Long-term effects of the global budget program and periodic price adjustment on antibacterial agents: A nationwide decomposition analysis between 2001 and 2016.

BACKGROUND: Previous studies have shown that financial strategies are beneficial for improving the appropriate use of antibiotics within a limited period of time. Long-term effects have rarely been explored. METHODS: This study evaluated the changes in expenditure and prescription patterns of antibacterial agents under the global budget (GB) program and drug price adjustment of a National Health Insurance scheme. Two structural methods, that is, the Laspeyres method and Fisher's Ideal Index decomposition method, were used to illustrate the impacts of price, volume, and drug change. RESULTS: During the first 5 years of the GB program (ie, 2001-2006), the expenses of antibacterial agents increased by 54.1%, while the volume decreased by 11% to 21.3%. Therapeutic choice was the predominant cause of expense growth. In the second and third 5-year periods (ie, 2006-2011 and 2011-2016), the driving force of therapeutic choice gradually decreased. The antibacterial expense remained stable with a slight increase in prescription volume. Periodic price adjustment contributed steadily to cost containment, by 21.9% to 39.9%. CONCLUSIONS: The GB program led to a remarkable increase in antibacterial expenses mainly attributed to therapeutic choice, especially in the early stage. In contrast, periodic price adjustment, provided steady benefits to pharmaceutical budget control without a noticeable increase in drug volume.

Longitudinal care continuity and avoidable hospitalization: the application of claims-based measures.

BACKGROUND: Longitudinal continuity between a patient and his/her primary care physician is an important aspect in measuring continuity of care (COC). The majority of previous studies employed questionnaire surveys to patients to measure the continual relationship between patients and their physicians. This study aimed to construct a provider duration continuity index (PDCI) by using longitudinal claims data and to examine its agreement with commonly used COC measures. Then, this study investigated the effects of the various types of COC measure on the likelihood of avoidable hospitalization while considering the level of comorbidity. METHODS: This study constructed a 4-year panel (from 2014 to 2017) of the nationwide health insurance claims data in Taiwan. In total, 328,044 randomly selected patients with 3 or more physician visits per year were analyzed. Two PDCIs were constructed to measure the duration of interaction between a patient and his/her physicians over time. The agreement between the PDCIs and three commonly used COC indicators, the Usual Provider of Care index, the Continuity of Care Index, and the Sequential Continuity Index, were examined. Generalized estimating equations were conducted to examine the association between COC and avoidable hospitalization by the level of comorbidity. RESULTS: The results showed that the correlations among the three commonly used COC indicators were high (γ = 0.787 ~ 0.958) and the correlation between the two longitudinal continuity measures was moderate (γ = 0.577 ~ 0.579), but the correlations between the commonly used COC indicators and the two PDCIs were low (γ = 0.001 ~ 0.257). All COC measures, both the PDCIs and the three commonly used COC indicators, showed independent protective effects on the likelihood of avoidable hospitalization in three comorbidity groups. CONCLUSION: The duration of interaction between patients and physicians is an independent domain in measuring COC and has a significant effect on health care outcomes.

Examining the Long-term Spillover Effects of a Pay-for-Performance Program in a Healthcare System That Lacks Referral Arrangements.

BACKGROUND: Several studies have examined the intended effects of pay-for-performance (P4P) programs, yet little is known about the unintended spillover effects of such programs on intermediate clinical outcomes. This study examines the long-term spillover effects of a P4P program for diabetes care. METHODS: This study uses a nationwide population-based natural experimental design with a 3-year follow-up period under Taiwan's universal coverage healthcare system. The intervention group consisted of 7688 patients who enrolled in the P4P program for diabetes care in 2017 and continuously participated in the program for three years. The comparison group was selected by propensity score matching (PSM) from patients seen by the same group of physicians. Each patient had four records: one pertaining to one year before the index date of the P4P program and the other three pertaining to follow-ups spanning over the next three years. Generalized estimating equations (GEEs) with difference-in-differences (DID) estimations were used to consider the correlation between repeated observations for the same patients and patients within the same matched pairs. RESULTS: Patients enrolled in the P4P program showed improvements in incentivized intermediate clinical outcomes that persisted over three years, including proper control of glycated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C). We found a slight positive spillover effect of the P4P program on the control of non-incentivized triglyceride [TG]). However, we found no such effects on the non-incentivized high-density lipoprotein cholesterol (HDL-C) control. CONCLUSION: The P4P program has achieved its primary goal of improving the incentivized intermediate clinical outcomes. The commonality in production among a set of activities is crucial for generating the spillover effects of an incentive program.

