The Effect of Bundled Payment on Emergency Department Use: Alternative Quality Contract Effects After Year One

Objectives The objective was to identify the effect of the Alternative Quality Contract (AQC), a global payment system implemented by Blue Cross Blue Shield (BCBS) of Massachusetts in 2009, on emergency department (ED) presentations. Methods Blue Cross Blue Shield of Massachusetts claims from 2006 through 2009 for 332,624 enrollees whose primary care physicians (PCPs) enrolled in the AQC, and 1,296,399 whose PCPs were not enrolled in the AQC, were evaluated. A pre–post, intervention–control, propensity‐scored difference‐in‐difference approach was used to isolate the AQC effect on ED visits. The analysis adjusted for age, sex, health status, and secular trends to compare ED use between the treatment and control groups. Results Overall, secular trends showed that the number of ED visits decreased slightly for both treatment and control groups. The adjusted analysis of the AQC group showed decreases from 0.131 to 0.127 visits per member/quarter, and the control group decreased from 0.157 to 0.152 visits per member/quarter. The difference‐in‐difference analysis showed the AQC had no statistically significant effect on total ED use compared to the control group. Conclusions In the first year of this AQC, we did not find evidence of change in aggregate ED use. Similar global budget programs may not alter ED use in the initial implementation period. Resumen Efecto del Pago Combinado en el Uso del Servicio de Urgencias: Los Efectos del Alternative Quality Contract tras un Año Objetivos Identificar el efecto del Alternative Quality Contract (AQC), un sistema de pago global implementado por el Blue Cross Blue Shield de Massachusetts en 2009, en las visitas a los servicios de urgencias (SU). Metodología Se evaluaron los 332.624 miembros cuyo médico de atención primaria (MAP) estaba incluido en el AQC y los 1.296.399 cuyo MAP no estaba incluido en el AQC del Blue Cross Blue Shield de Massachusetts de 2006 hasta 2009. Para identificar el efecto del AQC en las visitas al SU, se utilizó un diseño pre‐post, intervención‐control, con una aproximación por puntuación de propensión diferencia en diferencia. El análisis se ajustó por edad, sexo, estado de salud y tendencias seculares para comparar el uso del SU entre los grupos tratamiento y control. Resultados Del total, las tendencias seculares mostraron que el número de visitas al SU descendió discretamente tanto para el grupo tratamiento como control. El análisis ajustado del grupo AQC mostró un descenso de 0,131 a 0,127 v