| Summary: | 碩士 === 臺北醫學大學 === 醫務管理學研究所 === 96 === The Bureau of National Health Insurance (NHI) started to experiment an episode-based pay-for-performance program for breast cancer, the NHI Breast Cancer Quality Enhancement Pilot Project, in October of 2001. This study aims to examine whether or not the pilot project had impacts on the increase of the rates of breast-conserving surgery and subsequent radiation therapy after breast-conserving surgery, and on the one-year utilization of medical care resources for breast cancer patients.
The sample consisted of 15,574 patients who had been confirmed with breast cancer between 2001 and 2004 and undergone breast cancer surgeries within one year after confirmation. In the quasi-experimental design, the experimental group (6 hospitals) had 4,306 patients (2,103 and 2,203 in the pre- and post-pilot-project groups, respectively), while the control group (87 hospitals) had 11,268 patients. Results from the logit model found no sufficient evidence to indicate the pilot project had increased the rate of breast-conserving surgeries for patients in the experimental group, mainly because the breast-conserving surgery rates were also increasing in the control group.
For those who underwent breast-conserving surgeries (3,253 patients), 968 were in the experimental group (397 and 571 in the pre- and post-pilot-project groups). The logit model confirmed that patients in the pre-pilot-project group were more likely to receive radiation therapies than those in the control group, with an odds-ratio 4.56 approximately, whereas patients in the post-pilot-project group had even higher likelihood to undergo radiation therapies than those in the control group, and the odds-ratio was about 38.04.
Regarding the one-year utilization of medical care resources after and including breast cancer surgery, 15,557 patients had available data among those 15,574 cases. The multiple regression model demonstrated that the medical expenses of patients in the pre-pilot-project group were not statistically different from those in the control group, but patients in the post-pilot-project group had lower medical expenses than those in the control group.
Given the study results, and the complicated design and low participations of the pilot project, the study suggests that the Bureau of NHI may consider the following for policy change. First, who should be rewarded, those who are already outstanding or those who strive to improve their quality over time? How effective the current program has been? Second, the payment incentive in a pay-for-performance program should reward good quality rather than particular procedure. Therefore, the current higher payment for breast-conserving surgery should be revised so that the payments for different surgeries are all based on their costs. Third, the special claim reporting rule for the pilot project should be simplified to decrease administrative costs and encourage hospital participation. Finally, given the availability of the utilization data, the payment rates should be reviewed and revised periodically.
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