Breast Cancer Reimbursement Policy

in Taiwan

Mao-Ting SheenDirector

Bureau of National Health Insurance

Department of Health, Executive Yuan

November 10, 20111

Outline

• Current Status of Breast Cancer in Taiwan

• Medical Expenditures of Breast Cancer

• Reimbursement of Target-therapy Drugs

• The Breast Cancer Pay for Performance Pilot Program

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Current Status of Breast Cancer in Taiwan

• The 2008 Cancer Registry Report published by the Department of Health in Taiwan indicated that breast cancer still had the highest incidence rate among all female cancers and appeared a gradually year-by-year rising tendency.

• The incidence rate and death rate of breast cancer in Taiwan took the 2nd rank in Asian countries.

• The prevalence of breast cancer has become a global trend. In recent years, it has an obvious trend that the patient’s age has been dropping in Asian countries.

The Long-term Trend in the Incidence of Female Breast Cancer in Taiwan

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Source ： Taiwan Cancer Registry http://tcr.cph.ntu.edu.tw/main.php?Page=A5B2

0

10

20

30

40

50

60

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

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The Age-specific Incidence Rate of Taiwan’s Female Breast Cancer (1981 ~

2005)

Source ： Taiwan Cancer Registry http://tcr.cph.ntu.edu.tw/main.php?Page=A5B35

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Inpatient Medical Expenses of Breast Cancer in Taiwan

Source: Medical claims database of BNHI

In-patient 2006 2007 2008 2009 2010 　

　 (million) (%) (million) (%) (million) (%) (million) (%) (million) (%) 　

Total Exp. 1,600 100.0% 1,745 100.0% 1,961 100.0% 2,052 100.0% 2,219 100.0%

Drug Fees 658 41.1% 714 40.9% 759 38.7% 803 39.1% 930 41.9%

Diagnosis Fees 60 3.8% 66 3.8% 75 3.8% 83 4.0% 89 4.0%

Inpatient Surgical Fees 192 12.0% 208 11.9% 233 11.9% 245 11.9% 256 11.6%

Ward Fees 190 11.8% 211 12.1% 235 12.0% 255 12.4% 271 12.2%

Inpatient Laboratory Fees

131 8.2% 143 8.2% 166 8.5% 182 8.9% 206 9.3%

Inpatient X-ray Fees 117 7.3% 130 7.5% 144 7.4% 162 7.9% 173 7.8%

Inpatient Therapeutic Procedure Fees &

Medical Devices Fees113 7.1% 127 7.3% 151 7.7% 156 7.6% 162 7.3%

Others 138 8.7% 145 8.3% 198 10.1% 167 8.1% 133 6.0%

Number of patients 11,715 　 12,966 　 14,388 　 15,620 　 16,659 　 　Avg. admissions per patient

2.8 　 2.9 　 2.9 　 3.0 　 3.0 　 　Avg. length of stay per patient

14.0 　 13.8 　 13.6 　 13.3 　 13.3 　 　

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Outpatient Medical Expenses of Breast Cancer in Taiwan

Source: Medical claims database of BNHI

Out-patient 2006 2007 2008 2009 2010 　

　 (million) (%) (million) (%) (million) (%) (million) (%) (million) (%) 　

Total Exp. 2,642 100.0% 3,000 100.0% 3,447 100.0% 3,808 100.0% 4,649 100.0%

Drug Fees 1,381 52.3% 1,637 54.5% 1,839 53.4% 1,988 52.2% 2,577 55.4%

Diagnosis Fees 130 4.9% 140 4.7% 157 4.5% 176 4.6% 193 4.2%

Laboratory & Treatment Fees

1,067 40.4% 1,215 40.5% 1,434 41.6% 1,613 42.4% 1,830 39.4%

Others 64 2.4% 9 0.3% 18 0.5% 30 0.8% 48 1.0%

Number of patients 48,394 53,288 58,173 63,680 68,864 　

Avg. number of visits per patient

12.4 12.3 12.7 12.5 12.6 　

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Outpatient & Inpatient Medical Expenses of Breast Cancer in Taiwan

Reimbursement of Target-therapy Drugs for Breast Cancer

Trastuzumab ( Ex: Herceptin ) coverage• 2002/4/1 covered by NHI - used for metastatic breast cancer

(MBC) patients– Use alone ： HER2 excessive expression(IHC 3+ 或 FISH+) and

received at least one time of chemotherapy(C/T) MBC patients

– Use combined with paclitaxel or docetaxel: HER2 excessive expression(IHC 3+ 或 FISH+) and has never received C/T MBC patients

– MBC and HER2excessive expression patients who has never used trastuzumab.

