title: Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system.
abstract: BACKGROUND
  Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension.
  
  
  METHODS
  This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme.
  
  
  RESULTS
  Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation.
  
  
  CONCLUSIONS
  This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.
authors.affiliation: Department of Public Health, College of Medicine, Fu Jen Catholic University, Taipei, Taiwan and.
authors.forename: Chi-Chen
authors.initials: CC
authors.lastname: Chen
authors.affiliation: Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan shcheng@ntu.edu.tw.
authors.forename: Shou-Hsia
authors.initials: SH
authors.lastname: Cheng
mesh_terms: D000368:Aged; D002908:Chronic Disease / Q000453:epidemiology; D015897:Comorbidity; D003266:Continuity of Patient Care; D016208:Databases, Factual; D003695:Delivery of Health Care; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000191:economics*; D012052:Reimbursement, Incentive; D013624:Taiwan / Q000453:epidemiology; D019472:Universal Health Insurance
keywords: Continuity of care; diabetes mellitus; health care outcomes; multiple chronic conditions; pay-for-performance programme