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Kang KT, Chang RE, Lin MT, Chen YC. Pay-for-performance in Taiwan: A systematic review and meta-analysis of the empirical literature. Public Health 2024; 236:328-337. [PMID: 39299087 DOI: 10.1016/j.puhe.2024.09.005] [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: 01/29/2024] [Revised: 06/27/2024] [Accepted: 09/04/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVES This study aimed to assess the impact of pay-for-performance (P4P) programmes on healthcare in Taiwan. STUDY DESIGN This was a systematic review and meta-analysis. METHODS A systematic literature search was performed using the PubMed, Medline, Embase, Cochrane review, Scopus, Web of Science and PsycINFO databases up to July 2023. Meta-analysis of the available outcomes was conducted using a random-effects model. RESULTS The search yielded 85 studies, of which 58 investigated the programme for diabetes mellitus (DM), eight looked at the programme for chronic kidney disease (CKD), and the remaining studies examined programmes for breast cancer, tuberculosis, schizophrenia and chronic obstructive pulmonary disease. The DM P4P programme was a cost-effective strategy associated with reduced hospitalisation and subsequent complications. The CKD P4P was associated with a lower risk of dialysis initiation. The P4P programme also improved outcomes in breast cancer, cure rates in tuberculosis, reduced admissions for schizophrenia and reduced acute exacerbation in chronic obstructive pulmonary disease. The meta-analysis revealed that the P4P programme for DM (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.48-0.73) and CKD (OR = 0.73; 95% CI = 0.67-0.81) significantly reduced mortality risk. However, participation rate in the DM P4P programme was only 19% in 2014. CONCLUSIONS P4P programmes in Taiwan improve quality of care. However, participation was voluntary and the participation rate was very low, raising the concern of selective enrolment of participants (i.e. 'cherry-picking' behaviour) by physicians. Future programme reforms should focus on well-designed features with the aim of reducing healthcare disparities.
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Affiliation(s)
- Kun-Tai Kang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan; Department of Otolaryngology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan; Department of Otolaryngology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ray-E Chang
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taiwan; Department of Information Systems and Operations Management, College of Business Administration, University of Texas at, Arlington, USA.
| | - Ming-Tzer Lin
- Department of Internal Medicine, Hsiao Chung-Cheng Hospital, New Taipei City, Taiwan; Sleep Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yin-Cheng Chen
- Division of Nephrology, Department of Internal Medicine, Changhua Hospital, Ministry of Health and Welfare, Changhua, Taiwan
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Bayoumi I, Whitehead M, Li W, Kurdyak P, Glazier RH. Association of physician financial incentives with primary care enrolment of adults with serious mental illnesses in Ontario: a retrospective observational population-based study. CMAJ Open 2023; 11:E1-E12. [PMID: 36627127 PMCID: PMC9842098 DOI: 10.9778/cmajo.20210190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Financial incentives may improve primary care access for adults with schizophrenia or bipolar disorder (serious mental illness [SMI]). We studied the association between receipt of the SMI financial premium paid to primary care physicians and rostering of adults with SMI in different patient enrolment models (PEMs), including enhanced fee-for-service and capitation-based models with and without interdisciplinary team-based care. METHODS We conducted a retrospective cohort study involving Ontario adults (≥18 yr) with SMI in PEM practices, in fiscal years 2016/17 and 2017/18. Using negative binomial models, we examined relations between rostering and the primary care model and the contribution of the incentive. Similar models were developed for adults with type 1 or 2 diabetes mellitus and the general population. RESULTS Among 9730 physicians in PEM practices, 4866 (50.0%) received a premium and 448 319 (88.4%) people with SMI in PEMs were rostered. Compared with enhanced fee for service, the likelihood of rostering people with SMI was 3.0% higher for patients in capitation with team-based care (adjusted relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04), with similar results for capitation without team-based care (adjusted RR 1.00 95% CI 0.99-1.01). Rostering for people with diabetes was similar in team-based care (adjusted RR 1.02, 95% CI 1.02-1.03) but higher in capitation without team-based care (adjusted RR 1.03, 95% CI 1.02-1.03) and slightly higher for the Ontario population (team-based care 1.04, 95% CI 1.04-1.05, capitation without team-based care 1.03, 95% CI 1.03-1.04). INTERPRETATION Rostering of people with SMI was lower than for the general population. Additional policy measures are needed to address persisting inequities and to promote rostering of this underserved population with complex needs.
