Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
N Engl J Med. 2011 Sep 8;365(10):909-18. doi: 10.1056/NEJMsa1101416. Epub 2011 Jul 13.
In 2009, Blue Cross Blue Shield of Massachusetts (BCBS) implemented a global payment system called the Alternative Quality Contract (AQC). Provider groups in the AQC system assume accountability for spending, similar to accountable care organizations that bear financial risk. Moreover, groups are eligible to receive bonuses for quality.
Seven provider organizations began 5-year contracts as part of the AQC system in 2009. We analyzed 2006-2009 claims for 380,142 enrollees whose primary care physicians (PCPs) were in the AQC system (intervention group) and for 1,351,446 enrollees whose PCPs were not in the system (control group). We used a propensity-weighted difference-in-differences approach, adjusting for age, sex, health status, and secular trends to isolate the treatment effect of the AQC in comparisons of spending and quality between the intervention group and the control group.
Average spending increased for enrollees in both the intervention and control groups in 2009, but the increase was smaller for enrollees in the intervention group--$15.51 (1.9%) less per quarter (P=0.007). Savings derived largely from shifts in outpatient care toward facilities with lower fees; from lower expenditures for procedures, imaging, and testing; and from a reduction in spending for enrollees with the highest expected spending. The AQC system was associated with an improvement in performance on measures of the quality of the management of chronic conditions in adults (P<0.001) and of pediatric care (P=0.001), but not of adult preventive care. All AQC groups met 2009 budget targets and earned surpluses. Total BCBS payments to AQC groups, including bonuses for quality, are likely to have exceeded the estimated savings in year 1.
The AQC system was associated with a modest slowing of spending growth and improved quality of care in 2009. Savings were achieved through changes in referral patterns rather than through changes in utilization. The long-term effect of the AQC system on spending growth depends on future budget targets and providers' ability to further improve efficiencies in practice. (Funded by the Commonwealth Fund and others.).
2009 年，马萨诸塞州蓝十字蓝盾会（BCBS）实施了一种名为“替代质量合同”（AQC）的全球支付系统。AQC 系统中的医疗机构承担支出责任，类似于承担财务风险的责任医疗组织。此外，该组织有资格因质量获得奖金。
2009 年，7 家医疗机构开始了为期 5 年的 AQC 系统合同。我们分析了 2006-2009 年 380142 名参保人的索赔数据，这些参保人的初级保健医生（PCP）在 AQC 系统中（干预组），并分析了 1351446 名参保人的索赔数据，这些参保人的 PCP 不在系统中（对照组）。我们使用倾向评分加权差分法，根据年龄、性别、健康状况和趋势调整，以隔离 AQC 对干预组和对照组之间支出和质量的治疗效果。
2009 年，干预组和对照组的参保人支出均有所增加，但干预组的增幅较小——每季度减少 15.51 美元（1.9%）（P=0.007）。节省主要来自门诊护理向费用较低的医疗机构转移；程序、影像和检测支出减少；以及对预期支出最高的参保人支出减少。AQC 系统与成年人慢性病管理质量（P<0.001）和儿科护理（P=0.001）的绩效提高有关，但与成人预防保健无关。所有 AQC 组都达到了 2009 年的预算目标并获得了盈余。AQC 组的 BCBS 总付款，包括质量奖金，可能已经超过了第一年的估计节省。
AQC 系统与 2009 年支出增长适度放缓和医疗质量提高有关。通过改变转诊模式而不是利用模式来实现节约。AQC 系统对支出增长的长期影响取决于未来的预算目标和提供者在实践中进一步提高效率的能力。（由英联邦基金会和其他机构资助）。