Effect of a Pay-for-Performance Program on Renal Outcomes Among Patients With Early-Stage Chronic Kidney Disease in Taiwan.

BACKGROUND: With the promising outcomes of the pre-ESRD (end-stage renal disease) pay-for-performance (P4P) program, the National Health Insurance Administration (NHIA) of Taiwan launched a P4P program for patients with early chronic kidney disease (CKD) in 2011, targeting CKD patients at stages 1, 2, and 3a. This study aimed to examine the long-term effect of the early-CKD P4P program on CKD progression. METHODS: We conducted a matched cohort study using electronic medical records from a large healthcare delivery system in Taiwan. The outcome of interest was CKD progression to estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2 between P4P program enrolees and non-enrolees. The difference in the cumulative incidence of CKD progression between the P4P and non-P4P groups was tested using Gray's test. We adopted a cause-specific (CS) hazard model to estimate the hazard in the P4P group as compared to non-P4P group, adjusting for age, sex, baseline renal function, and comorbidities. A subgroup analysis was further performed in CKD patients with diabetes to evaluate the interactive effects between the early-CKD P4P and diabetes P4P programs. RESULTS: The incidence per 100 person-months of disease progression was significantly lower in the P4P group than in the non-P4P group (0.44 vs. 0.69, P<.0001), and the CS hazard ratio (CS-HR) for P4P program enrolees compared with non-enrolees was 0.61 (95% CI: 0.58-0.64, P<.0001). The results of the subgroup analysis further revealed an additive effect of the diabetes P4P program on CKD progression; compared to none of both P4P enrolees, the CS-HR for CKD disease progression was 0.60 (95% CI: 0.54-0.67, P<.0001) for patients who were enrolled in both early-CKD P4P and diabetes P4P programs. CONCLUSION: The present study results suggest that the early-CKD P4P program is superior to usual care to decelerate CKD progression in patients with early-stage CKD.

Differences in trends of perceived inpatient care quality based on regional socioeconomic level in the United States and Taiwan.

OBJECTIVE: To examine perceived inpatient care quality according to regional socioeconomic status (SES), measured by regional household income, across the United States and Taiwan. DATA SOURCES: Patient Experience in Hospital Care (PEHC) survey 2018-2019 data from National Taiwan University; US Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) 2018-2019 data from CMS.gov; and household income and facility data from publicly accessible databases. STUDY DESIGN: This retrospective study used multivariate logistic regression to estimate the effect of household income on the rate of positive inpatient experiences in Taiwan and the United States, adjusting for hospitals' teaching status and ownership, and physician density. DATA COLLECTION: Hospital administrators for HCAHPS and PEHC's research teams invited patients who received inpatient care during the data collection period in the United States and Taiwan, respectively. The analysis included 1024 facilities from nine US states and 350 facilities from twenty major cities/counties in Taiwan. PRINCIPAL FINDINGS: Perceived inpatient care quality was higher in the United States than in Taiwan for the three experience measures. In Taiwan, hospitals with higher regional SES were less likely to receive a highly positive response for perceived respect, accommodation quality, and understanding upon discharge, with odds ratios (ORs) ranging from 0.83 to 0.88. In contrast, in the United States, higher regional SES was associated with a higher likelihood of a positive response for accommodation quality and understanding upon discharge (ORs = 2.51 and 1.48). Regional physician density and individual hospital characteristics show varying effects on perceived quality between Taiwan and the United States. CONCLUSIONS: Higher overall experience scores in the United States are consistent with higher spending on health care compared with Taiwan. Varying associations between regional SES and perceived inpatient care quality highlight how systemic and cultural differences between the two countries affect scoring patterns.

