Association for Public Policy Analysis & Management

Tobacco use is the leading cause of preventable death and disability. Global payment and accountable care models initiated under the Affordable Care Act in the US have the potential to increase use of cost-effective tobacco cessation services. The objective of this study was to examine how one global payment and accountable care model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected tobacco cessation service use. 

 We used 2006-2011 BCBSMA claims and enrollment data included adults aged 18-64 enrolled in a BCBSMA. We examined the AQC’s effects on all enrollees; a subset at high risk of tobacco-related complications due to certain medical conditions; and behavioral health service users. 

To account for differences in the characteristics of enrollees across AQC and non-AQC organizations and secular trends in service utilization unrelated to the AQC, we used a difference-in-difference design that includes in the comparison group enrollees in organizations that, in a specific calendar year, had not yet entered the AQC but would in a future year, plus enrollees in organizations that never entered the AQC. We examined use of:  (1) any cessation treatment (pharmacotherapy or counseling); (2) varenicline or bupropion; (3) nicotine replacement therapies; (4) cessation counseling; and (4) combination therapy (pharmacotherapy plus counseling).  We also examined duration of pharmacotherapy use and number of counseling visits among users.  

 Rates of tobacco cessation treatment use were higher under the AQC relative to the comparison group overall (2.02% vs. 1.87%, p<0.0001), among enrollees at risk for tobacco-related complications (4.97% vs. 4.66%, p<0.0001), and among behavioral health service users (3.67% vs. 3.25%, p<0.0001).  The probability of using varenicline or bupropion under the AQC was higher (1.60% vs. 1.51%, p<0.0001), as was the probability of any counseling visits (0.43% vs. 0.33%, p<0.0001) and the probability of combination therapy (0.13% vs. 0.10%, p<0.0001).  We found no statistically significant difference in the probability of NRT use (0.14% vs. 0.15%, p=0.26), of receiving 90 or more days of pharmacotherapy among users (10.42% vs. 10.11%, p=0.54), or of receiving more than one counseling visit among users (21.82% vs. 19.89%, p=0.21).  AQC-related differences were statistically larger in Years 2 and 3 relative to Year 1.

 In its initial three years, the AQC was associated with greater efforts to promote tobacco cessation in the absence of outpatient cessation performance metrics, suggesting that global payment incentives alone may have been sufficient to encourage greater service provision.  Our finding that the AQC’s effects on tobacco cessation service use appeared to become larger over time suggests that the longer this type of model is in place, the larger the potential benefit may be, as measured by use of evidence-based practices such as tobacco cessation services.

 Our study provides the first evidence on the effect of new global payment and accountable care models on use of tobacco cessation treatments in the US.  The AQC resulted in increased use of both prescription medications and counseling interventions that have been proven cost-effective at reducing smoking and other tobacco use.