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Schneider T, Kuussaari K, Virtanen P. Drug treatment service procurement: A systematic review of models, goals, and outcomes. NORDIC STUDIES ON ALCOHOL AND DRUGS 2023; 40:424-442. [PMID: 37969897 PMCID: PMC10634391 DOI: 10.1177/14550725231157503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 01/31/2023] [Indexed: 11/17/2023] Open
Abstract
Aim: To explore the goals and outcomes of public procurement of drug treatment services in OECD countries. The study explores how these complex services are procured and delivered. Methods and data: A systematic review of the literature (1990-2020) identified four partly overlapping models of drug treatment service procurement that are here labelled traditional, value-based, outcome-based, and innovative. Results: Even though different forms of drug treatment services procurement are common, only 12 empirical studies that focused on procurement were found. The four models differ in their approaches to design and performance specifications and the role of competition and collaboration in the co-creation of value. Conclusions: Competition and incentives improve neither the efficiency nor the quality or the outcomes of complex drug treatment services. Whereas many studies focus on payment mechanisms, there are important research gaps that relate to the co-creation of value with and for the service-users and other stakeholders.
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Affiliation(s)
- Taina Schneider
- University of Vaasa, Finnish Institute for Health and Welfare, Helsinki, Finland
| | | | - Petri Virtanen
- University of Vaasa, Itla Children's Foundation, Vaasa, Finland
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Stewart RE, Mandell DS, Beidas RS. Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services. Psychiatr Serv 2021; 72:1219-1221. [PMID: 33853379 PMCID: PMC8928566 DOI: 10.1176/appi.ps.202000209] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.
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Affiliation(s)
- Rebecca E Stewart
- Department of Psychiatry, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (all authors); Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas)
| | - David S Mandell
- Department of Psychiatry, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (all authors); Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas)
| | - Rinad S Beidas
- Department of Psychiatry, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (all authors); Penn Implementation Science Center at the Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia (Beidas)
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Kilaru AS, Lubitz SF, Davis J, Eriksen W, Siegel S, Kelley D, Perrone J, Meisel ZF. A State Financial Incentive Policy to Improve Emergency Department Treatment for Opioid Use Disorder: A Qualitative Study. Psychiatr Serv 2021; 72:1048-1056. [PMID: 33593105 DOI: 10.1176/appi.ps.202000501] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation. METHODS Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals. RESULTS The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes. CONCLUSIONS A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.
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Affiliation(s)
- Austin S Kilaru
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Su Fen Lubitz
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jessica Davis
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Whitney Eriksen
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Sari Siegel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - David Kelley
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jeanmarie Perrone
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Zachary F Meisel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
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Reif S, Stewart MT, Torres ME, Davis MT, Dana BM, Ritter GA. Effectiveness of value-based purchasing for substance use treatment engagement and retention. J Subst Abuse Treat 2021; 122:108217. [PMID: 33509415 PMCID: PMC8380407 DOI: 10.1016/j.jsat.2020.108217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/25/2020] [Accepted: 11/30/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Many people drop out of substance use disorder (SUD) treatment within the first few sessions, which suggests the need for innovative strategies to address this. We examined the effectiveness of incentive-based contracting for Maine's publicly funded outpatient (OP) and intensive outpatient (IOP) SUD treatment, to determine its potential for improving treatment engagement and retention. METHODS Maine's incentive-based contract with federally block grant-funded OP and IOP treatment agencies created a natural experiment, in which we could compare treatment engagement and retention with a group of state-licensed treatment agencies that were not part of the incentive-based contract. We used administrative data for OP (N = 18,375) and IOP (N = 5986) SUD treatment admissions from FY2005-FY2011 to capture trends prior to and after the FY2008 contract implementation date. We performed multivariable difference-in-difference logistic regression models following propensity score matching of clients. RESULTS Two-thirds (66%) of OP admissions engaged in treatment, defined as 4+ treatment sessions, and 85% of IOP admissions satisfied the similar criteria of 4+ treatment days. About 40-45% of OP admissions reached the threshold for retention, defined as 90 days in treatment. IOP treatment completion was attained by 50-58% of admissions. For OP, the incentive and nonincentive groups had no significant differences in percentages with treatment engagement (AOR = 1.28, DID = 5.9%, p = .19), and 90-day retention was significant in the opposite direction of what we hypothesized (AOR = 0.80, DID = -4.6%, p = .0003). For IOP, the incentive group had a significant, but still small, increase in percentage with treatment engagement (AOR = 1.52, DID = 5.5%, p = .003), but the corresponding increase in treatment completion was not similarly significant (AOR = 1.12, DID = 2.7%, p = .53). In all models, individual-level variables were strong predictors of outcomes. CONCLUSION We found little to no impact of the incentive-based contract on the treatment engagement, retention, and completion measures, adding to the body of evidence that shows few or null results for value-based purchasing in SUD treatment programs. The limited success of such efforts is likely to reflect the bandwidth that providers and programs have to focus on new endeavors, the importance of the incentive funding to their bottom line, and forces beyond their immediate control.
