Incentives in Public Addiction Treatment: Testing Design and Enhancing Impact

描述（由申请人提供）：需要创新的方法来提高物质使用障碍（sud）的治疗质量，因为它可能有效但并不总是成功的。基于绩效的合同（PBC）旨在使治疗方案激励和购买者目标保持一致，以推动高质量的护理，但在药物滥用治疗系统中并不常见。因为改善需要项目、临床医生和工作人员的改变，所以激励这些群体一起工作可能是有益的。设计特征对P4P的有效性至关重要，然而很少有针对不同激励设计的对照试验被进行，并且对于有助于有效系统的特定设计特征仍然存在悬而未决的问题。2007年，缅因州实施了第二代PBC系统，为接受联邦政府整体拨款的门诊项目提供财政激励。以缅因州为实验室，我们超越了对SUD治疗PBC的评估，专注于意想不到的效果和结果；测试一种奖励临床医生/一线员工项目绩效的支付设计，直接向项目达到目标的临床医生/员工发送季度支票；并深入研究项目和临床医生对激励措施的反应，了解治疗项目和临床医生如何根据这些激励措施调整组织、管理和临床实践。与缅因州药物滥用办公室合作进行的拟议研究将使用从项目访谈和临床医生/工作人员调查中收集的行政数据和数据，结合多层次建模和差异中的差异方法。PBC是支付设计的重大变化，可能会影响SUD提供治疗服务的方式。随着PBC和其他形式的P4P的流行不断增加，了解项目如何应对PBC倡议至关重要。这种专注于对激励的“黑箱”反应的能力是拟议研究的一个独特和创新的方面。目标1和目标2使用2007年开始进行的缅因州PBC的回顾性数据。对于目标3和目标4，我们覆盖了一种新的方法来研究激励如何在项目层面上分配，并通过随机设计来检验这一点。具体来说，我们的目标是：1。确定PBC是否改善了获取和保留的奖励措施，并确定PBC是否产生了积极或消极的意想不到的影响。2. 检查客户结果如何受到PBC的影响，控制逆向选择，并确定相关的组织因素。3. 在随机试验中测试在程序水平是否添加

DESCRIPTION (provided by applicant): Innovative ways are needed to improve quality of treatment for substance use disorders (SUDs), since it can be effective but is not always successful. Performance-based contracting (PBC) aims to align treatment program incentives and purchaser goals to drive high-quality care, yet is uncommon in drug abuse treatment systems. Because improvements will require changes by programs, clinicians and staff, it may be beneficial to incentivize these groups to work together. Design features are paramount in the effectiveness of P4P, yet few controlled trials of different incentive designs have been conducted and open questions remain on particular design features that contribute to effective systems. In 2007, Maine implemented a 2nd-generation PBC system with financial incentives for outpatient programs that receive federal block grant funding. Using Maine as a laboratory, we go beyond evaluation of an SUD treatment PBC to focus on unintended effects and outcomes; test a payment design that rewards clinicians/front-line staff for program performance by sending quarterly checks directly to clinicians/staff whose program meets their targets; and delve into response to incentives by both programs and clinicians, to understand how treatment programs and clinicians adapt organizational, management and clinical practices due to such incentives. The proposed study, conducted in collaboration with Maine's Office of Substance Abuse, will use administrative data and data collected from program interviews and clinician/staff surveys, incorporating multilevel modeling and a difference-in-difference approach. PBC is a significant change in payment design and may affect how SUD treatment services are delivered. As prevalence of PBC and other forms of P4P continue to increase, it is critical to understand how programs respond to PBC initiatives. This ability to focus on the "black box" of response to incentives is a unique and innovative aspect of the proposed study. Aims 1 and 2 use retrospective data from the ongoing Maine PBC that began in 2007. For Aims 3 and 4, we overlay a new approach to how incentives are distributed at a program level and examine this with a randomized design. Specifically, we aim to: 1. Determine if the PBC improved the rewarded measures of access and retention and determine what, if any, positive or negative unintended effects stemmed from the PBC. 2. Examine how client outcomes were affected by the PBC, controlling for adverse selection if identified, and determine associated organizational factors. 3. Test in a randomized trial at the program level whether the addition of clinician group incentives, paid directly to clinicians and front-line staff to reward overall program performance as defined by the PBC, improves program performance. 4. Determine what changes, if any, are implemented by programs (e.g., quality improvement initiatives) or by clinicians (e.g., outreach to clients) after introduction of incentives. PUBLIC HEALTH RELEVANCE: Maine's 2nd generation performance-based contract (PBC) for treatment of substance use disorders allows a nuanced study of a relatively new way to drive quality of treatment, and offers an opportunity to test new incentive designs. As PBC becomes more common, it is essential to understand program and clinician response, unintended effects, client outcomes, and interactions with other initiatives. Both PBC and clinician group incentives may serve as important elements in the toolbox as purchasers and treatment systems strive to improve quality of care for clients with substance use disorders in a constrained fiscal environment.