PAY-FOR-PERFORMANCE IN TAIWAN
OUTLINE OF PRESENTATION
May Tsung-Mei Cheng
International Forum
Princeton University
I. QUICK OVERVIEW OF TAIWAN’S HEALTH SYSTEM
II. OVERVIEW OF TAIWAN’S P4P PROGRAMS
III. HOW P4P PROGRAMS IN TAIWAN WORK
Academy Health Annual Research Meeting 2006
IV. FUNDING FOR P4P PROGRAMS
IV. CONCLUDING OBSERVATIONS
Seattle, Washington
June 25-27, 2006
OVERVIEW OF TAIWAN’S HEALTH CARE SYSTEM
I. QUICK OVERVIEW OF TAIWAN’S HEALTH SYSTEM
• A single-payer system, “National Health Insurance”
(NHI), established in 1995 and administered by the
central government’s Bureau of National Health
Insurance (BNHI) under the Department of Health
(DOH).
• Covers 99% of Taiwan’s population of 22.3 million;
enrollment is mandatory
• Comprehensive benefits: in- and outpatient care,
drugs, dental, vision, traditional Chinese medicine,
etc.
• Smart Card (IC-Card) is used for accessing care in
100% of cases
OVERVIEW OF TAIWAN’S HEALTH CARE SYSTEM
OVERVIEW OF TAIWAN’S HEALTH CARE SYSTEM
• NHI accounts for 56.55% of that total
• Delivery system: private sector dominance (97%
doctors in private practice; 84.8% hospitals
private)
• Out of pocket payments: 32% (by way of
comparison, it is 30% in Canada)
• Global budget: 4 sectors -- hospital, primary
care, dental, traditional Chinese medicine
• NHI is financed from 3 sources: households (38%),
employers (35%) and government (27%)
• Payment of providers is primarily FFS, some
DRGs, case payment, capitation, and P4P
• The premium structure is very complex. Roughly
speaking, households pay a premium of 4.55% of
income.
• Patients have complete freedom to choose
providers; co-pay varies by level of providers
• Taiwan’s total NHE is 6.17% GDP (2004)
• 100% electronic claim submission
• No waiting lines like in the UK or in Canada
• Satisfaction rate among citizenry is high: 70s%
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GENESIS OF P4P INTIATIVES IN TAIWAN
• NHI Law made no special provision re quality;
emphasis was on access and coverage.
II. OVERVIEW OF TAIWAN’S P4P SYSTEM
• Even so, Taiwan’s BNHI has engaged in a number of
quality improvement initiatives, of which P4P is one.
• Several pilot programs began in late 2001.
• In January 2006, two additional programs were
initiated.
5 PILOT P4P PROGRAMS + 2 TRIAL PROGRAMS
A. The “Original 5”: Implementation began late 2001
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9
9
•
•
Asthma (based on process measures)
Diabetes (based on process measures)
Breast cancer (based on outcome measures)
Cervical cancer
Tuberculosis
III. HOW P4P PROGRAMS IN TAIWAN WORK
B. New - January 1, 2006: Trial period 1 yr.
• Hypertension
• Depression
Voluntary participation by primary care physicians,
hospitals, or clinics and other care facilities.
To participate in the program, providers must adopt
the following quality assurance measures:
– Meet formal qualification/certification requirements for
participating medical personnel (physicians, nurses,
dieticians), hospitals and clinics.
– Follow treatment guidelines such as the widely
accepted guidelines for DM care developed by the
U.S. based ADA.
– Establish case-based Electronic Medical Record
(EMR) and medical record management systems.
Reporting: claims data, supplemented by selfreported performance data on the outcome and
process parts, using a special webpage outside of
regular claims filing channel.
ILLUSTRATIONS:
- Breast Cancer
- Diabetes
- Asthma
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Breast Cancer
– Starting date: November 1, 2001
– Outcome-based payment, contingent upon yearend total survival and disease-free survival
– Provider participation: 3 medical centers, 5
hospitals, 2 regional hospitals for a combined
total of 200 professional medical personnel
committed to the program
– 2,381 new patients covered in the program in
2004 = 44.34% of all BRAC patients in Taiwan
EXTRA PAYMENTS FOR BREAST CANCER P4P
Outcome-based bonus payments on top of
regular case-based payment:
– 1% of regular case payment at 1st yr. survival
– 2% “
“
“
“
“
2nd yr.
“
– 5% “
“
“
“
“
5th yr.
“
Diabetes Mellitus (DM)
Breast Cancer
• Starting date: November 1, 2001
RESULTS:
• 4th leading cause of death in Taiwan (2003)
– The sole P4P program among the 5 that
bases payment on outcomes, the BRAC P4P
met 100% target goals for 5-year total
survival and disease-free survival.
– Patient satisfaction extremely high.
• Accounting for 11.5% of NHI spending
• Quality of care remained poor due to the
fragmented care under the FFS payment system
• Previous government attempts to improve the
quality of care yielded mediocre results, thought to
be due to lack of structural support and financial
incentive to providers to deliver appropriate care.
