PolicIes thaT Can improve the outcomes of substance use disorder treatment Keith Humphreys Veterans Affairs and Stanford University Medical Centers Palo Alto, California USA A. Thomas McLellan Treatment Research Institute and University of Pennsylvania Philadelphia, Pennsylvania USA

P4P Payment by Results Outcome Monitoring Performance Contracting Value-based purchasing P4P Payment by Results Health Care Quality Management Total Quality Improvement Clinical Practice Incentivization

A meta-distinction between two domains of policy strategies Process-focused quality improvement Patient outcome focused strategies N.B. Both share the same ultimate goal, but differ in how they approach it

Policy Domain #1: Process-focused Quality Improvement Strategies

1a: Increasing licensure/credentialing requirements Many U.S. programs lack medically-trained staff Credentials do allow certain activities But….

1b: Measuring and/or Incentivizing Evidence-Based Practices Must include reputational or economic consequences to work Succeeded in changing practice in U.S. VHA and individual U.S. States BUT as with other areas of health care, changed practice has weak relationship to outcome

1c: Improving Managerial Capacity and Business Practices Consultation model used by NIATx and Advancing Recovery Director walkthrough, fiscal advice, customer engagement, staff education Has greatly reduce patient waiting times and early dropout and increased adoption of MAT BUT…no documented relationship to outcome

Policy Domain #2: Patient outcome-Focused Strategies

2a: Rewarding Providers for Outcomes Some evidence of impact with hypertension and diabetes, never with substance use disorder Tracking patient after treatment problematic Linking long-term outcome to care quality also problematic Probably works best when done in treatment

2b: Rewarding Patients for Attaining Specific Outcomes Ample evidence of effect on contingency management treatment literature Also shown effective in certain therapeutic jurisprudence interventions (24/7 Sobriety) BUT…substantial political resistance to rewards AND serious questions about sustaining post-reward gains

2c Making the Patient a Customer with Vouchers Radically different approach, started under G.W. Bush Administration and expanded under Obama Uses usual market forces to drive quality Patients purchases aids to recovery, including dental care, education, transitional housing, resume assistance, baby sitting, work equipment and clothing Shown to increase employment and treatment retention

Summary Most policies are poorly developed, have weak evidence, or both We can change care processes, but need research linking these changes to outcomes Patient outcome focused strategies may be more powerful, though they too require more development

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