Pay for performance may improve treatment implementation for adolescent substance use disorders
Pay for performance appears to be associated with improved implementation of an adolescent substance use treatment program, although no significant differences were found in remission status between the pay-for-performance and implementation-as-usual groups, according to a report published Online First by Archives of Pediatrics & Adolescent Medicine, a JAMA Network publication.
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 the U.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.
(Arch Pediatr Adolesc Med. Published online August 13, 2012. doi:10.1001/archpediatrics.2012.802. Available pre-embargo to the media at http://media.jamanetwork.com.)
Editor’s Note: Financial assistance for the study was provided by grants from the National Institute on Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.