Context and Rationale for Pay for Performance in SUD Treatment NIATx-SI State Call April 2010

Core Foundation Health Care Arena – Addiction is a HEALTH problem: Part of mainstream healthcare Not fundamentally criminal justice Chronic not acute condition: Purchasers will need to change contracts, funding mechanisms and expectations Treatment programs will need to change from acute to chronic care design and service delivery (more)

Core Foundation Recovery is the goal Treatment prepares for recovery Continuing care Disease management Recovery Support Recovery Coaches/Linkage Coordinators Family and other “community strengths” support Return to treatment program for “tune ups”, etc. Medication Assisted Treatment (MAT) New medications for addiction Psychotropic meds for co-occurring MH disorders

Acute Care Assumptions Acute Care Assumptions Some fixed amount or duration of treatment will resolve the problem Treatment Completion is a goal and expected outcome Evaluation of effectiveness should occur following completion Poor outcome means failure

In Chronic Care The effects of treatment do not last very long after care stops Patients who are out of treatment/contact are at elevated risk for relapse Patients who are out of treatment/contact are at elevated risk for relapse

New Expectations Programs are responsible for results during treatment. Treatment offers choices – adaptive care. Evaluation is a clinical activity and every patient is evaluated.

Implications Let go of traditional beliefs and practices that are not grounded in science/research or proven practice Easy transition between levels of care and treatment programs Collaboration vs. competition among programs Continuing care and telephone based counseling (texting?)

Some System and Program Changes New funding models to purchase care System integration not autonomous programs Bundling services Collaboration across treatment agencies Connecting payment to performance: Reward Quality not Quantity Performance based contracting Incentives for results

Congressional Research Service Report for Congress P4P Defined A pay for performance system is a remuneration arrangement in which a portion of the payments is based on performance assessed against a defined measure. Typically, there is another component of the remuneration that is independent of the amount at risk. The terms merit and bonus pay are also used to describe similar systems.

Theory and Conceptual Foundation Elements common to P4P programs A set of targets or objectives that define what will be evaluated Measures and performance standards for establishing the target criteria Rewards – typically financial incentives – that are at risk, including the amount and the method for allocating payments among those who meet or exceed the reward threshold.

CEO Survival Guide: Pay for Performance – 2006 Edition National Committee for Quality Health Care 1701 K Street, NW Suite 205 Washington, DC

Impact of Private Sector P4P Programs (35-36) Rewarding Results grant program funded by RWJF and California Healthcare Foundation, and administered by the Leapfrog Group

Impact of Private Sector P4P Programs (35-36) Financial incentives motivate change – provided they are large enough to make a difference. Non-financial incentives also can make a difference. Engaging physicians is a critical activity – they must be brought in early as collaborators to ensure that the goals are clinically meaningful. There is no clear picture yet of return on investment. (more)

Impact of Private Sector P4P Programs (35-36) Public reporting is a strong catalyst for providers to improve care. Providers need feedback on their performance. Providers need to be better educated about P4P. Data integrity is important. (more)

Impact of Private Sector P4P Programs (35-36) P4P is not a magic bullet – it is one of a number of activities that can work to improve healthcare quality and change the way it is delivered and financed.

MedVantage P4P Survey 2008 N = 62 P4P Program Responses What Results do you attribute to P4P? 84% - Performance on clinical measures improved 66% - Improvement was statistically significant What changes do you anticipate making? 65% - Expand scope or number of measures used 53% - Change performance domains or relative weighting of measures 0% - Discontinue the program

Connecting Payment and Performance in SA Disorder Treatment

Personal Purchasing What do you do when buying a new: Car, Computer, Appliances, etc. Compare models, features, price Consider quality, performance and reliability

State As Purchaser State sets the expectations: Based on science/research/proven practice Defines the expectations and results Who can best provide what I want? Contracts and pays for performance and results. SA treatment provider = seller – how can they convince state to buy what they are selling?

Overall Context for P4P Need for new financing and funding models for healthcare and SA treatment: Fee for service, grant and contract funding do not reward performance and results Bundled care, networks and collaboratives Incentives for results P4P is not a stand-alone solution for performance improvement or achieving better results Government precedents

Paying For Performance Connecting payment to performance and results at a program or network level Not to individual practitioners Not to patients, clients – not contingency management/motivational enhancement Connecting payment to a few very specific targets that will improve service delivery and/or results: Examples - access, retention, continuing care

Chronic/Adaptive Care Chronic not acute care treatment design –System wide –Individual treatment programs Disease management not program approach –Continuing care –Recovery support –Self management Think/fund system of care not individual programs

P4P Design Implications Design system to require collaboration among providers, including continuity of care/maintenance Include rewards for collaboration – decide where to place the incentives (push-pull)

Examples Pay a % of base contract for providing agreed upon/contracted services –Pay remainder for achieving critical performance targets Pay incentives for meeting agreed upon performance targets.

Contact Information Jack Kemp