Keeping up with guideline recommendations: does patient volume matter in diabetes care?

OBJECTIVES: To examine the association between service volume and guideline adherence via multiyear observations. STUDY DESIGN: Repeated cross-sectional study. METHODS: This study employed nationwide claims data from Taiwan's National Health Insurance scheme and identified patients with newly diagnosed type 2 diabetes from 2001, 2005, and 2009; a new prescription guideline for diabetes care was introduced in 2006. Physician service volume was measured by the number of total outpatients with diabetes. The outcome variable indicated whether a patient was receiving metformin, the guideline-recommended antihyperglycemic agent, at the index date. RESULTS: Patients visiting physicians who had high or medium volumes of patients with diabetes were more likely to receive metformin than patients visiting physicians who had low volumes; the odds ratios (ORs) were 2.48 (95% CI, 2.03-3.04) and 1.76 (95% CI, 1.45-2.13), respectively. Patients with newly diagnosed diabetes in 2009 and 2005 were more likely to receive metformin than their counterparts in 2001, with ORs of 12.00 (95% CI, 11.19-12.86) and 2.44 (95% CI, 2.30-2.59), respectively. We also found that patients who visited younger physicians, physicians with fewer practice years, physicians practicing in large-scale hospitals, or physicians practicing in urban areas were more likely to receive metformin than their counterparts. CONCLUSIONS: In the process of implementing a new practice guideline for treating patients with diabetes, physicians with higher patient volumes are more likely to adhere to the guideline recommendation.

The Impact of a National Health Information Exchange Program Under a Single-payer System.

OBJECTIVE: This study aimed to evaluate the impact of the PharmaCloud program, a health information exchange program implemented in 2013, on medication duplication under a single-payer, universal health insurance program in Taiwan. STUDY DESIGN: This study employed a retrospective pre-post study design and used nationwide health insurance claim data from 2013 to 2015. A difference-in-difference analysis was conducted to evaluate the effects of inquiry rate on the probability of receiving duplicate medications and on the number of days of overlapping medication prescriptions after implementation of the PharmaCloud program. RESULTS: The study subjects included patients receiving medications in 7 categories: antihypertension drugs, 217,200; antihyperlipidemic drugs, 69,086; hypoglycemic agents, 103,962; antipsychotic drugs, 15,479; antidepressant drugs, 12,057; sedative and hypnotic drugs, 56,048; and antigout drugs, 18,250. Up to 2015, the overall PharmaCloud inquiry rate has increased to 55.36%-69.16%. Compared with subjects in 2013, subjects in 2014 and 2015 had a significantly lower likelihood of receiving duplicate medication in all 7 medication groups; for instance, for antihypertension drug users, the odds ratio (OR) was 0.91 with 95% confidence interval (CI)=0.90-0.92 in 2014, and the OR was 0.81 with 95% confidence interval=0.81-0.82 in 2015. However, a higher inquiry rate led to a lower likelihood of receiving duplicate medication and shorter periods of overlapping medications only in some of the medication groups. CONCLUSIONS: The health information exchange program has reduced medication duplication, yet the reduction was not entirely associated with record inquiries. The hospitals have responded to the challenge of medication duplication by enhancing internal prescription control via a prescription alert system, which may have contributed to the reduction in duplicate medications and is a positive, unintended consequence of the intervention.

Drug price, dosage and safety: Real-world evidence of oral hypoglycemic agents.

