Substance Use Disorder Treatment under New Payment and Delivery System Models

Payment and delivery system reforms are being considered by many payers to address concerns about health care spending growth and to improve the efficiency, coordination and quality of care. The Alternative Quality Contract (AQC) is one such initiative launched by Blue Cross Blue Shield of Massachusetts (BCBSMA) in 2009. The AQC combines global payment with performance incentives and resembles accountable care organization models authorized under the Affordable Care Act.  No information is available on how this model affects care for substance use disorders (SUDs).  Only certain provider organizations accepted risk for SUD treatment costs under the AQC. The AQC model may affect the SUD population differently depending on whether these services are included in the risk contract. The AQC could improve SUD care by addressing the historical separation of SUD treatment financing and delivery. On the other hand, provider organizations at risk for a population’s total costs may avoid enrolling or may under-provide services to individuals with SUD. We use BCBSMA claims data to conduct difference-in-differences (DD) analyses of the effects of the AQC on use of SUD services and spending on SUD services. In addition, we evaluate the impact of the SUD on three performance measures of SUD care: (1) identification; (2) treatment initiation, and (3) treatment engagement.  The purpose of these measures, which were developed by Washington Circle and adopted by the National Committee for Quality Assurance for the Healthcare Effectiveness Data and Information Set (HEDIS), is to provide indicators of performance using administrative claims data.  We compare two intervention groups – one with enrollees in AQC organizations that accept SUD risk and one with enrollees in AQC organizations that do not – to a group of BCBSMA enrollees not participating in the AQC.  Use and spending analyses are currently in progress. We have completed preliminary analyses on the performance measures outcomes.  These results suggest no difference attributable to the AQC in HEDIS performance measures of SUD identification, treatment initiation and treatment engagement among health plan enrollees in AQC organizations and comparison group enrollees. These findings are consistent with our initial hypotheses given that no SUD measures were included in the 64 different performance measures used to pay organizations under the AQC.  However, results suggest that the AQC may not be effective approach to improving detection and quality of care for SUD unless organizations are incentivized to improve care for this group. In pending analyses, we are testing our hypothesis that, when SUD is included in the risk contract, the AQC will increase use of SUD services and SUD spending, particularly services delivered in primary care.