Pay for performance may improve treatment implementation for adolescent substance use disorders

Pay for performance (P4P, when financial incentives are given for achieving predefined criteria) is a strategy recommended by the Institute of Medicine to help improve the delivery of high-quality care. While the number of P4P programs in theU.S.has increased (one study suggests more than 150 such programs exist), the increase has occurred largely without randomized controlled studies to evaluate P4P approaches, according to the study background.

Bryan R. Garner, Ph.D., and colleagues of the Lighthouse Institute, Chestnut Health Systems, Normal, Ill., report the main effectiveness findings from a cluster randomized trial to evaluate the efficacy of P4P methods to improve treatment implementation and effectiveness.

In the study, 29 community-based treatment organizations were assigned to either the implementation-as-usual (IAU) control group or P4P. Each organization delivered the same behavioral treatment program, the Adolescent Community Reinforcement Approach (A-CRA), a program designed to reward nonsubstance-using behaviors so they can replace substance-use behaviors. Therapists in the P4P group were paid $50 for each month they demonstrated competence in treatment delivery (A-CRA competence) and $200 for each patient who received a specific number of A-CRA procedures within a certain time period (target A-CRA), according to the study.

Adjusted analysis results indicate that therapists assigned to P4P had a "significantly higher likelihood" of demonstrating A-CRA competence compared with therapists assigned to IAU (24 percent for P4P vs. 8.9 percent for IAU). Patients in P4P also had a "significantly higher likelihood" of receiving target A-CRA compared with patients assigned to IAU (17.3 percent for P4P vs. 2.5 percent for IAU). However, "no statistically significant difference" in patient remission status was seen between the two groups (41.8 percent for P4P vs. 50.8 percent for IAU), according to study results.

"Findings from this trial suggest that P4P can be an effective method of improving implementation of evidence-based treatment in practice settings. As hypothesized, we found that offering monetary bonuses directly to therapists had a large effect on increasing their demonstration of (1) monthly competency in implementing treatment procedures with patients and (2) the delivery of a predefined threshold level of treatment to adolescent patients," the authors note.

Because the effects of P4P intervention associated with treatment implementation did not translate to a significant difference in patient treatment effectiveness (i.e. remission status), researchers conducted post hoc analyses to evaluate the association between A-CRA competence and target A-CRA with remission. They suggest that therapist-level A-CRA competence was not significantly associated with patient remissions status, but that patient target A-CRA was "significantly associated" with remission status, according to the results.

"Pay for performance can be an effective method of improving treatment implementation," the study concludes.

Editorial: Disparities in Health Care

In an editorial, Alyna T. Chien, M.D., M.S., of Boston Children's Hospital and Harvard Medical School, Boston, writes: "Although much more work must be done to connect improved care processes with desired clinical outcomes, this study supports the notion that frontline providers respond to piece-rate P4P incentives related to improving care processes in the treatment of children."

"Where do the findings of Garner et al fit in the broader landscape of experiments with P4P? First, large gaps in our understanding of the effectiveness of P4P strategies persist even though the number of stakeholders and the circumstances in which P4P tactics are being used continue to proliferate rapidly," Chien continues.

"The most recent catalyst for research into outstanding questions about P4P is the rise of accountable care organizations in theUnited States. Accountable care organizations will seek to maximize their earnings in contracts that combine P4P incentives (to improve quality) with risk-based capitation (to reduce spending), and payers, providers and policy makers will all want better evidence about appropriate ways to target and design P4P incentives for a variety of common conditions to structure fair and clinically meaningful agreements," Chien concludes.