Diabetes Mellitus (DM)
Diabetes Mellitus (DM)
• Using disease management team care model,
chronic care services are delivered by certified
DM physicians, nurses, and dietitians 4 x/yr.
Provider participation:
• Required services include and tests for HbA1C,
urine micro-albumin, eye exam, BP and LDL
check, foot care, and patient counseling
Hospitals/Clinics
2002
Cases
2003
2004
159
313
464
32,267
80,207
125,530
9/2005
596
143,148
• % DM patients enrolled in DM-P4P program:
2004
17.3%
2005
19.7%
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Diabetes Mellitus (DM)
EXTRA PAYMENTS FOR DIABETES P4P
Complex process-based bonus scheme:
–
–
–
–
–
1845 points for initial visit for new patient
875 points for each repeat visit (up to 3x/yr.)
2245 points for annual evaluation visit
200 points for drug refill prescription
Eye exam separate payment
NOTE: 1 POINT = NT$ 1 = US$ 0.03
Other medical services and drugs for DM patients
enrolled in the program are paid under the
traditional FFS payment scheme.
Asthma
• Provider participation:
Cases
A. Process indicators: Showed improvements across
the board in 2004 over previous studies
B. Outcomes indicators:
HbA1c
Systolic BP
Diastolic BP
LDL
Pre-trial*
22.1
44.5
24.2
14.1
Post-trial**
16.1
40.4
22.5
13.6
% Change
- 27.0 %
- 9.2 %
- 7.0 %
- 3.5 %
* ‘Pre-trial’ column: Numbers refer to % of DM patients in the experimental group whose
biological and metabolic conditions were not well-controlled before entering trial
** ‘Post-trial’ column: Numbers refer to % of patients whose biologic and metabolic conditions
remain not well-controlled after trial began.
EXTRA PAYMENTS FOR ASTHMA P4P
• Starting date: November 1, 2001; beginning in
January 2004 payments increased also for care for
co-morbidities of asthma patients
Hospitals/clinics
RESULTS:
2002
2003
2004
110
320
982
7,229
31,344
106,353
9/2005
1,252
148,831
1st Year:
–
–
–
–
NT$ 500 ‘management fee’ for new patients
NT$ 200 for 2nd visit
NT$ 200 for 3rd visit
NT$ 900 for year-end (4th) visit
2nd Year:
– 4 visits @ NT$ 200, 200, 200, and 900 for ea. visit
NOTE: NT$ 100 = US$ 3.05
Asthma
RESULTS After 2 yrs. of follow up:
– No apparent difference in frequency of
outpatient visits
– Cost for outpatient care: ↑ 16.27%
–
“ for TOTAL care: ↑ 9.17%
– Frequency of emergency visits: ↓ 39.94%
– Cost for emergency care: ↓ 30.90%
– Frequency of hospitalization: ↓ 46.31%
– Cost of inpatient care: ↓ 44%
– Length of stay: ↓ 51.74%
IV. FUNDING FOR P4P PROGRAMS
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HOW MUCH IS COMMITTED TO
“PERFORMANCE PAYMENTS”?
• Beginning in 2006, funds for bonus payments are
made available through a special, ear-marked
budget line item titled “Other Budgets” within the
NHI’s overall global budget.
• Therefore, the P4P system is not budget-neutral.
• Instead, performance payments are made in
addition to the regular FFS payments for services
rendered.
IV. CONCLUDING OBSERVATIONS
Total funding for P4P committed in 2006, by source
of funding:
GB for primary care
NT$
356 ml.
Hospital GB
NT$
725 ml.
Other sources
NT$
69 ml.
TOTAL $ COMMITTED:
NT$ 1,166 ml.
At this time, total P4P spending under Taiwan’s NHI
is between .3% and .4% of total NHI spending, but it
is slated to grow in the future.
It would appear that, based on the results of the
P4P programs currently being adopted in Taiwan,
financial incentives do play an important role in the
delivery of better quality care and better outcomes.
This is a conclusion the authors of a national DM
study also reached.
Of course, the “results” shown here may also be
driven by other factors, e.g.:
– guideline-based disease management helped
guide/change provider behavior.
– Coordinated efforts from other DOH agencies to promote
better process and outcome, e.g., the Bureau of Health
Promotion in the DOH actively works with the BNHI to
improve DM care.
To my knowledge, a full-fledged statistical analysis
of Taiwan’s P4P programs controlling for possibly
confounding factors has not yet been undertaken.
Finally, whatever one may think of single-payer health
insurance systems, Taiwan’s single payer system is
an ideal platform for P4P programs, because that
system embodies an information infrastructure that
yields comprehensive and up-to-date information on
the care actually delivered to patients.
It allows Taiwan to base its P4P system more heavily
on claims data, rather than on the less reliable, selfreported performance data now so widely used for
P4P throughout the world.
Of course, to the extent that claims for payment may
be fraudulent or miscoded, such data are no more
reliable than self-reported performance data.
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All P4P systems, around the world, should
operate on Ronald Reagan’s famous maxim:
TRUST, BUT VERIFY.
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