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

August 13, 2012

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.

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 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.

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 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 the United 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.

Explore further: No improvement in patient outcomes seen in hospitals with pay-for-performance programs

More information:
Arch Pediatr Adolesc Med. Published online August 13, 2012. doi:10.1001/archpediatrics.2012.802
Arch Pediatr Adolesc Med. Published online August 13, 2012. doi:10.1001/archpediatrics.2012.1186

Related Stories

No improvement in patient outcomes seen in hospitals with pay-for-performance programs

March 28, 2012
Paying hospitals to improve their quality of care, known as pay-for-performance, has gained wide acceptance in the U.S. and Medicare has spent tens of millions of dollars on bonuses and rewards for hospitals to improve. However, ...

Recommended for you

Higher blood sugar in early pregnancy raises baby's heart-defect risk

December 15, 2017
Higher blood sugar early in pregnancy raises the baby's risk of a congenital heart defect, even among mothers who do not have diabetes, according to a study led by researchers at the Stanford University School of Medicine.

Injuries from window blinds send two children to the emergency department every day

December 11, 2017
Most homes have them. They help keep our rooms warm or cold and even add a pop of color to tie the décor together. But window blinds can cause serious injuries or even death to young children. A new study from the Center ...

Blood flow altered in brains of preterm newborns vs. full-term infants

December 4, 2017
Cerebral blood flow (CBF) of key regions of newborns' brains is altered in very premature infants and may provide an early warning sign of disturbed brain maturation well before such injury is visible on conventional imaging, ...

HPV vaccine is effective, safe 10 years after it's given

November 29, 2017
A decade of data on hundreds of boys and girls who received the HPV vaccine indicates the vaccine is safe and effective long term in protecting against the most virulent strains of the virus, researchers report.

Antibiotics administered during labor delay healthy gut bacteria in babies

November 28, 2017
Antibiotics administered during labour for Group B Streptococcus (GBS) affect the development of gut bacteria in babies, according to a study from McMaster University.

Stress in pregnancy linked to changes in infant's nervous system, less smiling, less resilience

November 23, 2017
Maternal stress during the second trimester of pregnancy may influence the nervous system of the developing child, both before and after birth, and may have subtle effects on temperament, resulting in less smiling and engagement, ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.