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Affiliation(s)
- Imaan Bayoumi
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont.
| | - Marlo Whitehead
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Wenbin Li
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Paul Kurdyak
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Richard H Glazier
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
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3
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Borghi J, Binyaruka P, Mayumana I, Lange S, Somville V, Maestad O. Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania. BMJ Glob Health 2021; 6:e006409. [PMID: 34916272 PMCID: PMC8679076 DOI: 10.1136/bmjgh-2021-006409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 10/24/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes. METHODS We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change. RESULTS Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding. CONCLUSION Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.
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Affiliation(s)
- Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Binyaruka
- Ifakara Health Institute, Dar es Salaam, Tanzania, United Republic of
- Chr Michelsen Institute, Bergen, Norway
| | - Iddy Mayumana
- Ifakara Health Institute, Ifakara, Morogoro, Tanzania, United Republic of
| | - Siri Lange
- Chr Michelsen Institute, Bergen, Norway
- Department of Health Promotion and Development, University of Bergen, Bergen, Hordaland, Norway
| | - Vincent Somville
- Chr Michelsen Institute, Bergen, Norway
- NHH Norwegian School of Economics, Bergen, Norway
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Lian WC, Livneh H, Huang HJ, Lu MC, Guo HR, Tsai TY. Adding Pay-for-Performance Program to Routine Care Was Related to a Lower Risk of Depression Among Type 2 Diabetes Patients in Taiwan. Front Public Health 2021; 9:650452. [PMID: 34722429 PMCID: PMC8548469 DOI: 10.3389/fpubh.2021.650452] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Patients with type 2 diabetes (T2DM) often experience depression during treatment, negatively influencing their treatment compliance and clinical outcomes. Recently, the pay-for-performance (P4P) program for chronic diseases, with high-cost and high-risk feature, such as T2DM, has been implemented and has been operational for several years. Nevertheless, its effect on the risk of developing depression among T2DM cases is unknown. This study aims to explore the association of P4P use with the subsequent risk of developing depression among these patients. Methods: This cohort study used a nationwide health insurance database to identify patients 20-70 years of age newly diagnosed with T2DM who enrolled in the P4P program between 2001 and 2010. From this group, we enrolled 17,022 P4P users and then 17,022 non-P4P users who were randomly selected using propensity-score-matching. Enrolled patients were followed until the end of 2012 to record the occurrence of depression. The Cox proportional hazards regression was utilized to obtain the adjusted hazard ratio (aHR) for P4P use. Results: During the study period, a total of 588 P4P users and 1,075 non-P4P users developed depression at incidence rates of 5.89 and 8.41 per 1,000 person-years, respectively. P4P users had a lower depression risk than did non-P4P users (aHR, 0.73; 95% Confidence Interval, 0.65-0.80). This positive effect was particularly prominent in those receiving high-intensity use of the P4P program. Conclusion: Integrating P4P into routine care for patients with T2DM may have beneficial effects on curtailing the subsequent risk of depression.
