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Wu YF, Chen MY, Chen TH, Wang PC, Peng YS, Lin MS. The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study. BMC Health Serv Res 2021; 21:78. [PMID: 33478477 PMCID: PMC7818736 DOI: 10.1186/s12913-021-06091-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 01/14/2021] [Indexed: 01/14/2023] Open
Abstract
Background Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients. Methods This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths. Results After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients’ completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86–0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45–0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson’s Comorbidity Index scores and infection-related hospitalization in the previous 3 years. Conclusions The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06091-2.
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Affiliation(s)
- Yi-Fang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mei-Yen Chen
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan.,Department of Nursing, Chang Gung University, Taoyuan, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan.,Biostatistical Consultation Center of Chang Gung Memorial Hospital, Keelung, Taiwan Community Medicine Research Center of Chang Gung Memorial Hospital, Keelung, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Po-Chang Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yun-Shing Peng
- Department of Endocrinology and Metabolism, Department of internal medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ming-Shyan Lin
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan. .,Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Developing an Implementation Strategy for Systematic Measurement of Patient-Reported Outcomes at an Academic Health Center. J Healthc Manag 2020; 65:15-28. [PMID: 31913235 DOI: 10.1097/jhm-d-18-00279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
EXECUTIVE SUMMARY Patient-reported outcome measures (PROMs) are used in research and have the potential to improve clinical care. We sought to develop a strategy for integrating PROMs into routine clinical care at an academic health center. The implementation strategy consisted of three phases. The first, exploratory phase, focused on engaging leadership and conducting an inventory of current efforts to collect PROMs. The inventory revealed 87 patient-reported outcome efforts, 47 of which used validated PROMs (62% for research, 21% for clinical care, 17% for quality). In the second, preparatory phase, we identified three pilot implementation sites chosen with facilitators determined in the exploratory phase. Using data from local needs assessments at the pilot sites, we constructed a timeline for inclusion of PROM efforts across the clinical enterprise. In the third phase, we adapted a technology platform for capturing PROMs using the electronic health record and began implementing this platform at the pilot sites. We found that integrating PROMs into routine clinical practice is highly complex. This complexity necessitates change management at the enterprise level.
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Value Lies in the Eye of the Patients: The Why, What, and How of Patient-reported Outcomes Measures. Clin Ther 2020; 42:25-33. [DOI: 10.1016/j.clinthera.2019.11.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/23/2019] [Accepted: 11/27/2019] [Indexed: 12/22/2022]
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Sheu SJ, Lin WL, Kao Yang YH, Hwu CM, Cheng CL. Pay for performance program reduces treatment needed diabetic retinopathy - a nationwide matched cohort study in Taiwan. BMC Health Serv Res 2018; 18:638. [PMID: 30111370 PMCID: PMC6094472 DOI: 10.1186/s12913-018-3454-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 08/08/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Pay-for-Performance programs have shown improvement in indicators monitoring adequacy and target achievement in diabetic care. However, less is known regarding the impact of this program on the occurrence and long-term effects of diabetic retinopathy. The objective of this study was to determine the effect of pay-for-performance program on the development of treatment needed for diabetic retinopathy in type 2 diabetes patients. METHODS We conducted a nationwide retrospective cohort study with a matching design using the Taiwan National Health Insurance Research Database from 2000 to 2012. The outcome was defined as the treatment needed diabetic retinopathy. We matched Pay-for-Performance and non-Pay-for-Performance groups for age, gender, year diabetes was diagnosed and study enrollment, and duration of follow-up. RESULTS A total of 9311 patients entered the study cohort, of whom 2157 were registered in the Pay-for-Performance group and 7154 matched in the non-Pay-for-Performance group. The incidence of treatment needed diabetic retinopathy was not significantly different in two groups. However, the incidence of treatment needed diabetic retinopathy was significantly different if restricted the non-Pay-for-Performance group who had at least 1 eye examination or optical coherence tomography within 1 year (adjusted hazard ratio, 0.78; 95% confidence interval, 0.64-0.94). CONCLUSIONS Pay-for-Performance is valuable in preventing the development of treatment needed diabetic retinopathy, which could be attributed to the routine eye examination required in the Pay-for-Performance program. We could improve our diabetic care by promoting eye health education and patient awareness on the importance of regular examinations.
