Cost and Effectiveness of Long-Term Care Following Integrated Discharge Planning: A Prospective Cohort Study.

Little is known about the effects of seamless hospital discharge planning on long-term care (LTC) costs and effectiveness. This study evaluates the cost and effectiveness of the recently implemented policy from hospital to LTC between patients discharged under seamless transition and standard transition. A total of 49 elderly patients in the standard transition cohort and 119 in the seamless transition cohort were recruited from November 2016 to February 2018. Data collected from medical records included the Multimorbidity Frailty Index, Activities of Daily Living Scale, and Malnutrition Universal Screening Tool during hospitalization. Multiple linear regression and Cox regression models were used to explore risk factors for medical resource utilization and medical outcomes. After adjustment for effective predictors, the seamless cohort had lower direct medical costs, a shorter length of stay, a higher survival rate, and a lower unplanned readmission rate compared to the standard cohort. However, only mean total direct medical costs during hospitalization and 6 months after discharge were significantly (p < 0.001) lower in the seamless cohort (USD 6192) compared to the standard cohort (USD 8361). Additionally, the annual per-patient economic burden in the seamless cohort approximated USD 2.9-3.3 billion. Analysis of the economic burden of disability in the elderly population in Taiwan indicates that seamless transition planning can save approximately USD 3 billion in annual healthcare costs. Implementing this policy would achieve continuous improvement in LTC quality and reduce the financial burden of healthcare on the Taiwanese government.

Cancer incidence in the vicinity of nuclear power plants in Taiwan: a population-based study.

Numerous antinuclear demonstrations reveal that the public is anxious about the potential health effects caused by nuclear power plants. The purpose of this study is to address the question "Is there a higher cancer incidence rate in the vicinity of nuclear power plants in Taiwan?" The Taiwan Cancer Registry database from 1979 to 2003 was used to compare the standardized incidence rate of the top four cancers with strong evidence for radiation risks between the "plant-vicinity" with those "non-plant-vicinity" groups. All cancer sites, five-leading cancers in Taiwan, and gender-specific cancers were also studied. We also adopted different observation time to compare the incidence rate of cancers between two groups to explore the impact of the observation period. The incidences of leukemia, thyroid, lung, and breast cancer were not significantly different between two groups, but cervix uteri cancer showed higher incidence rates in the plant-vicinity group. The incidence of cervical cancer was not consistently associated with the duration of plant operation, according to a multiyear period comparison. Although there was higher incidence in cervix cancer in the plant-vicinity group, our findings did not provide the crucial evidence that nuclear power plants were the causal factor for some cancers with strong evidence for radiation risks.

Vertical equity of healthcare in Taiwan: health services were distributed according to need.

INTRODUCTION: To test the hypothesis that the distribution of healthcare services is according to health need can be achieved under a rather open access system. METHODS: The 2001 National Health Interview Survey of Taiwan and National Health Insurance claims data were linked in the study. Health need was defined by self-perceived health status. We used Concentration index to measure need-related inequality in healthcare utilization and expenditure. RESULTS: People with greater health need received more healthcare services, indicating a pro-need character of healthcare distribution, conforming to the meaning of vertical equity. For outpatient service, subjects with the highest health need had higher proportion of ever use in a year than those who had the least health need and consumed more outpatient visits and expenditures per person per year. Similar patterns were observed for emergency services and hospitalization. The concentration indices of utilization for outpatient, emergency services, and hospitalization suggest that the distribution of utilization was related to health need, whereas the preventive service was less related to need. CONCLUSIONS: The universal coverage plus healthcare networking system makes it possible for healthcare to be utilized according to need. Taiwan's experience can serve as a reference for health reform.

Outpatient-shopping behavior and survival rates in newly diagnosed cancer patients.

OBJECTIVES: To evaluate the appropriateness of the definition of outpatient-shopping behavior in Taiwanese patients. STUDY DESIGN: Linked study of 3 databases (Taiwan Cancer Registry, National Health Insurance [NHI] claim database, and death registry database). METHODS: Outpatient shopping behavior was defined as making at least 4 or 5 physician visits to confirm a cancer diagnosis. We analyzed patient-related factors and the 5-year overall survival rate of the outpatient-shopping group compared with a nonshopping group. Using the household registration database and NHI database, we determined the proportion of outpatient shopping, characteristics of patients who did and did not shop for outpatient therapy, time between diagnosis and start of regular treatment, and medical service utilization in the shopping versus the nonshopping group. RESULTS: Patients with higher incomes were significantly more likely to shop for outpatient care. Patients with higher comorbidity scores were 1.4 times more likely to shop for outpatient care than patients with lower scores. Patients diagnosed with more advanced cancer were more likely to shop than those who were not. Patients might be more trusting of cancer diagnoses given at higher-level hospitals. The nonshopping groups had a longer duration of survival over 5 years. CONCLUSIONS: Health authorities should consider charging additional fees after a specific outpatient- shopping threshold is reached to reduce this behavior. The government may need to reassess the function of the medical sources network by shrinking it from the original 4 levels to 2 levels, or by enhancing the referral function among different hospital levels.

Continuity of diabetes care is associated with avoidable hospitalizations: evidence from Taiwan's National Health Insurance scheme.

