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Tsai WC, Huang KH, Chen PC, Chang YC, Chen MS, Lee CB. Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system. Soc Sci Med 2023; 326:115930. [PMID: 37146356 DOI: 10.1016/j.socscimed.2023.115930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/14/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.
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Affiliation(s)
- Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Pei-Chun Chen
- International Master Program for Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, National Quemoy University, 1 University Rd., Jinning Township, Kinmen County, 892009, Kinmen, Taiwan; Department of Healthcare Administration, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, 41354, Taiwan
| | - Michael S Chen
- Department of Social Welfare, National Chung Cheng University, 168 Section 1, University Rd., Minhsiung, Chiayi, 621301, Taiwan
| | - Chiachi Bonnie Lee
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan.
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Liang LL, Huang N, Shen YJ, Chen AYA, Chou YJ. Do patients bypass primary care for common health problems under a free-access system? Experience of Taiwan. BMC Health Serv Res 2020; 20:1050. [PMID: 33208148 PMCID: PMC7677770 DOI: 10.1186/s12913-020-05908-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 11/09/2020] [Indexed: 11/10/2022] Open
Abstract
Background A common challenge for free-access systems is that people may bypass primary care and seek secondary care through self-referral. Taiwan’s government has undertaken various initiatives to mitigate bypass; however, little is known about whether the bypass trend has decreased over time. This study examined the extent to which patients bypass primary care for treatment of common diseases and factors associated with bypass under Taiwan’s free-access system. Methods This repeated cross-sectional study analyzed data from Taiwan’s National Health Insurance Research Database. A random sample of 1 million enrollees was drawn repeatedly from the insured population during 2000–2017. To capture visits beyond the community level, the bypass rate was defined as the proportion of self-referred visits to the top two levels of providers, namely academic medical centers and regional hospitals, among all visits to all providers. Subgroup analyses were conducted for visits with a single diagnosis. Logistic regressions were used to investigate factors associated with bypass. Results The standardized bypass rate for all diseases analyzed exhibited a decreasing trend. In 2017, it was low for common cold (0.7–1.3%), moderate for hypertension (14.0–29.5%), but still high for diabetes (32.0–47.0%). Moreover, the likelihood of bypass was higher for male, patients with higher salaries or comorbidities, and in areas with more physicians practicing in large hospitals or less physicians working in primary care facilities. Conclusions Although the bypass trend has decreased over time, continuing efforts may be required to reduce bypass associated with chronic diseases. Both patient sociodemographic and market characteristics were associated with the likelihood of bypass. These results may help policymakers to develop strategies to mitigate bypass. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-05908-w.
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Affiliation(s)
- Li-Lin Liang
- Department of Business Management, National Sun Yat-sen University, No. 70, Lienhai Rd, Kaohsiung, 804, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, No.155, Section 2, Li-Nong Street, Taipei, 112, Taiwan
| | - Yi-Jung Shen
- Institute of Hospital and Health Care Administration, National Yang-Ming University, No.155, Section 2, Li-Nong Street, Taipei, 112, Taiwan
| | - Annie Yu-An Chen
- RAND Corporation, 1766 Main Street, Santa Monica, CA, USA.,Pardee RAND Graduate School, 1766 Main Street, Santa Monica, CA, USA
| | - Yiing-Jenq Chou
- Institute of Public Health, National Yang-Ming University, No.155, Sec. 2, Li-Nong St., Beitou Dist, Taipei, 112, Taiwan.
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Kung FP, Tsai CF, Lu CL, Huang LC, Lu CH. Diabetes pay-for-performance program can reduce all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Medicine (Baltimore) 2020; 99:e19139. [PMID: 32049836 PMCID: PMC7035087 DOI: 10.1097/md.0000000000019139] [Citation(s) in RCA: 3] [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: 01/24/2023] Open
Abstract
This study aimed to examine the effect of a diabetes pay-for-performance (P4P) program on all-cause mortality in patients with newly diagnosed type 2 diabetes mellitus. Using a Taiwanese representative nationwide cohort, we recruited 5478 patients with newly diagnosed type 2 diabetes enrolled in the P4P program within 5 years after a diagnosis of diabetes between January 1, 2002 and December 31, 2010 and individuals not enrolled in the P4P program were recruited as the control group matched 1:1 with the study group. We used multivariate Cox proportional hazard models analysis to investigate the effect of the P4P program and adherence on all-cause mortality. A total of 250 patients died in the P4P group compared to 395 in the control group (mortality rate 104 vs 169 per 10,000 person-years, respectively, P < .0001). The control group also had more comorbidities. Patients enrolled in the P4P program demonstrated significant long-term survival benefits, of which the adjusted hazard ratio (aHR) for all-cause mortality was 0.58 [95% CI (0.48-0.69)]. In the study group, better adherence to the P4P program resulted in a greater reduction in mortality, with aHRs [95% CI] of 0.48 [0.38-0.62] and 0.36 [0.26-0.49] in subjects with a minimum 1-year and 2-year good P4P adherence, respectively. Participating in the P4P program within 5 years after the diagnosis of diabetes resulted in a significant reduction in all-cause mortality, and this effect was particularly pronounced in the patients with better adherence to the P4P program.
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Affiliation(s)
- Fang-Ping Kung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
| | - Ching-Fang Tsai
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chin-Li Lu
- Department of Medical Research, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung-Hsing University, Taichung
| | - Li-Chung Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Division of Psychiatry, Ditmanson Chia-Yi Christian Hospital, Chia-Yi City
| | - Chieh-Hsiang Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Ditmanson Chia-Yi Christian Hospital
- Kaohsiung Christian Hospital, Kaohsiung City, Taiwan
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Hu HY, Jian FX, Lai YJ, Yen YF, Huang N, Hwang SJ. Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study. BMJ Open 2019; 9:e031354. [PMID: 31519682 PMCID: PMC6747641 DOI: 10.1136/bmjopen-2019-031354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme. DESIGN Cross-sectional study. SETTING The National Health Insurance research database 2007-2012 in Taiwan. PARTICIPANTS Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results. PRIMARY OUTCOME MEASURE Enrolment in the pre-ESRD P4P programme. RESULTS In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time. CONCLUSION Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.
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Affiliation(s)
- Hsiao-Yun Hu
- Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
| | - Feng-Xuan Jian
- Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yun-Ju Lai
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Puli Branch of Taichung Veterans General Hospital, Nantou, Taiwan
| | - Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital, Taipei, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang-Ming University, Taipei, Taiwan
| | - Shang Jyh Hwang
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Value-based provider payment: towards a theoretically preferred design. HEALTH ECONOMICS POLICY AND LAW 2018; 15:94-112. [PMID: 30259825 DOI: 10.1017/s1744133118000397] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by 'value', however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at: (1) identifying value dimensions that are ideally stimulated by VBP and (2) constructing a framework of a theoretically preferred VBP design. Based on a synthesis of both theoretical and empirical studies on payment incentives, we conclude that VBP should consist of two components: a relatively large base payment that implicitly stimulates value and a relatively small payment that explicitly rewards measurable aspects of value (pay-for-performance). Being the largest component, the base payment design is essential, but often neglected when it comes to VBP reform. We explain that this base payment ideally (1) is paid to a multidisciplinary provider group (2) for a cohesive set of care activities for a predefined population, (3) is fixed, (4) is adjusted for the population's risk profile and (5) includes risk-mitigating measures. Finally, some important trade-offs in the practical operationalisation of VBP are discussed.
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