Breast Cancer Reimbursement Policy in Taiwan

1. Breast Cancer Reimbursement Policyin Taiwan Mao-Ting Sheen Director Bureau of National Health Insurance Department of Health, Executive Yuan November 10, 2011

2. 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

3. 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.

4. The Long-term Trend in the Incidence of Female Breast Cancer in Taiwan Source：Taiwan Cancer Registry http://tcr.cph.ntu.edu.tw/main.php?Page=A5B2

5. 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=A5B3

6. Inpatient Medical Expenses of Breast Cancer in Taiwan Source: Medical claims database of BNHI

7. Outpatient Medical Expenses of Breast Cancer in Taiwan Source: Medical claims database of BNHI

8. Outpatient & Inpatient Medical Expenses of Breast Cancer in Taiwan

9. 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.

10. 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.

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

12. Pay for Performance Pilot Program • Requirement in Process • Participation rate of cases • Completion rate of disease management for new patients • Completion rate of disease management for old patients • Annual assessment of disease management completion rate • The degree of adherence to the treatment guidelines • Requirement in Outcome • Extra payment based on the performance of quality indicators • Disease free survival rate, Overall survival rate

13. Payment Incentives for P4P Program • Payment 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.

14. Participation of P4P Program Note: Since the requirement and calculation of performance bonus was quite complicated, hospitals were not willing to partake.

15. Results of P4P Program • 5-year disease free survival rate Use Kaplan-Meier or life table to calculate survival rate as of 2010

16. Results of P4P Program • 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%.

17. Results of P4P Program • 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.

18. Conclusions • 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.

19. Thank you for your attention!