title: How Accountable Care Organizations Responded to Pediatric Incentives in the Alternative Quality Contract.
abstract: OBJECTIVE
  From 2009 to 2010, 12 accountable care organizations (ACOs) entered into the alternative quality contract (AQC), BlueCross BlueShield of Massachusetts's global payment arrangement. The AQC included 6 outpatient pediatric quality measures among 64 total measures tied to pay-for-performance bonuses and incorporated pediatric populations in their global budgets. We characterized the pediatric infrastructure of these adult-oriented ACOs and obtained leaders' perspectives on their ACOs' response to pediatric incentives.
  
  
  METHODS
  We used Massachusetts Health Quality Partners and American Hospital Association Survey data to characterize ACOs' pediatric infrastructure as extremely limited, basic, and substantial on the basis of the extent of pediatric primary care, outpatient specialist, and inpatient services. After ACOs had 16 to 43 months of experience with the AQC, we interviewed 22 leaders to gain insight into how organizations made changes to improve pediatric care quality, tried to reduce pediatric spending, and addressed care for children with special health care needs.
  
  
  RESULTS
  ACOs' pediatric infrastructure ranged from extremely limited (eg, no general pediatricians in their primary care workforce) to substantial (eg, 42% of workforce was general pediatricians). Most leaders reported intensifying their pediatric quality improvement efforts and witnessing changes in quality metrics; most also investigated pediatric spending patterns but struggled to change patients' utilization patterns. All reported that the AQC did little to incentivize care for children with special health care needs and that future incentive programs should include this population.
  
  
  CONCLUSIONS
  Although ACOs involved in the AQC were adult-oriented, most augmented their pediatric quality improvement and spending reduction efforts when faced with pediatric incentives.
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address: alyna.chien@childrens.harvard.edu.
authors.forename: Alyna T
authors.initials: AT
authors.lastname: Chien
authors.affiliation: Harvard Medical School, Boston, Mass; Department of Medicine and Pediatrics, Massachusetts General Hospital, Boston, Mass.
authors.forename: Katherine H
authors.initials: KH
authors.lastname: Schiavoni
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass.
authors.forename: Eli
authors.initials: E
authors.lastname: Sprecher
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Mass; Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Mass.
authors.forename: Bruce E
authors.initials: BE
authors.lastname: Landon
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Mass; Department of Radiology, Brigham and Women's Hospital, Boston, Mass.
authors.forename: Barbara J
authors.initials: BJ
authors.lastname: McNeil
authors.affiliation: Department of Health Care Policy, Harvard Medical School, Boston, Mass.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Chernew
authors.affiliation: Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
authors.forename: Mark A
authors.initials: MA
authors.lastname: Schuster
mesh_terms: D060866:Accountable Care Organizations; D054598:Blue Cross Blue Shield Insurance Plans; D003430:Cross-Sectional Studies; D006801:Humans; D016247:Information Storage and Retrieval; D008404:Massachusetts; D010372:Pediatrics; D036301:Qualitative Research; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012051:Reimbursement Mechanisms; D012052:Reimbursement, Incentive
keywords: accountable care organizations; payment incentives; pediatrics