Pay-for-Performance Bundled Payment Breast Cancer Care Program
The Koo Foundation Sun Yat-Sen Cancer Center (KFSYSCC) has developed a bundled payment model for breast cancer that leads to better adherence to quality indicators, better outcomes, and more effective cost control over time.
Since 1997, KFSYSCC has used multidisciplinary, team-based breast cancer care for patients. The breast cancer team includes radiologists, medical and surgical oncologists, surgeons, pathologists, psychiatrists, rehabilitation specialists and advanced nurse practitioners.
To improve patient outcomes through standard high-quality care while containing high societal health insurance costs, KFSYSCC’s multidisciplinary team of specialists worked with Taiwan’s national health insurer, the Bureau of National Health Insurance (BHNI), and other hospital providers to draft an initial set of 15 quality-of-care indicators related to process and outcomes. BNHI then used these measures to design a pilot pay-for-performance program for breast cancer care. KFSYSCC, through a joint project, worked with RAND in the United States to reconcile the indicators with existing ones from RAND QA Tools and the Cancer Care Outcomes Research and Surveillance Consortium. The team used a final list 10 indicators which had an impact on mortality.
Analysis included patients with newly diagnosed breast cancer who were treated at KFSYSCC and had
their data prospectively collected. After the treatment period, each patient was contacted or seen every 3–6 months up to 5 years, and then at least once per year or until they were no longer able to be contacted by the KFSYSCC staff. Death records were obtained from the Department of Health in Taiwan and updated annually.
Analysis shows that 81% of patients had no evidence of recurrence whereas 19% relapsed. The initial sites of relapse were local or regional in 3.2% of patients, distant in 12%, and both in 3.8%. The 5-year progression-free survival and overall survival were 82% and 89%, respectively.
To understand the impact the breast cancer pilot program had on costs, KFSYSCC compared bundled payment programs with fee-for-service programs in Taiwan.
Women with newly diagnosed breast cancer were followed for 5 years, with a final sample of propensity score-matched patients comprising 4485 in the bundled-payment group and 13,455 in the FFS group.
Researchers found that 34.9% of patients with applicable quality indicators had full adherence to quality indicators, compared with 27.5% with applicable quality indicators in the FFS group (P<.001). For patients with stages 0 to 3 breast cancer, the 5-year event-free survival rates were 84.48% and 80.88% for the bundled-payment and FFS groups, respectively (P<.01). The 5-year medical payments of the bundled-payment group remained stable, while there was an increase in the FFS group from USD $16,000 to $19,230; starting in 2008, payments for the FFS group exceeded bundled payments (published in JAMA Oncology).
The breast cancer model at KFSYSCC is unique in Taiwan because it aligns payment with quality measures. KFSYSCC’s 5-year overall survival for all stages is 92% compared to 85% in Taiwan. Our bundled-payment program is associated with better adherence to quality indicators and better outcomes over time when compared with a fee-for-service (FFS) program in breast cancer care.