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(SUDS)的治疗质量，因为它可以有效，但并不总是成功的。基于绩效的合同(PBC)旨在使治疗计划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。由于改进将需要项目、临床医生和工作人员的改变，因此激励这些群体共同工作可能是有益的。设计特征对P4P的有效性至关重要，但对不同激励设计进行的对照试验很少，关于有助于有效系统的特定设计特征仍存在悬而未决的问题。2007年，缅因州实施了第二代PBC制度，为接受联邦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，将重点放在意想不到的效果和结果上；测试通过将季度支票直接发送给计划达到目标的临床医生/工作人员来奖励计划绩效的临床医生/一线工作人员的薪酬设计；并深入研究计划和临床医生对激励的反应，以了解治疗计划和临床医生如何因此类激励而适应组织、管理和临床实践。这项拟议的研究是与缅因州物质滥用办公室合作进行的，将使用行政数据和从项目访谈和临床医生/工作人员调查中收集的数据，结合多水平建模和差异方法。PBC是支付设计的一个重大变化，可能会影响SUD治疗服务的提供方式。随着PBC和其他形式的P4P的流行继续增加，了解方案如何响应PBC倡议至关重要。这种专注于对激励措施作出反应的“黑箱”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使用了始于2007年的缅因州正在进行的PBC的回顾数据。对于目标3和4，我们覆盖了一种新的方法，即如何在计划层面上分配激励，并用随机设计进行检查。具体而言，我们的目标是：1.确定建设和平委员会是否改进了可获得性和保留性的奖励措施，并确定建设和平委员会产生了哪些积极或消极的意外影响。2.检查PBC是如何影响客户结果的，如果发现了逆向选择，则控制其结果，并确定相关的组织因素。3.在程序水平的随机试验中测试是否添加 临床医生小组激励直接支付给临床医生和一线工作人员，以奖励PBC定义的总体计划绩效，从而提高计划绩效。4.确定在引入激励措施后，由计划(例如，质量改进计划)或临床医生(例如，向客户推广)实施的变化(如果有)。 公共卫生相关性：缅因州治疗药物使用障碍的第二代绩效合同(PBC)允许对一种相对较新的方法进行细致入微的研究，以提高治疗质量，并提供测试新激励设计的机会。随着PBC变得越来越普遍，了解计划和临床医生的反应、意外影响、客户结果以及与其他计划的互动是至关重要的。PBC和临床医生群体激励可能是工具箱中的重要元素，因为购买者和治疗系统努力在有限的财政环境中提高对患有物质使用障碍的客户的护理质量。

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.