Raymond NC Kuo, PhD Candidate; Mei-Shu Lai, PhD; Kuo-Piao Chung, PhD

1. The influence of Breast Cancer Pay for Performance Initiatives on breast cancer survival and performance measures:a pilot study in Taiwan Raymond NC Kuo, PhD Candidate;Mei-Shu Lai, PhD;Kuo-Piao Chung, PhD Institute of Health Care Organization Administration, College of Public Health, National Taiwan University

2. Presenter Disclosures Raymond NC Kuo “No relationships to disclose” (1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:

3. Background

4. National health insurance in Taiwan • National Health Insurance program was established in 1995 • Fee-for-service and case payment under the global budget payment scheme • No gate-keeper system for outpatient visits • Patients are free to choose care providers for every visit • High satisfaction rate (over 75% satisfied) • High service volumes in outpatient department in most hospitals • Closed-staff system for hospitals

5. Comprehensive benefit package • Inpatient care • Outpatient care • Laboratory tests (combined within In/Outpatient care) • Prescription drugs and certain OTC drugs • Dental services • Traditional Chinese medicine • Day care for the mentally illness • Home care

6. P4P for Breast cancer care • Started in 2001 • Hospitals with more than 100 incident cases annually are eligible to participate in • Hospitals are ‘voluntary’ to join-in • P4p cases are reimbursed on a case-basis (higher financial incentive than FFS cases) • Hospitals which achieved goals on stage-specific survival rate could earn extra bonus • No penalty for low performance

7. Stage-specific survival rate for annual bonus

8. Objective • Difference of performance between care for P4P Initiatives enrollees or none enrollees? • If better performance could reflect in better survival?

9. Methods • Study cohort • 5,388 breast cancer incident cases diagnosed in 2002 and 2003 • followed to the end of 2007 • Data source: population based cancer registry

10. Methods • Measure performance of breast cancer care • measured by a composite score of performance measures • based on two pre-treatment and nine treatment Core Measure indicators collected through literature review • selected by an expert panel group • three stages of modified Delphi technique (Chung, K.P., et al., European Journal of Cancer Care, 2008. 17(1)) • composite scores : (counts of measures the case complies with)—————————————————————(counts of total measures applicable to the case)

11. Methods –breast Cancer core measure indicators • 2 Pre-treatment indicators • PT1: Proportion of women aged over 50 who received bilateral mammography or breast sonography 3 months before surgery • PT2: Proportion of breast cancer patients who have diagnosis in cytology and histology before surgery

12. Methods –breast Cancer core measure indicators (cont. ) • 9 Treatment indicators • T1: Proportion of breast cancer patients who were discussed by multi-disciplinary team • T2: Proportion of zero-stage breast cancer patients with ten or more lymph nodes on pathology report • T3: Proportion of Stage I and II patients who undergo Breast Conserving Surgery (BCS) • T4: Proportion of breast cancer patients with pathology report of tumor-size in the medical record after surgery

13. Methods –breast Cancer core measure indicators (cont. ) • T5: Proportion of invasive breast cancer after surgery with ten or more lymph nodes removed on pathology report • T6: Proportion of invasive breast cancer patients with estrogen receptor analysis results in the medical record • T7: Proportion of patients with invasive cancer who receive radiation treatment after BCS • T8: Proportion of breast cancer women aged less than and equal to 50 years (pre-menopausal) with positive lymph node receiving adjuvant chemotherapy • T9: Proportion of breast cancer women aged greater than 50 years (post-menopausal) with positive lymph node receiving adjuvant hormone therapy or chemotherapy

14. Methods • Data Combine with • National Health Insurance database (NHID) • Taiwan cancer registry • National death registry • Exclusion • not treated at the reporting hospital • not applicable with the performance composite score • lack of tumor size reported in cancer registry

15. Methods • Cox Proportional Hazard Modeling • Control for • Age • cancer staging • hospital service volume

16. Results • 4,273 (79.3%) cases are included • 792 cases are P4P treatment-complete enrollees (18.6%) • P4P-claimed patients • younger than none-enrollees • P4P-claimed patients are with less proportion of early stage (stage zero and stage one) cases (23.2% vs. 49.7%) • Have higher mean of composite scores (0.62 vs. 0.49, p<0.001)

17. Results

18. All hospitals (n=4,273) Exp(B) 95.0% CI for Exp(B) p - value Upper Lower Age 1.018 1.011 1 .024 <0.001 Stage (stage 0 as control) I 1.801 0.969 3.347 0.063 II 3.940 2.203 7.048 <0.001 III 14.436 8.065 25.841 <0.001 I V 64.058 35.313 116.204 <0.001 Service volume 1.000 1.000 1.001 0.203 Score of performance 0.633 0.481 0.832 0.001 P4P enroll . 0.741 0.599 0.917 0.006 Results: Cox’s PH Model (a)

19. Joined hospital (n=1,257) Exp(B) 95.0% CI for Exp(B) p - value Upper Lower Age 1.012 1.000 1.024 0.048 Stage (stage 0 as control) I 1.050 0.328 3.362 0.934 II 2.966 1.055 8.340 0.039 III 13.643 4.935 37.712 <0.001 I V 68.616 24.191 194.625 <0.001 Score of performance 0.830 0.568 1.212 0.334 P4P enroll . 0.661 0.480 0.910 0.011 Results: Cox’s PH Model (b)

20. Conclusion and Discussion • Breast Cancer P4P Initiatives in Taiwan has some positive influence on performance of cancer care and survival • P4P enrollees seem to receive care with better performance and have better outcome • design of financial incentive: • same goals for bonus • rewards hospitals that already performed better?