The Alternative Quality Contract (AQC) Model:
A Progress Report
Jeffrey L. Simmons, M.D.
Medical Director for Behavioral Health
Blue Cross Blue Shield of Massachusetts
April 3, 2014
The Alternative Quality Contract (AQC):
Key Components
Global Budget
• Covers all medical
services
• Health status adjusted
Quality Incentives
• Based on historical claims • Ambulatory and hospital
• Shared risk
• Declining trend
• Significant earning
potential
Long-Term Contract
• Nationally accepted
measures
• Sustained partnership
• 5-year agreement
• Supports ongoing
investment
Blue Cross Blue Shield of Massachusetts
2
Linking Quality and Efficiency
As quality improves, provider share of surplus increases or share
of deficit decreases
Blue Cross Blue Shield of Massachusetts
3
Nationally Accepted and Validated Measure Set for
Performance Incentives
The 60+ measures include:
Ambulatory
Process
Outcome
• Preventive screenings
• Acute care management
• Chronic care management
– Depression
– Diabetes
– Cardiovascular disease
• Control of chronic conditions
– Diabetes
– Cardiovascular disease
– Hypertension
Hospital
Evidence-based care elements for:
• Heart attack (AMI)
• Heart failure (CHF)
• Pneumonia
• Surgical infection prevention
• Post-operative complications
• Hospital-acquired infections
• Obstetrical injury
• Mortality (condition –specific)
***Triple weighted***
Patient
Experience
Blue Cross Blue Shield of Massachusetts
• Access, Integration
• Communication, Whole-person care
• Discharge quality, Staff responsiveness
• Communication (MDs, RNs)
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Incentive Risk
• BCBSMA employs several strategies
Incentive Risk
• Variation in costs and outcomes due
to factors within providers’ control—
care processes, unnecessary
utilization, etc.
• Examples: HbA1c control among
diabetics, ED use for ambulatorycare sensitive visits
Blue Cross Blue Shield of Massachusetts
to insulate providers from insurance
risk in the AQC:
– Health status adjustment
– Use of network-wide trend as
benchmark for budget-setting
– Prescription drug benefit
adjustment
– Reinsurance requirements/
contract terms
– Caps on provider liability for
budget deficits
– Upside risk-only in payment for
quality performance
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AQC Groups (Current as of March, 2014)
Blue Cross Blue Shield of Massachusetts
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AQC Participation (Current as of March 2014)
Most PCPs and specialists are
in AQC Contracts today
Most of our HMO Blue members
are patients of AQC groups*
100%
100%
15%
11%
14%
75%
75%
50%
50%
85%
89%
86%
25%
25%
0%
0%
PCPs
HMO Blue Members
Specialists
* In-State HMO members of an AQC PCP, membership
may fluctuate
Blue Cross Blue Shield of Massachusetts
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AQC Improving Adult and Pediatric Care Quality and Outcomes:
Improvement of the 2009 Cohort of AQC Groups from 2007-2012
Adult Chronic
Care
Pediatric Care
Optimal Care
100
83.1
84.0
79.6 80.4
81.1
86.0
86.7
80.8
81.0
88.2
89.9
Adult Health
Outcomes
91.3
91.6
92.2
92.1
69.7
70.7
71.6
71.7
79.2 80.3
77.7
68.1
69.5
72.2
74.0
68.3
65.6
61.5
59.8
62.1
61.2
61.4
61.9
62.2
61.9
50
2012
2007
BCBSMA
HEDIS National Average
2012
2007
BCBSMA
HEDIS National Average
2012
2007
BCBSMA
HEDIS National Average
These graphs show that the AQC has accelerated progress toward optimal care since it began in 2009. The first two scores are based on the delivery of
evidence-based care to adults with chronic illness and to children, including appropriate tests, services, and preventive care. The third score reflects the
extent to which providers helped adults with serious chronic illness achieve optimal clinical outcomes. Linking provider payment to outcome measures has
been one of the AQC’s pioneering achievements.
Blue Cross Blue Shield of Massachusetts
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What impact has the AQC had on BH care?
• Primary impact so far has been on awareness and staffing
– Perception of BH as a key component requiring active management
 Increasing interest in Collaborative Care Model
 Emerging measures – 11/17 AQCs chose a serial PHQ-9 Patient Reported
Outcomes Measure
– Addition of behavioral health clinicians to staffing patterns
– Partnerships with organized behavioral health clinical groups
• Academic review of the use of mental health and substance
abuse services has just begun in partnership with the Harvard
and Johns Hopkins Schools of Public Health
– Impact on mental health and substance abuse quality gates (HEDIS
Antidepressant Measure and Total Readmissions)
– Impact on inpatient and outpatient service utilization
– Impact on provision of medical services to those with BH needs
Blue Cross Blue Shield of Massachusetts
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AQC Impact on Medical Care for Behavioral
Health Members
Diabetic HgbA1c>9
25
15
Non-BH
10
BH
5
0
2009
2010
2011
Diabetic LDL-C<100
%
Preliminary analysis
shows that AQC-based
care results in
comparable
improvement in key
medical measures for
behavioral health
members.
%
20
66
64
62
60
58
56
54
52
50
Non-BH
BH
2009
2010
2011
Hypertension<140/90
80
%
75
Non-BH
70
BH
65
60
2009
Blue Cross Blue Shield of Massachusetts
2010
2011
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What do AQC Providers want from BH Providers?
• High impact interventions for those most in need
– Full integrated continuum of care
– Inpatient admission and ER avoidance where appropriate
• Urgent access to adult and child psychiatric consultation
• Appropriate and timely services in the PCP’s or pediatrician’s office
– Collaborative Care – a new professional model
– Appropriate use of video technology
• Effective communications to and from BH providers
– Shared EMR or standardized info/data exchange
• Reliable and valid measurement of outcomes
– Standardized measure sets
– PROMS
• Partnership on cost and quality
– Innovative payment arrangements
Blue Cross Blue Shield of Massachusetts
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How will behavioral health practices be organized to
meet these needs and what form will reimbursement take?
• Payment





Fee-for-service
Quality incentives (process measures and outcomes)
Case rates
Episode rates
Full risk-sharing
• Structures
 Salaried Staff
 Multidisciplinary Groups
 Bricks and Mortar
 Virtual
 CMHCs
 Small Groups
 Solo Practice
Blue Cross Blue Shield of Massachusetts
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