Association for Public Policy Analysis & Management

Importance:  Concerns about health care spending growth and quality of care have led to increasing interest in new models for healthcare delivery and payment.  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 ACA.  There is no information on the impact of these types of models on substance use disorder (SUD) service use, spending, and quality of care.  The AQC could improve SUD care by addressing the historical separation of SUD treatment financing and delivery from the rest of the health care sector. Alternatively, provider organizations at risk for a population’s total costs may avoid accepting patients with or under-provide services to high-cost individuals such as those with SUD. The AQC model may affect the SUD population differently depending on whether these services are included in the risk contract. Notably, only a subset of AQC provider organizations accepted risk for SUD treatment costs.

Objective:  To assess the impact of AQC implementation on utilization and spending for SUD services. 

Design/Setting/Participants:  We use BCBSMA administrative claims (2006-2011) on enrollees in the intervention and comparison groups aged 13-64.  We conducted difference-in-differences analyses to study the effects of the AQC on SUD service use and spending using two-part spending models. We compare enrollees in two intervention groups – those in AQC organizations that did and did not accept SUD risk – with enrollees not participating in the AQC.  We also estimated negative binomial regression models to examine effects on the quantity of SUD services and logistic regression to examine impacts on HEDIS-based SUD performance measures -- treatment identification, initiation and engagement.

Results:  Among enrollees of AQC organizations that accepted behavioral health risk, AQC implementation was not associated with a change in the probability of SUD service use, SUD spending, or total health care spending among SUD service users.  Among enrollees of AQC organizations that did not accept behavioral health risk, AQC implementation was associated with a small increase in the probability of any SUD service use (1.71% vs. 1.58%, p=0.001), but no change in either SUD or total health care spending.  There was some evidence that AQC implementation was associated with an increased number of inpatient SUD days for enrollees of organizations that accepted behavioral health risk (11.1 vs. 9.5, p=0.01) and an improvement in the HEDIS-based treatment initiation quality metric for enrollees of AQC organizations that did not accept behavioral health risk (23.7% vs. 27.0%, p=0.01). Overall, the effects were small in magnitude. 

Conclusion and Relevance:  An understanding of the effects of implementing global payment and accountable care models on individuals with SUD conditions is important for public and private payers considering these models, as well as providers operating under these contracts.  Despite persistent concerns about under-provision of SUD services generally and with global payment models in particular, SUD service use, and spending did not decline as a result of the AQC. 

NIDA (#R01 DA035214)