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Affiliation(s)
- Shwu-Jiuan Sheu
- Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,School of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Wen-Liang Lin
- Department of Pharmacy, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Min Hwu
- School of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.,Section of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Lan Cheng
- Department of Pharmacy, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan. .,School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Chen CH, Ma SH, Hu SY, Chang CM, Chiang JH, Hsieh VCR, Yen DHT, How CK, Hsieh MS. Diabetes Shared Care Program (DSCP) and risk of infection mortality: a nationwide cohort study using administrative claims data in Taiwan. BMJ Open 2018; 8:e021382. [PMID: 30002011 PMCID: PMC6082473 DOI: 10.1136/bmjopen-2017-021382] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The Diabetes Shared Care Program (DSCP) is an integrated care model in Taiwan that has been proven to improve the care quality of patients with diabetes. We aimed to evaluate the efficacy of DSCP in decreasing the hospital mortality of infectious diseases. METHODS From 1 662 929 patients with type 2 diabetes newly diagnosed between 1999 and 2013, we retrieved a total of 919 patients who participated in the DSCP with the first hospitalisation for an infectious disease as the study cohort and 9190 propensity score-matched patients with type 2 diabetes who did not participate as the comparison.The efficacy of DSCP was evaluated via the following comparisons between the DSCP and non-DSCP cohorts: hospital mortality, 1-year medical cost prior to and during the hospitalisation, and complications, such as receiving mechanical ventilation and intensive care unit admission. The ratio (OR) for hospital mortality of the DSCP participants was calculated by logistical regression. Further stratification analyses were conducted to examine which group of patients with type 2 diabetes benefited the most from the DSCP during hospitalisation for infectious diseases. RESULTS The DSCP cohort had a lower hospital mortality rate than the non-DSCP participants (2.18% vs 4.82%, p<0.001). The total medical cost during the hospitalisation was lower in the DSCP cohort than in the non-DSCP cohort (NT$72 454±30 429 vs NT$86 385±29 350) (p=0.006). In the logistical regression model, the DSCP participants exhibited a significantly decreased adjusted OR for hospital mortality (adjusted OR=0.42, 95% CI 0.26 to 0.66, p=0.0002). The efficacy of the DSCP was much more prominent in male patients with type 2 diabetes and in patients with lower incomes. CONCLUSION Participation in the DSCP was associated with a lower risk of hospital mortality for infectious diseases.
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Affiliation(s)
- Cheng-Han Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Sheng-Hsiang Ma
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- YongLin Healthcare Foundation, Taipei, Taiwan
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine and Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Chia-Ming Chang
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Jen-Huai Chiang
- Management Office for Health Data, China Medical University, Taichung, Taiwan
| | - Vivian Chia-Rong Hsieh
- Department of Health Services Administration, China Medical University, Taichung, Taiwan
| | - David Hung-Tsang Yen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chorng-Kuang How
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan
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Abstract
BACKGROUND Taiwan's National Health Insurance program implemented a pay-for-performance (P4P) program based on process measures in 2001. In late 2006, the P4P was revised to also include achievement of outcome measures. OBJECTIVES This study examined whether a change in P4P incentive design structure affected diabetes outcomes. RESEARCH DESIGN AND METHOD We used a longitudinal cohort study design using 2 population-based databases. Newly enrolled P4P patients with diabetes in 2002-2003 (phase 1) and 2007-2008 (phase 2) made up the study cohorts. Propensity score matching was used to match comparable cohorts in each phase. In total, 46,286 matched cohorts in phase 1 and 2 were analyzed. Process measures were defined as the provision of tests of glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and blood pressure, and outcome measures as changes in those values between baseline and last follow-up within 3 years. Patient-level generalized linear regression models were used and patient characteristics, physician characteristics, and health care facility characteristics were adjusted for. RESULTS Our results indicated that the process measures of HbA1c and low-density lipoprotein cholesterol tests did not differ significantly between the 2 phases. In addition, better improvements were noted in outcome measures for the phase 2 patients (ie, HbA1c level and lipid profiles), whereas nonincentivized intermediate measures (eg, blood pressure) showed no negative unintended consequences. CONCLUSIONS Quality of care tended to be better when both process and targeted outcome measures were combined as quality metrics in the P4P program in Taiwan.
