title: Effects of accountable care and payment reform on substance use disorder treatment: evidence from the initial 3 years of the alternative quality contract.
abstract: Global payment and accountable care reform efforts in the United States may connect more individuals with substance use disorders (SUD) to treatment. We tested whether such changes instituted under an Alternative Quality Contract (AQC) model within the Blue Cross Blue Shield of Massachusetts' (BCBSMA) insurer increased care for individuals with SUD.
  
  
  
  Difference-in-differences design comparing enrollees in AQC organizations with a comparison group of enrollees in organizations not participating in the AQC.
  
  
  
  Massachusetts, USA.
  
  
  
  BCBSMA enrollees aged 13-64 years from 2006 to 2011 (3 years prior to and after implementation) representing 1 333 534 enrollees and 42 801 SUD service users.
  
  
  
  Outcomes were SUD service use and spending and SUD performance metrics. Primary exposures were enrollment into an AQC provider organization and whether the AQC organization did or did not face risk for behavioral health costs.
  
  
  
  Enrollees in AQC organizations facing behavioral health risk experienced no change in the probability of using SUD services (1.64 versus 1.66%; P = 0.63), SUD spending ($2807 versus $2700; P = 0.34) or total spending ($12 631 versus $12 849; P = 0.53), or SUD performance metrics (identification: 1.73 versus 1.76%, P = 0.57; initiation: 27.86 versus 27.02%, P = 0.50; engagement: 11.19 versus 10.97%, P = 0.79). Enrollees in AQC organizations not at risk for behavioral health spending experienced a small increase in the probability of using SUD services (1.83 versus 1.66%; P = 0.003) and the identification performance metric (1.92 versus 1.76%; P = 0.007) and a reduction in SUD medication use (11.84 versus 14.03%; P = 0.03) and the initiation performance metric (23.76 versus 27.02%; P = 0.005).
  
  
  
  A global payment and accountable care model introduced in Massachusetts, USA (in which a health insurer provided care providers with fixed prepayments to cover most or all of their patients' care during a specified time-period, incentivizing providers to keep their patients healthy and reduce costs) did not lead to sizable changes in substance use disorder service use during the first 3 years following its implementation.
authors: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MS, USA.
authors: Elizabeth A
authors: EA
authors: Stuart
authors: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MS, USA.
authors: Colleen L
authors: CL
authors: Barry
authors: Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, PA, USA.
authors: Julie M
authors: JM
authors: Donohue
authors: McLean Hospital, Harvard Medical School, Belmont, MA, USA.
authors: Shelly F
authors: SF
authors: Greenfield
authors: Blue Cross Blue Shield of Massachusetts, Boston, MA, USA.
authors: Kenneth
authors: K
authors: Duckworth
authors: Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors: Zirui
authors: Z
authors: Song
authors: Heller School for Social Policy and Management, Brandeis University, Waltham, MA, USA.
authors: Robert
authors: R
authors: Mechanic
authors: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors: Elena M
authors: EM
authors: Kouri
authors: Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MS, USA.
authors: Cyrus
authors: C
authors: Ebnesajjad
authors: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors: Michael E
authors: ME
authors: Chernew
authors: Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
authors: Haiden A
authors: HA
authors: Huskamp
mesh_terms: D000293:Adolescent; D000328:Adult; D054598:Blue Cross Blue Shield Insurance Plans; D005260:Female; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D018854:Managed Competition / Q000706:statistics & numerical data*; D008404:Massachusetts; D008875:Middle Aged; D058996:Quality Improvement; D012052:Reimbursement, Incentive; D019966:Substance-Related Disorders / Q000628:therapy*; D014481:United States; D055815:Young Adult
keywords: Accountable care organizations; behavioral health; difference-in-differences; drug abuse treatment; global payment; performance measures