• 2010/1/1 expanded coverage to early breast ca. patients– Post surgery and C/T, early breast ca. patients with HER2 excessive

expression (IHC 3+ or FISH+), used as adjuvant therapy, and confined its use for less than one year.

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Reimbursement of Target-therapy Drugs for Breast Cancer

Lapatinib ( Ex: Tykerb ): not covered yet

• Reason: due to high uncertainty in the

effectiveness of increasing survival rate and the

total budget impact, this drug has not been

covered till date.

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The Drug Expenses of Trastuzumab

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Note: Use rate is defined as the rate of the patients who has ever used trastuzumab among the total number of breast cancer patients.

Year

Patient who has ever

used Trastuzumab

Use rateTrastuzumab drug

expenses(million)

Share of all medical cost

Share of all drug cost

2006 771 1.6% 282 6.7% 13.8%

2007 1038 1.9% 397 8.4% 16.9%

2008 1169 2.0% 481 8.9% 18.5%

2009 1403 2.2% 617 10.5% 22.1%

2010 2829 4.1% 1,372 20.0% 39.1%

Pay for Performance Pilot Program

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Requirement in ProcessParticipation rate of casesCompletion rate of disease management for new patientsCompletion rate of disease management for old patientsAnnual assessment of disease management completion rateThe degree of adherence to the treatment guidelines

Requirement in OutcomeExtra payment based on the performance of quality indicatorsDisease free survival rate, Overall survival rate

Payment Incentives for P4P ProgramPayment Incentives:Fee for Service ＋ Performance Bonus

Performance Bonus calculation：1.The bonus depends on the performance of the disease free survival rates in the stage 0 to 3 and the overall survival rate in the stage 4 in 5 years after treatment as indicated in the table.2. It is paid annually in percentage of the annual total payment amount calculated based on FFS if the required standard is met.

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Pathological stage First yr. Second yr. Third yr. Fourth yr. Fifth yr.

Stage 0(Disease free survival rate) 97% 94% 93% 93% 93%

Stage 1(Disease free survival rate) 97% 93% 89% 88% 86%

Stage 2(Disease free survival rate) 95% 86% 80% 78% 75%

Stage 3(Disease free survival rate) 85% 70% 50% 45% 40%

Stage 4(Overall survival rate) 64% 33% 23% 18% 10%

Extra bonus on top of FFS 2% 3% 4% 6% 7%

Participation of P4P Program

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2005 2006 2007 2008 2009 2010

Number of cases

5,852 6,927 8,438 9,807 10,743 11,678

Participation rate

12.09% 12.98% 13.60% 14.64% 14.50% 14.62%

Note: Since the requirement and calculation of performance bonus was quite complicated, hospitals were not willing to partake.

Results of P4P Program

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Use Kaplan-Meier or life table to calculate survival rate as of 2010

Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

99% 98% 95% 87% 71%

5-year disease free survival rate

Results of P4P Program

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Local recurrence rate after breast cancer surgery

This indicator is defined as the rate of the number of cases

occurred local recurrence (including supraclavicular lymph

nodes) among the total number of patients who performed

either partial or whole breast mastectomy. According to the

results of the hospitals which joined the pilot project, the

local recurrence rate was less than 2% annually , and five-

year local recurrence rate was less than 10%.

Results of P4P Program

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Re-treatment rate of breast cancer after surgery

This indicator refers to the rate of the number of cases who

received repeated chemotherapy or radiation therapy after

partial or whole breast mastectomy among the total number of

patients who performed either partial or whole breast

mastectomy. According to the results of the hospitals which

joined the pilot project, the re-treatment rate within 18 months,

24 months and 30 months were less than 10%, 15% and 20%,

respectively.

Conclusions

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The incidence of breast cancer in Taiwan has increased year

by year. And there’s a tendency that the patient age has been

obviously dropping in recent years.

The government has made promotion and provided funding for

early screening.

The National Health Insurance has also put helpful drugs,

exams and treatment items into coverage.

Strong activities of private society involved.

I believe with the joint efforts of government, medical

providers and private support groups, the prevention and

treatment of breast cancer will generate more effective results.

Thank you for your attention!

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