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Abstract
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.
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Affiliation(s)
- Anthony Scott
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Miao Liu
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Jongsay Yong
- The University of Melbourne, Melbourne, Victoria, Australia
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Chi MJ, Chou KR, Pei D, Hwang JS, Quinn L, Chung MH, Liao YM. Effects and Factors Related to Adherence to A Diabetes Pay-for-Performance Program: Analyses of a National Health Insurance Claims Database. J Am Med Dir Assoc 2016; 17:613-9. [DOI: 10.1016/j.jamda.2016.02.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 01/02/2023]
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Hsieh HM, Lin TH, Lee IC, Huang CJ, Shin SJ, Chiu HC. The association between participation in a pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: A nationwide population-based cohort study. Prev Med 2016; 85:53-59. [PMID: 26740347 DOI: 10.1016/j.ypmed.2015.12.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Diabetes and diabetes-related complications are major causes of morbidity and mortality worldwide and contribute substantially to health care costs. Proper care can prevent or delay vascular complications in people with type 2 diabetes. We sought to examine whether a diabetes pay-for-performance (P4P) program under Taiwan's National Health Insurance program decreased risk of macrovascular complications in type 2 diabetes patients, and associated risk factors. RESEARCH DESIGN AND METHOD We conducted a longitudinal observational case and control cohort study using two nationwide population-based databases in Taiwan, 2007-2012. Type 2 diabetes patients with a primary diabetes diagnosis in year 2007 and 2008 were included. We excluded patients with any diabetes complications within 2years before the index date. A propensity score matching approach was used to determine comparable P4P and non-P4P groups. We followed each P4P and non-P4P patient until December 31, 2012. Complication incidence rates per 1000 person-years for each complication were calculated. RESULTS Overall, our results indicated that P4P patients had lower risk of macrovascular complications than non-P4P patients. Specifically, hazard ratios (95% confidence intervals) were 0.84 (0.80-0.88) for stroke, 0.83 (0.75-0.92) for myocardial infarction, 0.72 (0.60-0.85) for atrial fibrillation, 0.93 (0.87-0.98) for heart failure, 0.61 (0.50-0.73) for gangrene, and 0.83 (0.74-0.93) for ulcer of lower limbs. CONCLUSIONS Compared with patients not enrolled in the P4P program, P4P patients had lower risk of developing serious vascular complications. Our empirical findings provide evidence for the potential long-term benefit of P4P programs in reducing risks of macrovascular complications.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Tsung-Hsien Lin
- Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan.
| | - I-Chen Lee
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Shyi-Jang Shin
- Graduate Institute of Medical Genetics, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan; Research Education and Epidemiology Center, Changhua, Taiwan.