OBJECTIVE: Taiwan's health-care system allows patients to utilize specialty services without referrals by primary care providers. This discontinuity of care may lead to increases in future hospitalizations. This study aims to determine whether the discontinuity of care is associated with the risk of hospitalization. DESIGN: A secondary data analysis based on a claim data of a nationally representative random sample of diabetic patients in Taiwan. A usual provider continuity (UPC) index was developed-a ratio of the visits to the physician that subjects most usually see relevant to diabetes care to the total physician visits relevant to diabetes care-to investigate its association with the risk of hospitalization. SETTING: Taiwan's National Health Insurance scheme from 1997 through 2002. PARTICIPANTS: Totally 6476 diabetic patients. INTERVENTION(s) None. MAIN OUTCOME MEASURE(s) Diabetes-related short-term and long-term ambulatory care sensitive condition (ACSC) admissions. RESULTS: Patients with ACSC admissions had significantly lower UPC scores compared with those without ACSC admissions. Using a Cox regression model that controlling for age, sex, severity of diabetes and the number of total visits, patients with low to medium continuity of care (UPC <0.75) were found to be significantly associated with increased risk of hospitalization as compared with patients with high continuity of care, especially for long-term ACSC admissions (relative risk: 1.336 [1.019-1.751]). CONCLUSIONS: Higher continuity of care with usual providers for diabetic care is significantly associated with lower risk of future hospitalization for long-term diabetic complication admissions. To avoid future hospitalization, health policy stakeholders are encouraged to improve the continuity of care through strengthening the provider-patient relationships.

Determinants of computed tomography and magnetic resonance imaging utilization in Taiwan.

OBJECTIVES: Magnetic resonance imaging (MRI) and computerized tomography (CT) scanners are high-tech equipment with the highest utilizations and expenditures in Taiwan. This study investigates the factors that affect MRI and CT utilization, such as whether supply-side factors have more impact than demand-side factors, and the effect of utilization control policies. METHODS: This study used the nationwide CT and MRI claim data for the years 1998 to 2001 from the Bureau of National Health Insurance (BNHI) in Taiwan. Multiple regression analysis was the statistical method used to determine the relative factors that influence CT and MRI utilization. RESULTS: CT: population ratio, hospital-based physician: population ratio, female ratio, pediatric (< or =14 years) : population ratio, and family income significantly influenced CT utilization. MRI : population ratio and hospital-based physician : population ratio, female ratio, and family income significantly influenced MRI utilization. However, the proportion of the aged (> or =65 years of age) did not significantly influence CT or MRI utilization after controlling for other factors. The rates of CT and MRI utilization for the outpatient and inpatient settings and the repeated uses of CT or MRI have decreased significantly after a utilization review was implemented by BNHI, which suggests that CT and MRI have been overused. CONCLUSIONS: Increases in supply-side factors significantly increase CT/MRI utilization, and supply-side factors impact CT/MRI utilization more than demand-side factors. The results show that the utilization instant report policy effectively decreases repeated uses of CT/MRI.

Development of a risk-adjusted capitation model based on principal inpatient diagnoses in Taiwan.

BACKGROUND AND PURPOSE: Taiwan's National Health Insurance (NHI) program has considered the use of capitation payments to health care providers as a method for control of the rising costs of the system. The establishment of capitation payments usually requires the performance of risk adjustment. The purposes of this study were to develop a diagnosis-based risk adjustment model for the NHI and to evaluate its predictability. METHODS: Using a 2% random sample of 371,620 NHI enrollees, the authors developed a Taiwan version of the Principal Inpatient Diagnosis Cost Groups (TPIPDCGs) from 1996 claim records to predict an individual's expenditure in 1997. Weighted least squares regression models were built in an estimation sample (two-thirds of the study sample), and were cross-validated in a validation sample (the remaining one-third of the study sample). Predictive R2 and predictive ratios were used to evaluate the model's predictability. RESULTS: Only 7.88% of the study sample could be classified into 1 of the 16 TPIPDCGs. Combined with demographic variables, which alone could explain 3.7% of the variation in an individual's future expenditure, the risk adjustment model based on TPIPDCGs could explain 12.2% of expenditure variation. In addition, the finding that the predictive ratios of the TPIPDCG model approximated unity better than those of the demographic model in all subgroups indicates that the capitation payment as predicted by the TPIPDCG model for each subgroup would better correlate to the actual spending. CONCLUSION: Taiwan's risk-adjusted capitation model based on principal inpatient diagnoses has higher predictability on individual's future expenditure than its counterpart in the USA. This finding provides insight into not only the development of Taiwan's diagnosis-based risk adjustment models but also the necessity of modification when applying foreign-developed risk adjustment models to the NHI.

The initial effects of Physician Compensation Programs in Taiwan hospitals: implications for staff model HMOs.

This paper examines whether a Physician Compensation Program (PCP), which was based on the responsibility centers system, improved departmental efficiency in a large Taiwan teaching hospital. PCPs in Taiwan may have implications for staff-model HMOs. Monthly financial data and related information for 58 departments in the 5 months following the introduction of the program (the PCP period) and the corresponding 5 months before the introduction of the program (the pre-PCP period) were provided by the case hospital. The Data Envelopment Analysis (DEA) model is used to measure the operational efficiency of each department in the case hospital over the two periods. We first use asymptotic DEA-based tests to examine whether differences in efficiency scores between the two periods are significant. Then, a multi-factor tobit model is used to examine factors that might explain the observed differences in efficiency. The data of each month in the PCP period (November 1996-March 1997) and the pre-PCP period (November 1995-March 1996) are used to calculate efficiency scores and control for monthly effects. We find that average efficiency improves after the implementation of the PCP, with or without controlling for other related factors. Physicians' seniority and percentage of physicians' service time in the department are associated with improved efficiency. Finally, departments with higher profits and fewer numbers of employees are associated with higher efficiency. The findings suggest that to achieve an increase in hospital efficiency in Taiwan, responsibility centers should be integrated with formal physician compensation programs. Such results have implications for staff model HMOs in the US and their variants in countries with national health insurance.