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，因为它可以有效，但并不总是成功的。基于绩效的合同（PBC）旨在调整治疗计划的激励措施和购买者的目标，以推动高质量的护理，但在药物滥用治疗系统中并不常见。由于改进将需要程序，临床医生和工作人员的变化，它可能是有益的，激励这些团体一起工作。设计功能是至关重要的P4P的有效性，但很少有不同的激励设计的对照试验已经进行和开放的问题仍然对特定的设计功能，有助于有效的系统。2007年，缅因州实施了第二代PBC系统，为接受联邦整笔赠款资助的门诊项目提供财政激励。使用缅因州作为实验室，我们超越了SUD治疗PBC的评估，专注于意外的影响和结果;测试支付设计，通过直接向计划达到目标的临床医生/工作人员发送季度支票来奖励临床医生/一线工作人员的计划绩效;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适应组织，管理和临床实践，由于这种激励措施。拟议的研究，与缅因州的药物滥用办公室合作进行，将使用行政数据和从程序访谈和临床医生/工作人员调查收集的数据，结合多层次建模和差异的方法。PBC是支付设计的重大变化，可能会影响SUD治疗服务的交付方式。随着PBC和其他形式的P4P的流行继续增加，了解方案如何应对PBC倡议至关重要。这种关注对激励措施反应的“黑匣子”的能力是拟议研究的一个独特和创新的方面。目标1和2使用了2007年开始的缅因州PBC的回顾性数据。对于目标3和4，我们覆盖了一个新的方法来激励如何分布在一个程序的水平，并检查这与一个随机设计。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获取和保留的奖励措施，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如何影响客户的结果，如果发现逆向选择，则进行控制，并确定相关的组织因素。 3.在项目水平的随机试验中测试是否增加了 临床医生群体激励，直接支付给临床医生和一线工作人员，以奖励PBC定义的整体计划绩效，提高了计划绩效。 4.确定程序实现了哪些更改（如果有）（例如，质量改进计划）或由临床医生（例如，在引入激励措施后，对客户进行外联。

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.