Alternative Quality Contract (AQC)
Deborah Devaux
Senior Vice President, Health Care Services
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Massachusetts
1
Financial Structure of the
Alternative Quality Contract
Financial structure based on four
components:
 Global Payment Budget
• B
Basedd on total
t t l medical
di l expenses
• Health status adjusted
 Margin Opportunity
Margin Expansion
Expanded Margin
Opportunity
Inflation
P f
Performance
INITIAL GLOBAL
PAYMENT
LEVEL
• Initial global payment includes
inefficiencies
 Performance Incentive
• Up to 10% of total medical
expense
 Inflation
• Derived from general inflation
Year 1
Blue Cross Blue Shield of Massachusetts
Year 2
Year 3
Year 4
Year 5
2
Performance Measure Set
Hospital Quality and Safety
Clinical process measures
•
•
•
•
Acute MI
Heart Failure care
Pneumonia care
Surgical care
Clinical outcomes measures
• Hospital-acquired infections
• Complications after major surgery (AMI,
PE/DVT, Pneumonia)
• Obstetric trauma
Patient Care Experiences
• Communication (MD, nursing staff)
• Responsiveness
• Discharge support/planning
Ambulatory Care Quality
Clinical process measures
•
•
•
•
•
•
Depression
Diabetes
Cardiovascular Disease
Cancer Screening
Pediatric: Appropriate Testing / Treatment
P di t i Well
Pediatric:
W ll Child Visits
Vi it
Clinical outcomes measures
• Diabetes (HbA1c in poor control, LDL-C
control, blood pressure control)
• Hypertension (blood pressure control)
• Cardiovascular Disease (blood pressure
control LDL
control,
LDL-C
C control)
Patient Care Experiences
• Quality of clinical interactions
• Integration
I t
ti off care
• Access to care
Blue Cross Blue Shield of Massachusetts
3
Performance Achievement Model
An aggregate performance score is calculated based on the provider’s
hospital and ambulatory quality to determine a percentage payout
Performance Payment Model
10%
10 0%
10.0%
9.0%
% Payout
8%
6%
5.0%
4%
3.0%
2%
2.0%
0%
1.0
2.0
3.0
4.0
5.0
Performance Score
Example:
Blue Cross Blue Shield of Massachusetts
An aggregate score of 33.00 would yield a 5% payout
payout, which if applied to a global
payment of $300 PMPM, would yield an additional $15 PMPM for the provider.
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