Fee-for-service reimbursement cuts may put damper on stroke gains

Taiwan's reimbursement cuts may have slowed progress in reducing 30-day mortality rates for ischemic stroke, according to a study published online Dec. 9 in Circulation: Cardiovascular Quality and Outcomes.

The study explored whether reimbursement cuts for fee-for-service structures helped improve or was detrimental to the nation’s healthcare system. Yu-Chi Tung, PhD, of the Institute of Health Policy and Management at National Taiwan University in Taipei, and colleagues reviewed data in a national health insurance database from 1997 through 2010. Their time-series assessment broke the data into quarters to review changes pre and post a hospital budget cap implemented in Taiwan in 2002.

They found that 30-day mortality rates had been decreasing much more rapidly prior to the global budget caps. Rates in 1997 were around 5.7 percent, in 2002 4.6 percent, and then dipped to only 4.2 percent by 2010. These findings were coupled with increases in the use of CT and MR imaging at a rate of 4.21 percent per quarter, 0.31 percent more per quarter than before the implementation of budget caps. Antiplatelet and anticoagulant therapy use slowed to an increase of 0.09 percent per quarter. This translated to antiplatelet and anticoagulant therapy rates of 80.5 percent in 1997, 89 percent in 2002 and 92.8 percent in 2010.

Statin use had the highest rate of increased use: In 1997, 3.1 percent of patients received statin therapy and in 2002 that number was 12 percent. By 2010, however, 30 percent of patients were prescribed statins.

They also noted that the use of physiotherapy and occupational therapy rose among stroke patients, increasing from 39 percent in 1997, 41.1 percent in 2002 and leaping to 51.8 percent in 2010.

While many of these increased rates related to larger recommendations in the community, Tung et al expressed concern that some of the drivers for these increases were not related to improved care.

Among the speculative reasons for increased imaging, for example, were higher margins for hospitals. Meanwhile, they were concerned that decreased quality nursing staffing and slower use of antiplatelet and anticoagulant therapy, a more costly approach, may have resulted from cuts. They were unable to speak in greater detail as the data available did not include hospital staffing rates, nor did it provide reasons for use of treatment.

Tung et al noted that their findings largely reflected those of earlier studies on the subject, and that more long-term studies are needed to determine how changes affect outcomes.