OBJECTIVES: Drug price reduction is one of the major policies to restrain pharmaceutical expenses worldwide. This study explores whether there is a relationship between drug price and clinical quality using real-world data. METHODS: Patients with newly-diagnosed type 2 diabetes receiving metformin or sulfonylureas during 2001 and 2010 were identified using the claim database of the Taiwan universal health insurance system. Propensity score matching was performed to obtain comparable subjects for analysis. Pharmaceutical products were categorized as brand-name agents (BD), highpriced generics (HP) or low-priced generics (LP). Indicators of clinical quality were defined as the dosage of cumulative oral hypoglycemic agents (OHA), exposure to other pharmacological classes of OHA, hospitalization or urgent visit for hypoglycemia or hyperglycemia, insulin utilization and diagnosis of diabetic complications within 1 year after diagnosis. RESULTS: A total of 40,152 study subjects were identified. A generalized linear mix model showed that HP and BD users received similar OHA dosages with comparable clinical outcomes. By contrast, LP users had similar outcomes to BD users but received a 39% greater OHA dosage. A marginally higher risk of poor glycemic control in LP users was also observed. CONCLUSIONS: Drug price is related to indicators of clinical quality. Clinicians and health authorities should monitor the utilization, effectiveness and clinical safety indicators of generic drugs, especially those with remarkably low prices.

A community pharmacist home visit project for high utilizers under a universal health system: A preliminary assessment.

Due to the increasing prevalence of multimorbidity, the percentage of heavy users of health care services increased rapidly. To contain inappropriate outpatient visits and improve better medication management of high utilizers, the National Health Insurance Administration in Taiwan launched a community pharmacist home visit (CPHV) project for high utilizers in 2010. We employed a natural experimental design to evaluate the preliminary effects of the CPHV project. The intervention group consisted of patients enrolled in the CPHV project during 2010 and 2013. Patients in the comparison group were non-enrollees selected via a propensity score matching technique. A difference-in-differences analysis was conducted by using multilevel models to examine the effects of the project. The average number of physician visits decreased from 130.0 to 98.9 visits (23.8%) among the CPHV project enrollees, while the average number decreased from 99.5 to 89.5 visits (10.1%) among the non-enrollees, with a net effect of a 21.0-visit reduction. The CPHV project also led to modest reductions in the number of medication items used per day, the probability of hospital admission and yearly healthcare expenses. The CPHV project seems promising for decreasing health care utilization and costs of the patients with high-needs.

What can be achieved with a single-payer NHI system: The case of Taiwan.

The United Nations has incorporated the noble goal of Universal Health Coverage (UHC) in its 2030 Agenda for Sustainable Development. Most nations have already embraced UHC as their goal. However, an intense policy debate has risen about which health system structure can best achieve UHC. Is a single-payer system more efficient, equitable and effective than a multiple-payer system for middle income countries? We argue that empirical evidence and in-depth analysis of single-payer and multiple-payer systems should inform this debate. First, we need a clear definition of single- and multiple-payer health systems that enables us to compare their differences and clarify the issues to be debated. Second, at least four key issues confront any nation that wishes to achieve UHC: (1) how to design an affordable comprehensive health benefit package for UHC and to finance it (2) how the health expenditure inflation rate can be managed to sustain UHC (3) how modern information technology can be used to enhance efficiency and quality of healthcare and (4) how to assure an adequate supply of high-quality services will be distributed equitably throughout a nation. This paper offers a definition of single- and multiple-payer and compares them. We then use Taiwan's National Health Insurance system to address the four key issues, and illuminate how its policies and operations led to Taiwan's successful UHC.

Assessing quality of primary diabetes care in South Korea and Taiwan using avoidable hospitalizations.

