuberculosis (MDR-TB) patient care, the Taiwan MDR-TB Consortium (TMTC) was launched in May 2007 with the collaboration of five medical care groups that have provided both care and DOT. This study aimed to determine whether the TMTC provided a better care model for MDR-TB patients than the conventional model.

METHODS AND FINDINGS

A total of 651 pulmonary MDR-TB patients that were diagnosed nation-wide from January 2000-August 2008 were enrolled. Of those, 290 (45%) MDR-TB patients whose initial sputum sample was taken in January 2007 or later were classified as patients in the TMTC era. All others were classified as patients in the pre-TMTC era. The treatment success rate at 36 months was better in the TMTC era group (82%) than in the pre-TMTC era group (61%) (p<0.001). With multiple logistic regressions, diagnosis in the TMTC era (adjusted odds ratio (aOR) 2.8, 95% confidence interval (CI) 1.9-4.2) was an independent predictor of a higher treatment success rate at 36 months. With the time-dependent proportional hazards method, a higher treatment success rate was still observed in the TMTC era group compared to the pre-TMTC era group (adjusted hazard ratio 6.3, 95% CI 4.2-9.5).

CONCLUSION

The improved treatment success observed in the TMTC era compared to the pre-TMTC era is encouraging. The detailed TMTC components that contribute the most to the improved outcome will need confirmation in follow-up studies with large numbers of MDR-TB patients.

Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program

In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.

Pay for Performance in Health Care

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.

Effect of the Pay-for-Performance Program for Breast Cancer Care in Taiwan

PURPOSE

To evaluate the impact of the nationwide pay-for-performance (P4P) program for breast cancer care (BC-P4P) in Taiwan on care quality, patient survival, and recurrence.

STUDY DESIGN

A population-based observational study with cross-sectional design.

METHODS

Retrospective analysis of population-based cancer registration and claims data was used in this study. A total of 4,528 patients with stage I or II breast cancer diagnosed in 2002 or 2003 who received curative surgery were observed until the end of 2008. This study applied multivariate linear regression to explore the association between BC-P4P enrollment and quality of care. Cox regression was applied to examine the effect of BC-P4P enrollment on 5-year recurrence and overall survival among patients with breast cancer.

RESULTS

After controlling for age, stage, type of surgery, and other factors, BC-P4P enrollees were found to have received better quality care than nonenrollees (P = .001). Cox regression models also indicated that after controlling for patient characteristics, quality of care was related to better 5-year overall survival (odds ratio [OR], 0.212; P = .001) and recurrence (OR, 0.289; P < .001). Even when controlled by quality of care provided to patients and its interaction with status of BC-P4P enrollment, BC-P4P enrollment remained statistically significant regarding 5-year overall survival (OR, 0.167; P < .001) and recurrence (OR, 0.370; P = .002).

CONCLUSION

Patients with breast cancer enrolled in the BC-P4P program received better quality care and had better outcome than nonenrolled patients. Evidence from this study indicates that financial incentives in the payment design had a positive impact on outcome of breast cancer care.