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Chiu HC, Hsieh HM, Lin YC, Kuo SJ, Kao HY, Yeh SCJ, Chang WH, Hsiao PJ, Chen YS, Lin SL, Lo GH, Ker CG, Hung YH, Cheng HA, Chou TH, Chou SY, Wang JH, Wang CF. Patient assessment of diabetes care in a pay-for-performance program. Int J Qual Health Care 2016; 28:183-90. [PMID: 26819445 DOI: 10.1093/intqhc/mzv120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Affiliation(s)
- Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan Research Education and Epidemiology Center, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 500-06, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Yi-Chieh Lin
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Shou-Jen Kuo
- Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 500-06, Taiwan
| | - Hao-Yun Kao
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Shu-Chuan Jennifer Yeh
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan Department of Business Management, College of Management, National Sun Yat-sen University, 70 Lian Hai Road, Kaohsiung, 80424 Taiwan
| | - Wen-Hsin Chang
- MacKay Memorial Hospital, No. 92, Section 2, Zhongshan North Road, Zhongshan District, Taipei City 104, Taiwan
| | - Pi-Jung Hsiao
- College of Medicine, Kaohsiung Medical University, Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Yao-Shen Chen
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying District, Kaohsiung City 813, Taiwan
| | - Shoei-Loong Lin
- President Superintendent, Choninn Healthcare System, No. 196, Sec. 1, Wenhua Rd., BanqiaoDist. New Taipei City 22041, Taiwan
| | - Gin-Ho Lo
- E-DA Hospital; School of Medicine for International Students, I-Shou University 1 ,Yi-Da Road, Yanchao district, Kaohsiung, 82445 Taiwan
| | - Chen-Guo Ker
- Department of Surgery, Yuan's General Hospital, 162, Chen-Kong 1st Road, Kaohsiung 80249, Taiwan
| | - Yu-Han Hung
- Yuan's General Hospital, No. 162, Cheng gong 1st Road, Ling ya District, Kaohsiung City 80249, Taiwan
| | - Hsien-An Cheng
- Department of Neurology, Yuan's General Hospital, 162, Chen-Kun 1st Road, Kaohsiung 80249, Taiwan
| | - Tiang-Hong Chou
- Mennonite Christian Hospital, 44, Min-Chuan Road, Hualien 970, Taiwan
| | - Sze-Yuan Chou
- Cheng Ching General Hospital, 139 Ping Tien Street, Taichung, Taiwan
| | - Jao-Hsien Wang
- Department of Education and Research, Jiannren Hospital, 136 Nanyang Road, Kaohsiung 811, Taiwan
| | - Chien-Fu Wang
- Division of Physical Therapy, Taitung Christian Hospital, 350 Kai-Feng Street, Taitung City, Taitung County 950, Taiwan
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Hsieh HM, Tsai SL, Mau LW, Chiu HC. Effects of Changes in Diabetes Pay-for-Performance Incentive Designs on Patient Risk Selection. Health Serv Res 2015; 51:667-86. [PMID: 26152649 DOI: 10.1111/1475-6773.12338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Taiwan's National Health Insurance (NHI) Program implemented a Diabetes Pay-for-Performance Program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was reformed to also include achievement of intermediate health outcomes. This study examined how the change in design affected patient risk selection. DESIGNS/STUDY POPULATIONS Study populations were identified from a 2002 to 2003 period (Phase 1) and a 2007 to 2008 period (Phase 2), spanning pre- and postimplementation of reforms in the P4P incentive design. Phase 1 had 74,529 newly enrolled P4P patients and 215,572 non-P4P patients, and Phase 2 had 76,901 newly enrolled P4P patients and 299,573 non-P4P patients. Logistic regression models were used to estimate the effect of changes in design on P4P patient selection. PRINCIPAL FINDINGS Patients with greater disease severity and comorbidity were more likely to be excluded from the P4P program in both phases. Furthermore, the additional financial incentive for patients' intermediate outcomes moderately worsened patient risk selection. CONCLUSIONS Policy makers need to carefully monitor the care of the diabetes patients with more severe and complex disease statuses after the changes of P4P financial incentive design.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Ling Tsai
- National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan
| | - Lih-Wen Mau
- Patient & Health Professional Services, National Marrow Donor Organization, Edina, MN
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
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Basch E, Spertus J, Dudley RA, Wu A, Chuahan C, Cohen P, Smith ML, Black N, Crawford A, Christensen K, Blake K, Goertz C. Methods for Developing Patient-Reported Outcome-Based Performance Measures (PRO-PMs). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:493-504. [PMID: 26091604 DOI: 10.1016/j.jval.2015.02.018] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 02/03/2015] [Accepted: 02/15/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To recommend methods for assessing quality of care via patient-reported outcome-based performance measures (PRO-PMs) of symptoms, functional status, and quality of life. METHODS A Technical Expert Panel was assembled by the American Medical Association-convened Physician Consortium for Performance Improvement. An environmental scan and structured literature review were conducted to identify quality programs that integrate PRO-PMs. Key methodological considerations in the design, implementation, and analysis of these PRO-PM data were systematically identified. Recommended methods for addressing each identified consideration were developed on the basis of published patient-reported outcome (PRO) standards and refined through public comment. Literature review focused on programs using PROs to assess performance and on PRO guidance documents. RESULTS Thirteen PRO programs and 10 guidance documents were identified. Nine best practices were developed, including the following: provide a rationale for measuring the outcome and for using a PRO-PM; describe the context of use; select a measure that is meaningful to patients with adequate psychometric properties; provide evidence of the measure's sensitivity to differences in care; address missing data and risk adjustment; and provide a framework for implementation, interpretation, dissemination, and continuous refinement. CONCLUSION Methods for integrating PROs into performance measurement are available.