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Affiliation(s)
- Wei-Cheng Lian
- Division of Metabolism and Endocrinology, Department of Internal Medicine, Dalin Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Hanoch Livneh
- Rehabilitation Counseling Program, Portland State University, Portland, OR, United States
| | - Hui-Ju Huang
- Department of Nursing, Dalin Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Chiayi, Taiwan
| | - Ming-Chi Lu
- School of Medicine, Tzu Chi University, Hualien, Taiwan.,Division of Allergy, Immunology and Rheumatology, Dalin Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Chiayi, Taiwan
| | - How-Ran Guo
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Occupational and Environmental Medicine, National Cheng Kung University Hospital, Tainan, Taiwan.,Occupational Safety, Health, and Medicine Research Center, National Cheng Kung University, Tainan, Taiwan
| | - Tzung-Yi Tsai
- Department of Environmental and Occupational Health, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Medical Research, Dalin Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, Chiayi, Taiwan.,Department of Nursing, Tzu Chi University of Science and Technology, Hualien, Taiwan
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Cheng SL, Li YR, Huang N, Yu CJ, Wang HC, Lin MC, Chiu KC, Hsu WH, Chen CZ, Sheu CC, Perng DW, Lin SH, Yang TM, Lin CB, Kor CT, Lin CH. Effectiveness of Nationwide COPD Pay-for-Performance Program on COPD Exacerbations in Taiwan. Int J Chron Obstruct Pulmon Dis 2021; 16:2869-2881. [PMID: 34703221 PMCID: PMC8539057 DOI: 10.2147/copd.s329454] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/05/2021] [Indexed: 12/17/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. It has also imposed a substantial economic and social burden on the health care system. In Taiwan, a nationwide COPD pay-for-performance (P4P) program was designed to improve the quality of COPD-related care by introducing financial incentives for health care providers and employing a multidisciplinary team to deliver guideline-based, integrated care for patients with COPD, reducing adverse outcomes, especially COPD exacerbation. However, the results of a survey of the effectiveness of the pay-for-performance program in COPD management were inconclusive. To address this knowledge gap, this study evaluated the effectiveness of the COPD P4P program in Taiwan. Methods This retrospective cohort study used data from Taiwan’s National Health Insurance claims database and nationwide COPD P4P enrollment program records from June 2016 to December 2018. Patients with COPD were classified into P4P and non-P4P groups. Patients in the P4P group were matched at a ratio of 1:1 based on age, gender, region, accreditation level, Charlson Comorbidity Index (CCI), and inhaled medication prescription type to create the non-P4P group. A difference-in-difference analysis was used to evaluate the influence of the P4P program on the likelihood of COPD exacerbation, namely COPD-related emergency department (ED) visit, intensive care unit (ICU) admission, or hospitalization. Results The final sample of 14,288 patients comprised 7144 in each of the P4P and non-P4P groups. The prevalence of COPD-related ED visits, ICU admissions, and hospitalizations was higher in the P4P group than in the non-P4P group 1 year before enrollment. After enrollment, the P4P group exhibited a greater decrease in the prevalence of COPD-related ED visits and hospitalizations than the non-P4P group (ED visit: −2.98%, p<0.05, 95% confidence interval [CI]: −0.277 to −0.086; hospitalization: −1.62%, p<0.05, 95% CI: −0.232 to −0.020), whereas no significant difference was observed between the groups in terms of the changes in the prevalence of COPD-related ICU admissions. Conclusion The COPD P4P program exerted a positive net effect on reducing the likelihood of COPD exacerbation, namely COPD-related ED visits and hospitalizations. Future studies should examine the long-term cost-effectiveness of the COPD P4P program.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, 220, Taiwan.,Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli, Taoyuan, 320, Taiwan
| | - Yi-Rong Li
- Changhua Christian Hospital, Thoracic Medicine Research Center, Changhua, 500, Taiwan
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, 112, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Hao-Chien Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, 100, Taiwan
| | - Meng-Chih Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, 833, Taiwan
| | - Kuo-Chin Chiu
- Division of Chest, Department of Internal Medicine, Poh-Ai Hospital, Luodong, 265, Taiwan
| | - Wu-Huei Hsu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, 404, Taiwan
| | - Chiung-Zuei Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, National Cheng Kung University, College of Medicine and Hospital, Tainan, 701, Taiwan
| | - Chau-Chyun Sheu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, 807, Taiwan.,Department of Internal Medicine, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, 112, Taiwan
| | - Sheng-Hao Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Tsung-Ming Yang
- Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi Branch, 613, Taiwan
| | - Chih-Bin Lin
- Department of Internal Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Hualien, 970, Taiwan
| | - Chew-Teng Kor
- Big Data Center, Changhua Christian Hospital, Changhua, Changhua Christian Hospital, Changhua, 500, Taiwan
| | - Ching-Hsiung Lin
- Department of Internal Medicine, Division of Chest Medicine, Changhua Christian Hospital, Changhua, 500, Taiwan.,Institute of Genomics and Bioinformatics, National Chung Hsing University, Taichung, 402, Taiwan.,Department of Recreation and Holistic Wellness, MingDao University, Changhua, 523, Taiwan
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Chen TT, Oldenburg B, Hsueh YS. Chronic care model in the diabetes pay-for-performance program in Taiwan: Benefits, challenges and future directions. World J Diabetes 2021; 12:578-589. [PMID: 33995846 PMCID: PMC8107979 DOI: 10.4239/wjd.v12.i5.578] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/08/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
In this review, we discuss the chronic care model (CCM) in relation to the diabetes pay-for-performance (P4P) program in Taiwan. We first introduce the 6 components of the CCM and provide a detailed description of each of the activities in the P4P program implemented in Taiwan, mapping them onto the 6 components of the CCM. For each CCM component, the following three topics are described: the definition of the CCM component, the general activities implemented related to this component, and practical and empirical practices based on hospital or local government cases. We then conclude by describing the possible successful features of this P4P program and its challenges and future directions. We conclude that the successful characteristics of this P4P program in Taiwan include its focus on extrinsic and intrinsic incentives (i.e., shared care network), physician-led P4P and the implementation of activities based on the CCM components. However, due to the low rate of P4P program coverage, approximately 50% of patients with diabetes cannot enjoy the benefits of CCM-related activities or receive necessary examinations. In addition, most of these CCM-related activities are not allotted an adequate amount of incentives, and these activities are mainly implemented in hospitals, which compared with primary care providers, are unable to execute these activities flexibly. All of these issues, as well as insufficient implementation of the e-CCM model, could hinder the advanced improvement of diabetes care in Taiwan.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei 24205, Taiwan
| | - Brian Oldenburg
- Noncommunicable Disease Control Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
| | - Ya-Seng Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
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Chen TT, Yang JJ, Hsueh YSA, Wang V. The effects of a schizophrenia pay-for-performance program on patient outcomes in Taiwan. Health Serv Res 2019; 54:1119-1125. [PMID: 31131891 DOI: 10.1111/1475-6773.13174] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To examine the effects of a schizophrenia pay-for-performance (P4P) program on the health outcomes of patients in Taiwan. DATA SOURCES Seven years (2007-2013) of data from the National Health Insurance Administration (NHIA) databases were examined. STUDY DESIGN P4P patients included those who were treated at participating facilities and consecutively included in the regular group (classified by the NHIA). Non-P4P patients were treated at nonparticipating facilities and never included in the regular group. The caliper matching method and a generalized estimating equation were used to estimate difference-in-differences models (baseline year 2009) and examine the short- and long-term effects of the P4P program on adverse outcomes. PRINCIPAL FINDINGS The schizophrenia P4P program was associated with decreases in unscheduled outpatient visits (OR: 0.69, P < 0.001) and compulsory admissions (incidence rate ratio: 0.33, P < 0.05). However, this program was not associated with decreases in other outcomes including emergency department visits for any disease, admissions to an acute psychiatric ward, and readmission within 6 months. CONCLUSIONS Although the disease management component of the P4P program can be beneficial for compulsory admissions, more sophisticated activities, such as health promotion targeting disadvantaged patients, could be implemented to reduce the occurrence of complicated adverse outcomes.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, R.O.C
| | - Jing-Jung Yang
- Department of Psychiatry, Cardinal Tien Hospital, New Taipei City, Taiwan, R.O.C.,School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, R.O.C
| | - Ya-Seng Arthur Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Victoria, Australia
| | - Vinchi Wang
- School of Medicine, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, R.O.C.,Department of Neurology, Neurological Center, Cardinal Tien Hospital, New Taipei City, Taiwan, R.O.C
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