title: Long-term effect of fee-for-service-based reimbursement cuts on processes and outcomes of care for stroke: interrupted time-series study from Taiwan.
abstract: BACKGROUND
  As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke.
  
  
  RESULTS
  We analyzed all 411,487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan's National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P=0.013), antiplatelet/anticoagulant use (-0.20% per quarter; P<0.001), statin use (0.18% per quarter; P=0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P<0.001), and 30-day mortality (0.06% per quarter; P<0.001).
  
  
  CONCLUSIONS
  There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care.
authors.affiliation: From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.).
authors.forename: Yu-Chi
authors.initials: YC
authors.lastname: Tung
authors.affiliation: From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.).
authors.forename: Guann-Ming
authors.initials: GM
authors.lastname: Chang
authors.affiliation: From the Institute of Health Policy and Management, National Taiwan University, Taipei, Taiwan (Y.-C.T., S.-H.C.); Department of Family Medicine, Cardinal Tien Hospital, New Taipei City, Taiwan (G.-M.C.); and School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan (G.-M.C.). shcheng@ntu.edu.tw.
authors.forename: Shou-Hsia
authors.initials: SH
authors.lastname: Cheng
mesh_terms: D000368:Aged; D002017:Budgets; D017046:Cost Savings; D016208:Databases, Factual; D018588:Fee-for-Service Plans / Q000191:economics* / Q000639:trends; D005260:Female; D018166:Health Care Reform / Q000191:economics* / Q000639:trends; D006295:Health Resources / Q000191:economics / Q000706:statistics & numerical data; D006769:Hospitals, General / Q000191:economics* / Q000639:trends; D006801:Humans; D008297:Male; D010343:Patient Admission / Q000191:economics; D017064:Process Assessment, Health Care / Q000191:economics* / Q000639:trends; D058996:Quality Improvement / Q000191:economics* / Q000639:trends; D019984:Quality Indicators, Health Care / Q000191:economics* / Q000639:trends; D020521:Stroke / Q000191:economics* / Q000628:therapy*; D013624:Taiwan; D013997:Time Factors; D016896:Treatment Outcome
keywords: health policy; insurance, health, reimbursement; outcome and process assessment (health care); stroke