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Affiliation(s)
- Ethan Basch
- University of North Carolina, Chapel Hill, NC, USA.
| | | | - R Adams Dudley
- University of California, San Francisco, San Francisco, CA, USA
| | - Albert Wu
- Johns Hopkins School of Public Health, Baltimore, MD, USA
| | | | - Perry Cohen
- Parkinson Pipeline Project, Washington, DC (Patient Representative), USA
| | - Mary Lou Smith
- Research Advocacy Network, Plano, TX (Patient Representative), USA
| | - Nick Black
- London School of Hygiene and Tropical Medicine, London, England
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Abstract
BACKGROUND Taiwan's National Health Insurance (NHI) Program implemented a diabetes pay-for-performance program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was revised to also include achievement of intermediate health outcomes. OBJECTIVES This study examined to what extent these 2 P4P incentive designs have been cost-effective and what the difference in effect may have been. RESEARCH DESIGN AND METHOD Analyzing data using 3 population-based longitudinal databases (NHI's P4P dataset, NHI's claims database, and Taiwan's death registry), we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in each phase. Propensity score matching was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings, and incremental cost-effectiveness ratios. RESULTS QALYs for P4P patients and non-P4P patients were 2.08 and 1.99 in phase 1 and 2.08 and 2.02 in phase 2. The average incremental intervention costs per QALYs was TWD$335,546 in phase 1 and TWD$298,606 in phase 2. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD$602,167 in phase 1 and TWD$661,163 in phase 2. The findings indicated that both P4P programs were cost-effective and the resulting return on investment was 1.8:1 in phase 1 and 2.0:1 in phase 2. CONCLUSIONS We conclude that the diabetes P4P program in both phases enabled the long-term cost-effective use of resources and cost-savings regardless of whether a bonus for intermediate outcome improvement was added to a process-based P4P incentive design.
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Hsu JC, Lu CY. The evolution of Taiwan's National Health Insurance drug reimbursement scheme. ACTA ACUST UNITED AC 2015; 23:15. [PMID: 25889754 PMCID: PMC4333892 DOI: 10.1186/s40199-014-0080-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 11/27/2014] [Indexed: 11/10/2022]
Abstract
BACKGROUND The rapid growth of health care expenditures, especially pharmaceutical spending, is a challenge for many countries. To control increasing pharmaceutical expenditures and to enhance rational use of drugs, Taiwan's National Health Insurance drug reimbursement system has evolved over time since its introduction in 1995. This study reviewed Taiwan's drug reimbursement scheme: its development and evolution in the last two decades, and implications and impacts of recent policies for drug pricing. We also provide recommendations for possible improvement. METHODS We conducted a review of Taiwan's National Health Insurance drug reimbursement scheme. We focused on three major components of the scheme: (i) the scope of drug coverage; (ii) pricing system for pharmaceuticals under the scheme; and (iii) adjustment of drug reimbursement prices. We reviewed the literature and public policy documents. RESULTS The National Health Insurance delisted 176 and another 240 behind-the-counter products (e.g., antacids, vitamins) between 2005 and 2006 to reduce pharmaceutical expenditures. For the pricing of pharmaceuticals, policy evolution can be divided into four phases since 1995; the present system emphasizes stakeholder engagement, health technology assessment, domestic R&D, and improving quality of products. To close the gap between drug reimbursement prices and procurement prices, eight rounds of drug price surveys and adjustments have been implemented since 2000. CONCLUSIONS Taiwan's National Health Insurance drug reimbursement scheme has evolved substantially over time to provide more equitable and affordable access to prescription medicines. However, more work is still needed as irrational difference in reimbursement and procurement prices persists and the total expenditure of the drug reimbursement scheme continues to increase at unsustainable rates.
