Duke 2008 | ASHE | Equity and Efficiency in Health and Healthcare

CONTEXT Pay-for-performance (P4P) has been widely adopted in many countries to improve healthcare outcomes. Tuberculosis (TB) is still a prevailing health threat worldwide. In Taiwan, there were 16,472 new cases found in 2005 (an incidence of 72.5 per 100,000 populations). To improve treatment outcomes of TB patients, the Bureau of National Health Insurance (NHI) implemented a P4P program since 2001. This new payment program was integrated with Taiwan CDC management system for TB patients between the years 2002 and 2003. Hospitals/clinics which enrolled in program could receive extra payment for case management, medical examination, and treatment success (or COT, completion of treatment) rewards in addition to regular NHI claims for treating TB patients. This payment program aimed to encourage active participation of physicians in TB patient treatment and cooperation with public health authorities for TB control. OBJECTIVE To examine the preliminary effects of the NHI pay-for-performance program for TB patient on healthcare expenditure and treatment outcomes in Taiwan. METHODS Two major data sources were used in this study; CDC mandatory reporting system as well as the Bureau of National Health Insurance. Patient's characteristics and results of medical examination and tests such as biochemistry examination, sputum smear/culture result, chest X-ray, and prescription orders were obtained from the CDC mandatory reporting system for analysis. Information concerning the healthcare expenditures, including regular treatment claims and extra payments for the new P4P program for TB were obtained from the Bureau of the NHI. The two data sources were then linked to identify TB patients who were enrolled in the P4P program or not. To avoid the possible confounding effect of the DOTS (Directly Observed Treatment Short-course) program implemented in 2006 in Taiwan, this study analyzed the data in 2005 only. RESULTS In 2005, there were 22,663 reports of new TB cases, and 16,472 patients were confirmed with all forms of TB. A total of 175 hospitals and clinics enrolled in the P4P program. Among the confirmed TB cases, 10,817 patients (66% of them) enrolled in the P4P program. The average fee for disease management within the P4P program was $3697.9 NTD (approximately $113.8 USD) a year for each enrolled patient, and the total cost was nearly 40 million NTD in 2005 (approximately $1.231 million USD). Meanwhile, the total healthcare claimed expenditure was 4.2 billion NTD, so the proportion of the P4P costs was 0.95%. As for the treatment outcomes, the preliminary results indicated that treatment success (COT, completion of treatment) rate for those who enrolled in the program were 73%; versus 55% for those non-enrollees. The death rate was 13% for the enrolled patients, and 34% for the non-enrollees. While comparing to the overall treatment outcomes in 2005, treatment success (COT) was 61%, and the death rate was 23%. CONCLUSIONS The pay-for-performance program showed significant impacts on the treatment success rate and mortality rate among TB patients in Taiwan. More detailed cost-effectiveness analysis need to be conducted in the future.