The Early Impact Of The ‘Alternative Quality Contract’ On Mental Health Service Use And Spending In Massachusetts

Abstract

Accountable care using global payment with performance bonuses has shown promise in controlling spending growth and improving care. This study examined how an early model, the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA), has affected care for mental illness. We compared spending and use for enrollees in AQC organizations that did and did not accept financial risk for mental health with enrollees not participating in the contract. Compared with BCBSMA enrollees in organizations not participating in the AQC, we found that enrollees in organizations participating in the AQC were slightly less likely to use mental health services and had small declines in total health care spending, but no change was found in mental health spending among all users. The declines in probability of use of mental health services and in total health spending attributable to the AQC were concentrated among enrollees in AQC organizations that accepted financial risk for behavioral health. Interviews with AQC organization leaders suggested that the contractual arrangements did not meaningfully affect mental health care delivery in the program’s initial years, but organizations are now at varying stages of efforts to improve integration.

Medicare Accountable Care Organizations and Antidepressant Use by Patients With Depression

“…These findings contribute to evidence of unchanged or improved quality associated with participation in the Medicare ACO programs(5–7) in general. Our findings are also consistent with recent quantitative research that found limited gains in performance on other behavioral health quality metrics associated with ACOs(11, 13). More generally, the absence of large effects on antidepressant use and adherence in ACOs is consistent with previous documentation that depression is commonly under-recognized and under-treated(14).…”

“…Additionally, leaders of Medicare and commercial ACOs have described considerable challenges in improving behavioral health care management, including inadequate data availability for managing behavioral health due to federal and state privacy restrictions that limit information sharing between behavioral health and general medical providers, incomplete SUD data provided by CMS due to restrictions from 42 CFR Part 2, and shortages of mental health care providers(13, 15). …”

The Alternative Quality Contract: Impact on Service Use and Spending for Children With ADHD

“…While AQC provider organizations reported little initial focus on improving integration of behavioral health and other services, many have since initiated efforts to improve such integration (7). It will be critical to understand how these new efforts affect children with ADHD over the longer term.…”

“…Global payment models, such as the AQC, provide an opportunity to address fragmentation of care by incorporating mental and substance use disorder (behavioral health) services with general medical services under one integrated payment system (6,7). Under this type of model, primary care physicians (PCPs) play the central role in patients' care and are typically given greater flexibility to coordinate the health of the population in their patient panels with attention to reducing the burden of disease over a longer time horizon than is typical in traditional payment models.…”

Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract

“…It is also consistent with knowledge about the implementation of the AQC program itself; AQC organization leaders reported little focus on this area during the AQC’s first three years as they struggled to reorient their systems in response to the AQC. Likewise, leaders of specialty behavioral health provider organizations in Massachusetts have indicated a low level of awareness of the AQC, and no substantial changes in referral patterns or contracting practices due to the AQC (33). …”