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Affiliation(s)
- Jason C Hsu
- School of Pharmacy and Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No.1, Daxue Rd., East Dist., Tainan City, 70101, Taiwan R.O.C.
| | - Christine Y Lu
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
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15
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Farley H, Enguidanos ER, Coletti CM, Honigman L, Mazzeo A, Pinson TB, Reed K, Wiler JL. Patient satisfaction surveys and quality of care: an information paper. Ann Emerg Med 2014; 64:351-7. [PMID: 24656761 DOI: 10.1016/j.annemergmed.2014.02.021] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 01/31/2014] [Accepted: 02/21/2014] [Indexed: 11/17/2022]
Abstract
With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.
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Affiliation(s)
- Heather Farley
- Department of Emergency Medicine, Christiana Care Health System, Newark, DE.
| | - Enrique R Enguidanos
- Department of Emergency Medicine, Providence Regional Medical Center, Everett, WA
| | | | - Leah Honigman
- Department of Emergency Medicine, the George Washington University Hospital, Washington, DC
| | - Anthony Mazzeo
- Department of Emergency Medicine, Mercy Fitzgerald Hospital, Darby, PA
| | - Thomas B Pinson
- Department of Emergency Medicine, Mayes County Medical Center, Pryor, OK
| | - Kevin Reed
- Department of Emergency Medicine, MedStar Harbor Hospital, Baltimore, MD
| | - Jennifer L Wiler
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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16
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Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan? Qual Life Res 2013; 23:687-96. [PMID: 23975377 DOI: 10.1007/s11136-013-0502-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective. METHODS A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios. RESULTS Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained. CONCLUSIONS Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.
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Abstract
Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.
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Affiliation(s)
- Tim Doran
- Institute of Population Health, University of Manchester, Williamson Building Oxford Road, Manchester, M13 9PL, UK.
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Jiang YD, Chang CH, Tai TY, Chen JF, Chuang LM. Incidence and prevalence rates of diabetes mellitus in Taiwan: analysis of the 2000-2009 Nationwide Health Insurance database. J Formos Med Assoc 2012; 111:599-604. [PMID: 23217595 DOI: 10.1016/j.jfma.2012.09.014] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Revised: 09/04/2012] [Accepted: 09/06/2012] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND/PURPOSE Formerly, Taiwan's diabetic population has been estimated by surveys conducted at irregular intervals and using different sampling methods. To obtain nationwide data on the incidence and prevalence of diabetes mellitus (DM) in Taiwan, we performed an analysis of the 2000-2009 claim data from the National Health Insurance (NHI) database. METHODS One-third of the claims in the NHI database from 2000 to 2009 were randomly sampled. DM was defined by three or more outpatient visits with diagnostic codes (ICD-9-CM: 250 or A code: A181) within 1 year or by one inpatient discharge diagnosis of DM. Confirmation of type 1 diabetes mellitus was based on the issue of a catastrophic illness certificate with the same diagnostic codes. Age and/or gender distribution for DM were determined. RESULTS In accordance with the global trend for DM, with a near constant standardized incidence rate, there was a more than 70% increase in the total diabetic population, or a 35% increase in the standardized prevalence rate, in Taiwan from 2000 to 2009. The incidence of diabetes was higher in men, especially in the 20-59-year-old age group, and the total number of men with diabetes exceeded the number of women with diabetes in 2005. However, the prevalence and incidence rates in women over the age of 60 years were higher than those in men. Type 1 DM was present in less than 1% of the diabetic population in Taiwan. CONCLUSION The incidence of diabetes, including type 1, remained stable over this 10-year period in Taiwan. However, the incidence rate in men aged 20-59 years was higher than that in age-matched women. With our nationwide database, subgroup analysis of DM incidence can be performed to refine our health policies for the prevention, screening, and treatment of diabetes mellitus.
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Affiliation(s)
- Yi-Der Jiang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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