title: Association of a Bundled-Payment Program With Cost and Outcomes in Full-Cycle Breast Cancer Care.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  METHODS
  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
  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.
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan2Center for Policy, Outcomes, and Prevention, Center for Health Policy/Primary Care Outcomes Research, Stanford University School of Medicine, Stanford, California3Division of General Pediatrics, Stanford University School of Medicine, Stanford, California.
authors: C Jason
authors: CJ
authors: Wang
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Skye H
authors: SH
authors: Cheng
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Jen-You
authors: JY
authors: Wu
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Yi-Ping
authors: YP
authors: Lin
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Wen-Hsin
authors: WH
authors: Kao
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Chia-Li
authors: CL
authors: Lin
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan.
authors: Yin-Jou
authors: YJ
authors: Chen
authors: National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan.
authors: Shu-Ling
authors: SL
authors: Tsai
authors: National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan.
authors: Feng-Yu
authors: FY
authors: Kao
authors: Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan5Department of Medicine, Duke University, Durham, North Carolina.
authors: Andrew T
authors: AT
authors: Huang
mesh_terms: D000328:Adult; D000970:Antineoplastic Agents / Q000191:economics* / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000191:economics; D003362:Cost-Benefit Analysis; D018588:Fee-for-Service Plans / Q000191:economics*; D005260:Female; D005102:Health Expenditures; D006801:Humans; D008875:Middle Aged; D064872:Patient Care Bundles / Q000191:economics*; D017410:Practice Guidelines as Topic / Q000592:standards; D011787:Quality of Health Care; D012042:Registries; D012051:Reimbursement Mechanisms; D016019:Survival Analysis; D013624:Taiwan; D016896:Treatment Outcome
chemical_list: D000970:Antineoplastic Agents