Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care.

IMPORTANCE: Value-driven payment system reform is a potential tool for aligning economic incentives with the improvement of quality and efficiency of health care and containment of cost. Such a payment system has not been researched satisfactorily in full-cycle cancer care. OBJECTIVE: To examine the association of outcomes and medical expenditures with a bundled-payment pay-for-performance program for breast cancer in Taiwan compared with a fee-for-service (FFS) program. DESIGN, SETTING, AND PARTICIPANTS: Data were obtained from the Taiwan Cancer Database, National Health Insurance Claims Data, the National Death Registry, and the bundled-payment enrollment file. Women with newly diagnosed breast cancer and a documented first cancer treatment from January 1, 2004, to December 31, 2008, were selected from the Taiwan Cancer Database and followed up for 5 years, with the last follow-up data available on December 31, 2013. Patients in the bundled-payment program were matched at a ratio of 1:3 with control individuals in an FFS program using a propensity score method. The final sample of 17 940 patients included 4485 (25%) in the bundled-payment group and 13 455 (75%) in the FFS group. MAIN OUTCOMES AND MEASURES: Rates of adherence to quality indicators, survival rates, and medical payments (excluding bonuses paid in the bundled-payment group). The Kaplan-Meier method was used to calculate 5-year overall and event-free survival rates by cancer stage, and the Cox proportional hazards regression model was used to examine the effect of the bundled-payment program on overall and event-free survival. Sensitivity analysis for bonus payments in the bundled-payment group was also performed. RESULTS: The study population included 17 940 women (mean [SD] age, 52.2 [10.3] years). In the bundled-payment group, 1473 of 4215 patients (34.9%) with applicable quality indicators had full (100%) adherence to quality indicators compared with 3438 of 12 506 patients (27.5%) with applicable quality indicators in the FFS group (P < .001). The 5-year event-free survival rates for patients with stages 0 to III breast cancer were 84.48% for the bundled-payment group and 80.88% for the FFS group (P < .01). Although the 5-year medical payments of the bundled-payment group remained stable, the cumulative medical payments for the FFS group steadily increased from $16 000 to $19 230 and exceeded pay-for-performance bundled payments starting in 2008. CONCLUSIONS AND RELEVANCE: In Taiwan, compared with the regular FFS program, bundled payment may lead to better adherence to quality indicators, better outcomes, and more effective cost-control over time.

A proposed framework for understanding the forces behind legislation of universal health insurance: lessons from ten countries.

OBJECTIVE: To understand the forces propelling countries to legislate universal health insurance. DATA SOURCE/STUDY DESIGN: Descriptive review and exploratory synthesis of historic data on economic, geographic, socio-demographic, and political factors. DATA EXTRACTION METHODS: We searched under "insurance, health" on MEDLINE and Google Scholar, and we reviewed relevant books and articles via a snowball approach. PRINCIPAL FINDINGS: Ten countries with universal health insurance were studied. For the five countries that passed final universal insurance laws prior to 1958, we found that two forces of "historical context" (i.e., social solidarity and historic patterns), one "ongoing dynamic force" (political pressures), and "one uniqueness of the moment" force (legislative permissiveness) played a major role. For the five countries that passed final legislation between 1967 and 2010, the predominant factors were two "ongoing dynamic forces" (economic pressures and political pressures) and one "uniqueness of the moment" force (leadership). In general, countries in the former group made steady progress, whereas those in the latter group progressed in abrupt leaps. CONCLUSIONS: The lessons of more recent successes-almost all of which were achieved via abrupt leaps-strongly indicate the importance of leadership in taking advantage of generalized economic and political pressures to achieve universal health insurance.