Health Care Spending and Quality in Year 1 of the Alternative Quality Contract
Health Care Spending and Quality in Year 1 of the Alternative Quality Contract
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DOI：
10.1056/nejmsa1101416
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发表时间：
2011-09-08
影响因子：
158.5
通讯作者：
Chernew, Michael E.
中科院分区：
文献类型：
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作者：
Song, Zirui;Safran, Dana Gelb;Chernew, Michael E.
背景2009 年，马萨诸塞州蓝十字蓝盾 (BCBS) 实施了名为替代质量合同 (AQC) 的全球支付系统。 AQC 系统中的提供者群体承担支出责任，类似于承担财务风险的责任医疗组织。此外，团体还有资格获得质量奖金。 方法 七家医疗服务提供者组织于 2009 年开始签订为期 5 年的合同，作为 AQC 系统的一部分。我们分析了 2006-2009 年初级保健医生 (PCP) 在 AQC 系统中的 380,142 名注册者（干预组）和 PCP 不在系统中的 1,351,446 名注册者（对照组）的索赔。我们使用倾向加权双重差分法，对年龄、性别、健康状况和长期趋势进行调整，以比较干预组和对照组之间的支出和质量来分离 AQC 的治疗效果。 结果 2009 年干预组和对照组的参与者的平均支出均有所增加，但干预组的参与者的增幅较小，每季度减少 15.51 美元 (1.9%)（P = 0.007）。节省的费用主要来自门诊护理转向收费较低的机构；手术、成像和测试支出减少；以及减少预期支出最高的参与者的支出。 AQC 系统与成人慢性病管理质量 (P < 0.001) 和儿科护理 (P = 0.001) 质量衡量指标的改善相关，但与成人预防护理的绩效改善无关。所有 AQC 小组都达到了 2009 年的预算目标并获得了盈余。 BCBS 向 AQC 小组支付的总费用（包括质量奖金）很可能超过了第一年的估计节省。结论 AQC 系统与 2009 年支出增长的适度放缓和护理质量的提高有关。节省是通过转诊模式的变化而不是通过利用率的变化来实现的。 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商在实践中进一步提高效率的能力。 （由联邦基金和其他机构资助。）
BackgroundIn 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.MethodsSeven 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.ResultsAverage 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.ConclusionsThe 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.)