Quality of primary diabetes care is a key health policy concern in many OECD countries with an aging population. This cross-national, population-based study examined the extent and attributes of diabetes-related avoidable hospitalizations (DRAHs) in South Korea and Taiwan, both of which have social health insurance-based health systems with limited gate-keeping for hospitalizations. We analyzed comparable, nationally representative health insurance beneficiary datasets for the two countries (2002-2013), linked with community health resource data. The age- and sex-standardized DRAH rates were calculated, and multivariate, multi-level longitudinal modeling approaches were adopted. The DRAH rate decreased in Taiwan consistently during 2002-2013 and in Korea after 2011 only. Under the universal health coverage, people enjoyed high accessibility to care. A higher number of physician visits reduced DRAHs in Korea but not in Taiwan. Socio-economic disparities in DRAHs still existed in both countries, especially in Taiwan. We found a different trajectory in two similar health systems for the selected health system performance indicator for primary diabetes care. This can be partly explained by different policy approaches to diabetes management in the two countries over the years. Necessary are policy efforts to improve the quality and equality of primary diabetes care and better control of hospital admissions in these two health systems that provide generous access to care at a low cost in East Asia.

The impact of a medication record sharing program among diabetes patients under a single-payer system: The role of inquiry rate.

OBJECTIVE: Taiwan's single health insurer introduced a medication record exchange platform, the PharmaCloud program, in 2013. This study aimed to evaluate the effects of the medication record inquiry rate on medication duplication among patients with diabetes. MATERIALS AND METHODS: A retrospective pre-post design with a comparison group was conducted using nationwide health insurance claim data of diabetic patients from 2013 to 2014. Patients whose medication record inquiry rate fell within the upper 25th percentile were classified as the high-inquiry group, and the others as the low-inquiry group. The dependent variables were the likelihood of receiving duplicated medication and the overlapped medication days of the study subjects. Generalized estimation equations with difference-in-difference analysis were calculated to examine the net effect of the PharmaCloud inquiry rate for a matched sub-sample. RESULTS: In total, 106,508 patients with diabetes were randomly selected. From 2013 to 2014, the medication duplication rate was reduced 7.76 percentile (54.12%-46.36%) for the high-inquiry group and 9.58 percentile (63.72%-54.14%) for the low-inquiry group; the average medication overlap periods were shortened 4.36 days (8.49-4.13) and 6.29 days (11.28-4.99), respectively. The regression models showed patients in the high-inquiry group were more likely to receive duplicated medication (OR = 1.11, 95% C.I. = 1.07-1.16) and with longer overlapped days (7.53%, P = 0.0081) after the program. CONCLUSION: The medication record sharing program has reduced medication duplication among diabetes patients. However, higher inquiry rate did not lead to greater reduction in medication duplication; the overall effect might be due to enhanced internal control via prescription alert system in hospitals rather physician's review of the records.

Health Expenditure Growth under Single-Payer Systems: Comparing South Korea and Taiwan.

OBJECTIVE: Achieving universal health coverage has been an important goal for many countries worldwide. However, the rapid growth of health expenditures has challenged all nations, both those with and without such universal coverage. Single-payer systems are considered more efficient for administrative affairs and may be more effective for containing costs than multipayer systems. However, South Korea, which has a typical single-payer scheme, has almost the highest growth rate in health expenditures among industrialized countries. The aim of the present study is to explicate this situation by comparing South Korea with Taiwan. METHODS: This study analyzed statistical reports published by government departments in South Korea and Taiwan from 2001 to 2015, including population and economic statistics, health statistics, health expenditures, and social health insurance reports. RESULTS: Between 2001 and 2015, the per capita national health expenditure (NHE) in South Korea grew 292%, whereas the corresponding growth of per capita NHE in Taiwan was only 83%. We find that the national health insurance (NHI) global budget cap in Taiwan may have restricted the growth of health expenditures. Less comprehensive benefit coverage for essential diagnosis/treatment services under the South Korean NHI program may have contributed to the growth of out-of-pocket payments. The expansion of insurance coverage for vulnerable individuals may also contribute to higher growth in NHE in South Korea. Explicit regulation of health care resource distribution may also lead to more limited provisioning and utilization of health services in Taiwan. CONCLUSION: Under analogous single-payer systems, South Korea had a much higher growth in health spending than Taiwan. The annual budget cap for total reimbursement, more comprehensive coverage for essential diagnosis and treatment services, and the regulation of health care resource distribution are important factors associated with the growth of health expenditures.

