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JAMA Oncol. 2017 Mar 1;3(3):327-334. doi: 10.1001/jamaoncol.2016.4549.

Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care.

Author information

1
Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan2Center for Policy, Outcomes, and Prevention, Center for Health Policy/Primary Care Outcomes Research, Stanford University School of Medicine, Stanford, California3Division of General Pediatrics, Stanford University School of Medicine, Stanford, California.
2
Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
3
National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan.
4
Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan5Department of Medicine, Duke University, Durham, North Carolina.

Abstract

Importance:

Value-driven payment system reform is a potential tool for aligning economic incentives with the improvement of quality and efficiency of health care and containment of cost. Such a payment system has not been researched satisfactorily in full-cycle cancer care.

Objective:

To examine the association of outcomes and medical expenditures with a bundled-payment pay-for-performance program for breast cancer in Taiwan compared with a fee-for-service (FFS) program.

Design, Setting, and Participants:

Data were obtained from the Taiwan Cancer Database, National Health Insurance Claims Data, the National Death Registry, and the bundled-payment enrollment file. Women with newly diagnosed breast cancer and a documented first cancer treatment from January 1, 2004, to December 31, 2008, were selected from the Taiwan Cancer Database and followed up for 5 years, with the last follow-up data available on December 31, 2013. Patients in the bundled-payment program were matched at a ratio of 1:3 with control individuals in an FFS program using a propensity score method. The final sample of 17 940 patients included 4485 (25%) in the bundled-payment group and 13 455 (75%) in the FFS group.

Main Outcomes and Measures:

Rates of adherence to quality indicators, survival rates, and medical payments (excluding bonuses paid in the bundled-payment group). The Kaplan-Meier method was used to calculate 5-year overall and event-free survival rates by cancer stage, and the Cox proportional hazards regression model was used to examine the effect of the bundled-payment program on overall and event-free survival. Sensitivity analysis for bonus payments in the bundled-payment group was also performed.

Results:

The study population included 17 940 women (mean [SD] age, 52.2 [10.3] years). In the bundled-payment group, 1473 of 4215 patients (34.9%) with applicable quality indicators had full (100%) adherence to quality indicators compared with 3438 of 12 506 patients (27.5%) with applicable quality indicators in the FFS group (P < .001). The 5-year event-free survival rates for patients with stages 0 to III breast cancer were 84.48% for the bundled-payment group and 80.88% for the FFS group (P < .01). Although the 5-year medical payments of the bundled-payment group remained stable, the cumulative medical payments for the FFS group steadily increased from $16 000 to $19 230 and exceeded pay-for-performance bundled payments starting in 2008.

Conclusions and Relevance:

In Taiwan, compared with the regular FFS program, bundled payment may lead to better adherence to quality indicators, better outcomes, and more effective cost-control over time.

PMID:
27768180
DOI:
10.1001/jamaoncol.2016.4549
[Indexed for MEDLINE]

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