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Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America.
| | - Maureen T Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America
| | - Maria E Torres
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America
| | - Margot T Davis
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America
| | - Beth Mohr Dana
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America
| | - Grant A Ritter
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, United States of America
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Carlo AD, Benson NM, Chu F, Busch AB. Association of Alternative Payment and Delivery Models With Outcomes for Mental Health and Substance Use Disorders: A Systematic Review. JAMA Netw Open 2020; 3:e207401. [PMID: 32701157 PMCID: PMC7378751 DOI: 10.1001/jamanetworkopen.2020.7401] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Health care spending in the United States continues to grow. Mental health and substance use disorders (MH/SUDs) are prevalent and associated with worse health outcomes and higher health care spending; alternative payment and delivery models (APMs) have the potential to facilitate higher quality, integrated, and more cost-effective MH/SUD care. OBJECTIVE To systematically review and summarize the published literature on populations and MH/SUD conditions examined by APM evaluations and the associations of APMs with MH/SUD outcomes. EVIDENCE REVIEW A literature search of MEDLINE, PsychInfo, Scopus, and Business Source was conducted from January 1, 1997, to May 17, 2019, for publications examining APMs for MH/SUD services, assessing at least 1 MH/SUD outcome, and having a comparison group. A total of 27 articles met these criteria, and each was classified according to the Health Care Payment Learning and Action Network's APM framework. Strength of evidence was graded using a modified Oxford Centre for Evidence-Based Medicine framework. FINDINGS The 27 included articles evaluated 17 APM implementations that spanned 3 Health Care Payment Learning and Action Network categories and 6 subcategories, with no single category predominating the literature. APMs varied with regard to their assessed outcomes, funding sources, target populations, and diagnostic focuses. The APMs were primarily evaluated on their associations with process-of-care measures (15 [88.2%]), followed by utilization (11 [64.7%]), spending (9 [52.9%]), and clinical outcomes (5 [29.4%]). Medicaid and publicly funded SUD programs were most common, with each representing 7 APMs (41.2%). Most APMs focused on adults (11 [64.7%]), while fewer (2 [11.8%]) targeted children or adolescents. More than half of the APMs (9 [52.9%]) targeted populations with SUD, while 4 (23.5%) targeted MH populations, and the rest targeted MH/SUD broadly defined. APMs were most commonly associated with improvements in MH/SUD process-of-care outcomes (12 of 15 [80.0%]), although they were also associated with lower spending (4 of 8 [50.0%]) and utilization (5 of 11 [45.5%]) outcomes, suggesting gains in value from APMs. However, clinical outcomes were rarely measured (5 APMs [29.4%]). A total of 8 APMs (47.1%) assessed for gaming (ie, falsification of outcomes because of APM incentives) and adverse selection, with 1 (12.5%) showing evidence of gaming and 3 (37.5%) showing evidence of adverse selection. Other than those assessing accountable care organizations, few studies included qualitative evaluations. CONCLUSIONS AND RELEVANCE In this study, APMs were associated with improvements in process-of-care outcomes, reductions in MH/SUD utilization, and decreases in spending. However, these findings cannot fully substitute for assessments of clinical outcomes, which have rarely been evaluated in this context. Additionally, this systematic review identified some noteworthy evidence for gaming and adverse selection, although these outcomes have not always been duly measured or analyzed. Future research is needed to better understand the varied qualitative experiences across APMs, their successful components, and their associations with clinical outcomes among diverse populations and settings.