Reimbursement changes and drug switching: are severe patients more affected?

Objectives To examine the long-term effects of drug reimbursement adjustments on drug-switching decisions and to investigate whether patients with complicated or severe conditions are more affected. Methods A population-based, longitudinal study with a before-and-after design. Analysis of 141,703 patients with type 2 diabetes covered by the universal health insurance program in Taiwan. Observation of five 6-month phases before and after a drug reimbursement adjustment implemented in October 2009. Drug switching was defined as a brand change within the same anatomical therapeutic chemical group between two consecutive physician visits. Generalized estimating equations were employed to control for the random subject effect. Results The drug-switching rates in the five phases were 10.85% and 13.71% before implementation and 31.53%, 28.29% and 15.61% after implementation. Results from the regression model revealed a higher likelihood of receiving switched drugs in phases 3, 4 and 5, with odds ratios of 3.16, 2.72 and 1.44 (with 95% confidence interval 3.04-3.29, 2.61-2.84 and 1.38-1.51), respectively, compared with phase 1. Patients with complicated or severe conditions were more likely to have their drugs switched after the reimbursement adjustment. Conclusions The drug reimbursement adjustment under the health insurance program resulted in an increase in drug-switching decisions, and patients were not exempt from medication switching regardless of the complications or the severity level of their illness.

Comparative analysis of the cost and effectiveness of generic and brand-name antibiotics: the case of uncomplicated urinary tract infection.

PURPOSE: Generic medications used for chronic diseases are beneficial in containing healthcare costs and improving drug accessibility. However, the effects of generic drugs in acute and severe illness remain controversial. This study aims to investigate treatment costs and outcomes of generic antibiotics prescribed for adults with a urinary tract infection in outpatient settings. METHODS: The data source was the Longitudinal Health Insurance Database of Taiwan. We included outpatients aged 20 years and above with a urinary tract infection who required one oral antibiotic for which brand-name and generic products were simultaneously available. Drug cost and overall healthcare expense of the index consultation, healthcare cost during a 42-day follow-up period, and treatment failure rates were the main dependent variables. Data were compared between brand-name and generic users from the entire cohort and a propensity score-matched samples. RESULTS: Results from the entire cohort and propensity score-matched samples were similar. Daily antibiotic cost was significantly lower among generic users than brand-name users. Significant lower total drug claims of the index consultation only existed in patients receiving the investigated antibiotics, while the drug price between brand-name and generic versions were relatively large (e.g., >50%). The overall healthcare cost of the index consultation, healthcare expenditure during a 42-day follow-up period, and treatment failure rates were similar between the two groups. CONCLUSIONS: Compared with those treated with brand-name antibiotics, outpatients who received generic antibiotics had equivalent treatment outcomes with lower drug costs. Generic antibiotics are effective and worthy of adoption among outpatients with simple infections indicating oral antibiotic treatment. Copyright © 2016 John Wiley & Sons, Ltd.

Half-Managed Care: A Preliminary Assessment of a Capitation Program in a Health Care System Without Gatekeepers.

In 2011, a novel capitation program was launched in Taiwan under its universal health insurance plan. This study aimed to assess the short-term impact of the program. Two hospitals in the greater Taipei area, one participating in the "loyal patient" model (13,319 enrollees) and one in the "regional resident" model (13,768 enrollees), were analyzed. Two comparison groups were selected by propensity score matching. Generalized estimating equation models with differences-in-differences analysis were used to examine the net effects of the capitation program on health care utilization, expenses, and outcomes. Enrollees in the loyal patient model had fewer physician visits in the host hospital, but more physician visits outside that hospital during the program year than they had the year before. Compared with non-enrollees, the loyal patient model enrollees incurred fewer physician visits (ß = -0.042, p < .001), fewer emergency department visits, (ß = -0.140, p < .001), and similar total expenses and outcome. For the regional resident model, no differences were found in the number of physician visits, expenses, or outcomes between enrollees and non-enrollees. The novel capitation models in Taiwan had minimal impact on health care utilization after 1 year of implementation and the health care outcome was not compromised.

