Objective: Payment and delivery system reforms are being considered by many payers to address concerns about health care spending growth and to improve the efficiency, coordination and quality of care.  The Alternative Quality Contract (AQC) is one such initiative launched by Blue Cross Blue Shield of Massachusetts (BCBSMA) in 2009.  The AQC combines global payment with performance incentives and resembles accountable care organization models authorized under the Affordable Care Act.  There is no information on the impact of these types of models on spending, use and quality of care for mental health and substance use disorder (MH/SUD) treatment.  Only certain provider organizations accepted risk for these treatment costs under the AQC. The AQC model may affect the persons with MH/SUD differently depending on whether these services are included in the risk contract.  The AQC could improve care by addressing the historical separation of MH/SUD treatment financing and delivery.  On the other hand, provider organizations at risk for a population’s total costs may avoid enrolling or may under-provide services to individuals with MH/SUD.

Method: We use 2006-2011 BCBSMA claims data to conduct difference-in-differences analyses of the effects of the AQC on MH/SUD spending and utilization outcomes.  In addition, we evaluate the impact of the AQC on three performance measures of SUD care: (1) identification, (2) treatment initiation, and (3) treatment engagement.  The purpose of these measures, which were developed by Washington Circle and adopted by the National Committee for Quality Assurance for the Healthcare Effectiveness Data and Information Set (HEDIS), is to provide indicators of performance using claims data.  We compare two intervention groups – one with enrollees in AQC organizations that accept MH/SUD risk and one with enrollees in AQC organizations that do not – to a group of BCBSMA enrollees not participating in the AQC.

Findings: We examine the AQC’s impact on use of inpatient services, outpatient services (e.g., psychotherapy, medication management), and psychiatric medications, and examine use of MH/SUD services delivered in the primary care setting versus the specialty care setting.  Spending and utilization analyses are in progress, and final results will be available by the November 2014 conference.  We have completed preliminary analyses on the performance measures outcomes.  These results suggest no difference attributable to the AQC in HEDIS performance measures of SUD identification, treatment initiation and treatment engagement among health plan enrollees in AQC organizations and comparison group enrollee findings are consistent with our initial hypotheses given that no SUD measures were included in the 64 different performance measures used to pay organizations under the AQC.  However, results suggest that the AQC may not be effective approach to improving detection and quality of care for SUD unless organizations are incentivized to improve care for this group.

Impact: An understanding of the effects of implementing global payment and accountable care models on individuals with MH/SUD treatment needs is important for public and private payers considering these models, as well as providers operating under these types of contracts.