jeffrey l. simmons, m.d. medical director for behavioral health
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
The Alternative Quality Contract (AQC) Model:A Progress Report
Jeffrey L. Simmons, M.D.Medical Director for Behavioral HealthBlue Cross Blue Shield of Massachusetts
April 3, 2014
2Blue Cross Blue Shield of Massachusetts
Global Budget
•Covers all medical services
•Health status adjusted
•Based on historical claims
•Shared risk
•Declining trend
Quality Incentives
•Ambulatory and hospital
•Significant earning potential
•Nationally accepted measures
Long-Term Contract
•5-year agreement
•Sustained partnership
•Supports ongoing investment
The Alternative Quality Contract (AQC): Key Components
3Blue Cross Blue Shield of Massachusetts
Linking Quality and Efficiency
As quality improves, provider share of surplus increases or share of deficit decreases
4Blue Cross Blue Shield of Massachusetts
The 60+ measures include:
Ambulatory Hospital
Process • Preventive screenings• Acute care management• Chronic care management
– Depression– Diabetes– Cardiovascular disease
Evidence-based care elements for: • Heart attack (AMI)• Heart failure (CHF)• Pneumonia• Surgical infection prevention
Outcome • Control of chronic conditions– Diabetes – Cardiovascular disease – Hypertension
***Triple weighted***
• Post-operative complications• Hospital-acquired infections• Obstetrical injury• Mortality (condition –specific)
Patient Experience
• Access, Integration• Communication, Whole-person care
• Discharge quality, Staff responsiveness• Communication (MDs, RNs)
Nationally Accepted and Validated Measure Set for Performance Incentives
5Blue Cross Blue Shield of Massachusetts
Incentive Risk
• BCBSMA employs several strategies 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
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 ambulatory-care sensitive visits
6Blue Cross Blue Shield of Massachusetts
AQC Groups (Current as of March, 2014)
7Blue Cross Blue Shield of Massachusetts
AQC Participation (Current as of March 2014)
85% 89%
15% 11%
0%
25%
50%
75%
100%
PCPs Specialists
86%
14%
0%
25%
50%
75%
100%
HMO Blue Members
Most PCPs and specialists are in AQC Contracts today
Most of our HMO Blue members are patients of AQC groups*
* In-State HMO members of an AQC PCP, membership may fluctuate
8Blue Cross Blue Shield of Massachusetts
AQC Improving Adult and Pediatric Care Quality and Outcomes:Improvement of the 2009 Cohort of AQC Groups from 2007-2012
Op
tim
al C
are
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.
83.1 84.086.0 86.7
80.4 81.1 80.8 81.077.7
79.6
79.2 80.3
2007 2012
BCBSMA HEDIS National Average
Adult Chronic Care
Pediatric Care
91.3 91.6 92.2 92.1
69.7 70.7 71.6 71.7
88.289.9
68.1 69.5
2007 2012
BCBSMA HEDIS National Average
Adult Health Outcomes
65.668.3
72.274.0
61.4 61.9 62.2 61.9
61.5 62.1
59.8 61.2
2007 2012
BCBSMA HEDIS National Average
100100
5050==
9Blue Cross Blue Shield of Massachusetts
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
10Blue Cross Blue Shield of Massachusetts
AQC Impact on Medical Care for BehavioralHealth Members
Diabetic HgbA1c>9
0
5
10
15
20
25
2009 2010 2011
%
Non-BH
BH
Diabetic LDL-C<100
505254565860626466
2009 2010 2011
%
Non-BH
BH
Hypertension<140/90
60
65
70
75
80
2009 2010 2011
%
Non-BH
BH
Preliminary analysis shows that AQC-based care results in comparable improvement in key medical measures for behavioral health members.
Preliminary analysis shows that AQC-based care results in comparable improvement in key medical measures for behavioral health members.
11Blue Cross Blue Shield of Massachusetts
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
12Blue Cross Blue Shield of Massachusetts
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
