Alternative Quality Contract model improves quality of care for sickest pediatric patients

Within two years of implementation, Blue Cross Blue Shield of Massachusetts' Alternative Quality Contract (AQC) had a small but significant positive effect on the quality of pediatric care, according to a new study from Boston Children's Hospital. The results were published online Dec. 23 in Pediatrics.

To stem the continued growth in health care spending, Blue Cross Blue Shield of Massachusetts-the state's largest commercial payer-implemented an AQC in 2009. A prototypical arrangement, the AQC offers providers a baseline budget to cover the continuum of care, while also awarding pay-for-performance bonuses for improved care quality metrics. This AQC was unique for including pediatric quality measures in its contract.

"Because the size and spending levels of the adult population are so much greater than for kids, how large health care contracts affect pediatric patients is often treated as an afterthought," says the study's lead author Alyna Chien, MD, from Boston Children's Division of General Pediatrics. "But children, especially those with chronic or severe medical conditions, can contribute significantly to health care costs. If spending is to be contained, it's important to understand the impact of the AQC on children as well as adults."

Researchers compared the quality and cost of care provided to 126,975 cases within the AQC structure against 415,331 similar patients who were not in the AQC, across a study period from 2006 to 2010. Quality measures tied to pay-for-performance rates of preventive/screening care and acute care were analyzed, as was care of asthma and attention deficit disorder, which were not directly tied to bonuses.

"We examined whether the AQC affected asthma and ADHD care in an unintended fashion, since they are the two most common chronic conditions of childhood," says Chien. "A better understanding of the effect of the AQC on their care and cost could provide much needed insight into how similar pediatric physical or behavioral health conditions are affected."

After analyzing and aggregating all data, the researchers found the AQC had a small yet significant positive effect on preventive and acute care quality when tied to pay-for-performance models. Children with chronic illness experienced higher quality gains (up 1.8 percent) than children without chronic illness (up 1.2 percent). The AQC had no effect on quality measures not tied to the pay-for-performance model, nor did it have an effect on reducing overall health care costs for children.

"The fact that the quality of preventive and acute care improved under the AQC is encouraging," Chien says. "Lowering costs likely requires more in-depth tracking, effort and experience."