Disease burden of enterovirus infection in Taiwan: Implications for vaccination policy.

OBJECTIVES: This study aimed to assess the disease burden and economic impacts of human nonpolio enteroviruses (NPEV) and enterovirus A71 (EV-A71) infection in Taiwan. MATERIALS AND METHODS: We included children under five years old (n=983,127-1,118,649) with ICD-9-CM codes 0740 (herpangina) or 0743 (hand-foot-and-mouth disease) from the 2006 to 2010 National Health Insurance Database. Severity of enterovirus infection was assessed from outpatient/emergency visits, hospitalization (with/without intensive care unit [ICU] admission), infection with severe complications, and death. We estimated medical costs and indirect costs from the societal perspective. RESULTS: The annual rates of NPEV events for children under five years old ranged from 13.9% to 38.4%, of which 5.1-8.8% were hospitalized. EV-A71 accounted for 7.8% of all NPEV medical costs, but 79.1% of NPEV ICU costs. Travel costs and productivity loss of caregivers were $37.1 (range: $24.5-$64.7) million per year. These costs were not higher in the EV-A71 dominant year ($34.4 million) compared with those in the other years. Productivity losses resulting from premature mortality by NPEV infection were $0.8 (range: $0.0-$2.9) million per year, of which 96.3% were caused by EV-A71. CONCLUSIONS: Diseases associated with NPEV other than EV-A71 were responsible for most of the medical expenses. In addition, caregiver productivity loss by high rates of NPEV infection impacted the society much more than medical costs. A multi-valent vaccine that includes EV-A71 and other serotypes, for example coxsackievirus A16, may be beneficial to the health of children in Taiwan.

Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system.

INTRODUCTION: Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension. METHODS: This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme. RESULTS: Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation. CONCLUSION: This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Using financial incentives to improve the care of tuberculosis patients.

OBJECTIVES: Tuberculosis (TB) is a serious public health concern, and Taiwan has implemented a pay-for-performance (P4P) program to incentivize healthcare professionals to provide comprehensive care to TB patients. This study aims to examine the effects of the TB P4P program on treatment outcomes and related expenses. STUDY DESIGN: A population-based natural experimental design with intervention and comparison groups. METHODS: Propensity score matching was conducted to increase the comparability between the P4P and non-P4P group. A total of 12,018 subjects were included in the analysis, with 6009 cases in each group. Generalized linear models and multinomial logistic regression were employed to examine the effects of the P4P program. RESULTS: The regression models indicated that patients enrolled in the P4P program had 14% more ambulatory visits than non-P4P patients (P < .001), but there were no differences in hospitalization rates. On average, P4P enrollees spent $215 (4.6%) less on TB-related expenses than their counterparts. In addition, P4P enrollees had a higher likelihood of being successfully treated (odds ratio, 1.56; P < .001) and were less likely to die compared with nonenrollees. CONCLUSIONS: Patients in the P4P program were less likely to die, were more likely to be treated successfully, and incurred lower costs. Providing financial incentives to healthcare institutions could be a feasible model for better TB control.

Long-term effect of fee-for-service-based reimbursement cuts on processes and outcomes of care for stroke: interrupted time-series study from Taiwan.

BACKGROUND: As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke. METHODS AND RESULTS: We analyzed all 411,487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan's National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P=0.013), antiplatelet/anticoagulant use (-0.20% per quarter; P<0.001), statin use (0.18% per quarter; P=0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P<0.001), and 30-day mortality (0.06% per quarter; P<0.001). CONCLUSIONS: There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care.