Song Zirui, Fendrick A Mark, Safran Dana Gelb, Landon Bruce, Chernew Michael E
Healthc (Amst). 2013 Jun;1(1-2):15-21. doi: 10.1016/j.hjdsi.2013.04.003.
In 2009-2010, Blue Cross Blue Shield of Massachusetts entered into global payment contracts (the Alternative Quality contract, AQC) with 11 provider organizations. We evaluated the impact of the AQC on spending and utilization of several categories of medical technologies, including one considered high value (colonoscopies) and three that include services that may be overused in some situations (cardiovascular, imaging, and orthopedic services).
Approximately 420,000 unique enrollees in 2009 and 180,000 in 2010 were linked to primary care physicians whose organizations joined the AQC. Using three years of pre-intervention data and a large control group, we analyzed changes in utilization and spending associated with the AQC with a propensity-weighted difference-in-differences approach adjusting for enrollee demographics, health status, secular trends, and cost-sharing.
In the 2009 AQC cohort, total volume of colonoscopies increased 5.2 percent (p=0.04) in the first two years of the contract relative to control. The contract was associated with varied changes in volume for cardiovascular and imaging services, but total spending on cardiovascular services in the first two years decreased by 7.4% (p=0.02) while total spending on imaging services decreased by 6.1% (p<0.001) relative to control. In addition to lower utilization of higher-priced services, these decreases were also attributable to shifting care to lower-priced providers. No effect was found in orthopedics.
As one example of a large-scale global payment initiative, the AQC was associated with higher use of colonoscopies. Among several categories of services whose value may be controversial, the contract generally shifted volume to lower-priced facilities or services.
2009 - 2010年，马萨诸塞州蓝十字蓝盾公司与11个医疗服务提供机构签订了全球支付合同（替代质量合同，AQC）。我们评估了AQC对几类医疗技术的支出和使用情况的影响，其中包括一类被认为具有高价值的技术（结肠镜检查）以及三类在某些情况下可能存在过度使用情况的服务（心血管、影像和骨科服务）。
2009年约420,000名独立参保者以及2010年约180,000名参保者与加入AQC的基层医疗医生建立了关联。利用三年的干预前数据和一个大型对照组，我们采用倾向加权差异法分析了与AQC相关的使用情况和支出变化，并对参保者的人口统计学特征、健康状况、长期趋势和费用分担进行了调整。
在2009年AQC队列中，与对照组相比，合同签订后的头两年结肠镜检查总量增加了5.2%（p = 0.04）。该合同与心血管和影像服务的量变化各异，但相对于对照组，头两年心血管服务的总支出下降了7.4%（p = 0.02），影像服务的总支出下降了6.1%（p < 0.001）。除了高价服务的使用减少外，这些下降还归因于将医疗服务转向了低价提供者。在骨科方面未发现影响。
作为大规模全球支付倡议的一个例子，AQC与结肠镜检查的更高使用率相关。在几类价值可能存在争议的服务中，该合同总体上使服务量转向了低价机构或服务。