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Affiliation(s)
- Andrew D. Carlo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | | | - Frances Chu
- University of Washington School of Nursing, Seattle
| | - Alisa B. Busch
- Department of Health Care Policy, McLean Hospital, Harvard Medical School, Boston, Massachusetts
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Garnick DW, Horgan CM, Acevedo A, Lee MT, Lee P, Ritter GA, Campbell K. Rural Clients' Continuity Into Follow-Up Substance Use Disorder Treatment: Impacts of Travel Time, Incentives, and Alerts. J Rural Health 2020; 36:196-207. [PMID: 31090968 PMCID: PMC6856385 DOI: 10.1111/jrh.12375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 12/17/2022]
Abstract
PURPOSE Treatment after discharge from detoxification or residential treatment is associated with improved outcomes. We examined the influence of travel time on continuity into follow-up treatment and whether financial incentives and weekly alerts have a modifying effect. METHODS For a research intervention during October 2013 to December 2015, detoxification and residential substance use disorder treatment programs in Washington State were randomized into 4 groups: potential financial incentives for meeting performance goals, weekly alerts to providers, both interventions, and control. Travel time was used as both a main effect and interacted with other variables to explore its modifying impact on continuity of care in conjunction with incentives or alerts. Continuity was defined as follow-up care occurring within 14 days of discharge from detoxification or residential treatment programs. Travel time was estimated as driving time from clients' home ZIP Code to treatment agency ZIP Code. FINDINGS Travel times to the original treatment agency were in some cases significant with longer travel times predicting lower likelihood of continuity. For detoxification clients, those with longer travel times (over 91 minutes from their residence) are more likely to have timely continuity. Conversely, residential clients with travel times of more than 1 hour are less likely to have timely continuity. Interventions such as alerts or incentives for performance had some mitigating effects on these results. Travel times to the closest agency for potential further treatment were not significant. CONCLUSIONS Among rural clients discharged from detoxification and residential treatment, travel time can be an important factor in predicting timely continuity.
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Affiliation(s)
- Deborah W. Garnick
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Constance M. Horgan
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Andrea Acevedo
- Department of Community Health, Tufts University, Medford, Massachusetts
| | - Margaret T. Lee
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Panas Lee
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Grant A. Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Kevin Campbell
- Research and Data Analysis, Washington State Department of Social and Health Services, Olympia, Washington
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Hodgkin D, Garnick DW, Horgan CM, Busch AB, Stewart MT, Reif S. Is it feasible to pay specialty substance use disorder treatment programs based on patient outcomes? Drug Alcohol Depend 2020; 206:107735. [PMID: 31790980 PMCID: PMC6941579 DOI: 10.1016/j.drugalcdep.2019.107735] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 11/06/2019] [Accepted: 11/09/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Some US payers are starting to vary payment to providers depending on patient outcomes, but this approach is rarely used in substance use disorder (SUD) treatment. PURPOSE We examine the feasibility of applying a pay-for-outcomes approach to SUD treatment. METHODS We reviewed several relevant literatures: (1) economic theory papers that describe the conditions under which pay-for-outcomes is feasible in principle; (2) description of the key outcomes expected from SUD treatment, and the measures of these outcomes that are available in administrative data systems; and (3) reports on actual experiences of paying SUD treatment providers based on patient outcomes. RESULTS The economics literature notes that when patient outcomes are strongly influenced by factors beyond provider control and when risk adjustment performs poorly, pay-for-outcomes will increase provider financial risk. This is relevant to SUD treatment. The literature on SUD outcome measurement shows disagreement on whether to include broader outcomes beyond abstinence from substance use. Good measures are available for some of these broader constructs, but the need for risk adjustment still brings many challenges. Results from two past payment experiments in SUD treatment reinforce some of the concerns raised in the more conceptual literature. CONCLUSION There are special challenges in applying pay-for-outcomes to SUD treatment, not all of which could be overcome by developing better measures. For SUD treatment it may be necessary to define outcomes more broadly than for general medical care, and to continue conditioning a sizeable portion of payment on process measures.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA.
| | - Deborah W Garnick
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Constance M Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Alisa B Busch
- McLean Hospital, and the Department of Health Care Policy, Harvard Medical School, USA
| | - Maureen T Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
| | - Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, USA
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