Tuesday, October 27, 2009

Promoting Quality in Public Addiction Treatment: Performance Contracting in Delaware

Promoting Quality in Public Addiction Treatment: Performance Contracting in Delaware

Study by Treatment Research Institute suggests government purchasing for performance may have created substance abuse treatment "value", fostering quality improvement, accountability in Delaware system.

Philadelphia, PA (PRWEB) March 13, 2008

A government that pays substance abuse treatment providers for results, not services, may foster improved quality of care, according to the first published study of a novel performance based contracting system implemented by the State of Delaware in 2002. The study, published in Health Policy, was co-authored by A. Thomas McLellan, Ph. D. and colleagues from the Treatment Research Institute (TRI) in Philadelphia, and Jack Kemp, TRI Consultant and former Director of Substance Abuse Services in Delaware.

"Substance abuse treatment providers who stood to gain or lose financially under the contract system may have taken steps to make their services more appealing to patients and do more to integrate evidence-based practices," McLellan and Kemp said. "Ultimately, the providers improved their ability to attract patients and keep them engaged in treatment longer -- both signs of improved addiction treatment quality and accountability for services," they added.

Perhaps based on improvements already documented, Delaware later opened a new front on the government pay for performance experiment: using financial incentives to increase numbers of detoxification patients subsequently referred to and retained in rehabilitative care. Detoxification services are some of the most expensive state governments pay for, yet studies show marginal impact on long-term recovery when detoxification patients don't continue into rehabilitative care. "The entire addiction field will be watching if Delaware is able to cut into its 'detox-only' rates through performance contracting," McLellan said.

The unusual pay for performance system was undertaken in fiscal year 2002 by the Delaware Division of Substance Abuse and Mental Health when it replaced its cost reimbursement contracts with performance based contracts with all outpatient addiction treatment programs. Rather than the government reimbursing providers on a fixed basis (regardless of the number of patients treated), or for the number of addiction treatment services delivered (regardless of the results), the new model included financial rewards and penalties based on success or failure to achieve agreed-upon targets that most experts agree are predictive of accountability and effectiveness in drug and alcohol treatment: 80% and later 90% capacity utilization, and active patient participation in treatment. "Capacity utilization" is the number of treatment slots filled by providers; "active patient participation" is the length of time a patient stays in treatment, in this case, the percentage who stayed more than 30 days.

The experiment demonstrated marked increases on both indicators. Comparing 2001 -- the year before the performance contracting -- through 2006, average rates of patient capacity utilization increased from 54% to 95%; and the average proportion of patients who were actively engaged in more than 30 days of substance abuse treatment went from 53% to 70%.

Importantly, the changes were not due to programs admitting more selectively. Indeed, there were significant increases in the severity of drug, alcohol and other problems presented by patients across the years of the incentives, the TRI study noted.

Kemp cited several factors which may have contributed to the performance improvement. Programs integrated evidence-based practices into daily care and made other structural changes to make their facilities and services more appealing. More treatment venues, better proximity to the populations most needing services, more convenient hours of operation, and refurbished facilities were some of them.

Additional steps the State took to make the experiment a success included efforts to engage addiction treatment providers as full partners from the outset, allowing them to select practices and procedures they thought would work (rather than forcing a specific set of practices), re-designing reimbursement and auditing procedures to expedite provider payments, and expressly promoting sharing of ideas and "lessons learned" among the providers.

Although the TRI study found "clinically and financially significant changes" in the Delaware outpatient addiction treatment system that coincided with pay-for-performance, McLellan and Kemp warned against attributing the dramatic improvement exclusively to contracting changes when it's possible other forces played a role.

"All indications are that relative to other system wide efforts to improve treatment accountability, performance based contracting is less costly and complicated to implement and seemingly quite compatible with other accountability initiatives," McLellan said. Kemp added that performance contracting "... is the type of intervention a small to mid-sized system can do within the limits imposed by most contemporary budgets."

The Treatment Research Institute is a not-for-profit research and development organization specializing in science-driven reform of practice and policy in addiction and substance use. More information about TRI is available from its web site at www. tresearch. org or by calling Bonnie Catone, Director of Communications, at 215-399-0980.