1. 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

2. 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

3. 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

4. Policy Domain #1: Process-focused Quality Improvement Strategies

5. 1a: Increasing licensure/credentialing requirements
Many U.S. programs lack medically-trained staff
Credentials do allow certain activities
But….

7. 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

8. 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

9. Policy Domain #2: Patient outcome-Focused Strategies

10. 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

11. 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

12. 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

13. 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

14. Thank you for
your attention!