Effects and Factors Related to Adherence to A Diabetes Pay-for-Performance Program: Analyses of a National Health Insurance Claims Database

Objectives: To compare the effects of a diabetes pay-for-performance (P4P) program on diabetes-related/nondiabetes-related healthcare utilization/expenses between participants who adhered to the program and those who did not, and explore factors related to program adherence.

Design: A secondary data analysis with a natural experimental design.

Setting: Taiwan's National Health Insurance claims database (2001-2011) of newly diagnosed patients with diabetes in 2001 was used for the analyses.

Participants: The database under analyses contained 119,970 patients who were newly diagnosed with diabetes in 2001. Longitudinal data from 2001 to 2011 were obtained. A sample of 5592 patients who were enrolled in the diabetes P4P program during 2003-2006 was identified. After a 3-year follow-up of the enrolled patients, 2647 (47.3%) of them adhered to the program. To minimize the differences between the characteristics of the patients who adhered to the program and those who did not, propensity score matching was adopted. A total of 5294 patients (adherence: 2647 vs nonadherence: 2647) were included for analyses.

Measurements: We estimated utilization/expenses of healthcare services for both groups at 6 time points and applied t tests to test each utilization and expense of healthcare services between the 2 groups. A repeated-measures analysis of variance was applied to examine changes in the annual diabetes-related healthcare service expenses and total annual expenses by group. Logistic regression models were used to examine factors related to program adherence. Covariates included participant age, gender, diabetes-related complications, Charlson Comorbidity Index, Continuity of Care Index, time since diagnosis of diabetes, hospitalization in the previous year, and location receiving healthcare services.

Results: Total annual healthcare expenses spent by the adherence group were significantly lower than those of the nonadherence group. Gender, continuity of care, time since diagnosis of diabetes, hospitalizations in the previous year, and location receiving healthcare services were factors related to program adherence.

Conclusions: Long-term, beneficial effects of the diabetes P4P program might have been present if patients had adhered to the program. Interventions and strategies which could improve program adherence and continuity of care are suggested to achieve optimal disease control and clinical outcomes.