context and rationale for pay for performance in sud treatment niatx-si state call april 2010
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Context and Rationale for Pay Context and Rationale for Pay for Performance in SUD for Performance in SUD
TreatmentTreatment
NIATx-SI State CallNIATx-SI State Call
April 2010April 2010
Core FoundationCore Foundation
Health Care Arena – Addiction is a Health Care Arena – Addiction is a HEALTH problem:HEALTH problem:
Part of mainstream healthcarePart of mainstream healthcareNot fundamentally criminal justiceNot fundamentally criminal justice
Chronic not acute condition:Chronic not acute condition:Purchasers will need to change contracts, funding Purchasers will need to change contracts, funding mechanisms and expectationsmechanisms and expectationsTreatment programs will need to change from acute to chronic Treatment programs will need to change from acute to chronic care design and service delivery care design and service delivery
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Core FoundationCore Foundation
Recovery is the goalRecovery is the goalTreatment prepares for recoveryTreatment prepares for recoveryContinuing care Continuing care Disease managementDisease management
Recovery SupportRecovery SupportRecovery Coaches/Linkage CoordinatorsRecovery Coaches/Linkage CoordinatorsFamily and other “community strengths” supportFamily and other “community strengths” supportReturn to treatment program for “tune ups”, etc.Return to treatment program for “tune ups”, etc.
Medication Assisted Treatment (MAT)Medication Assisted Treatment (MAT)New medications for addictionNew medications for addictionPsychotropic meds for co-occurring MH disordersPsychotropic meds for co-occurring MH disorders
Acute Care AssumptionsAcute Care Assumptions
Some fixed amount or duration of treatment will Some fixed amount or duration of treatment will resolve the problemresolve the problem
Treatment Completion is a goal and expected Treatment Completion is a goal and expected outcomeoutcome
Evaluation of effectiveness should occur following Evaluation of effectiveness should occur following completion completion
Poor outcome means failurePoor outcome means failure
In Chronic CareIn Chronic Care
The effects of treatment do not last very The effects of treatment do not last very long after care stopslong after care stops
Patients who are out of treatment/contact Patients who are out of treatment/contact are at elevated risk for relapseare at elevated risk for relapse
New ExpectationsNew Expectations
Programs are responsible for results Programs are responsible for results duringduring treatment.treatment.
Treatment offers choices – adaptive care.Treatment offers choices – adaptive care.
Evaluation is a clinical activity and every Evaluation is a clinical activity and every patient is evaluated.patient is evaluated.
ImplicationsImplications
Let go of traditional beliefs and practices Let go of traditional beliefs and practices that are not grounded in science/research that are not grounded in science/research or proven practiceor proven practice
Easy transition between levels of care and Easy transition between levels of care and treatment programstreatment programs
Collaboration vs. competition among Collaboration vs. competition among programsprograms
Continuing care and telephone based Continuing care and telephone based counseling (texting?)counseling (texting?)
Some System and Program Some System and Program ChangesChanges
New funding models to purchase careNew funding models to purchase careSystem integration not autonomous System integration not autonomous programsprograms
Bundling servicesBundling services
Collaboration across treatment agenciesCollaboration across treatment agencies
Connecting payment to performance:Connecting payment to performance:Reward Quality not QuantityReward Quality not Quantity
Performance based contractingPerformance based contracting
Incentives for resultsIncentives for results
Congressional Research ServiceCongressional Research ServiceReport for CongressReport for Congress
P4P DefinedP4P Defined
A pay for performance system is a remuneration A pay for performance system is a remuneration arrangement in which a portion of the payments arrangement in which a portion of the payments is based on performance assessed against a is based on performance assessed against a defined measure.defined measure.
Typically, there is another component of the Typically, there is another component of the remuneration that is independent of the amount remuneration that is independent of the amount at risk.at risk.
The terms merit and bonus pay are also used to The terms merit and bonus pay are also used to describe similar systems.describe similar systems.
Theory and Conceptual Theory and Conceptual FoundationFoundation
Elements common to P4P programsElements common to P4P programsA set of targets or objectives that define what will A set of targets or objectives that define what will be evaluatedbe evaluated
Measures and performance standards for Measures and performance standards for establishing the target criteriaestablishing the target criteria
Rewards – typically financial incentives – that are Rewards – typically financial incentives – that are at risk, including the amount and the method for at risk, including the amount and the method for allocating payments among those who meet or allocating payments among those who meet or exceed the reward threshold.exceed the reward threshold.
CEO Survival Guide: Pay for CEO Survival Guide: Pay for Performance – 2006 EditionPerformance – 2006 Edition
National Committee for Quality Health CareNational Committee for Quality Health Care
1701 K Street, NW Suite 2051701 K Street, NW Suite 205
Washington, DC 20006Washington, DC 20006
www.ncqhc.orgwww.ncqhc.org
Impact of Private Sector P4P Impact of Private Sector P4P Programs Programs (35-36)(35-36)
Rewarding Results grant program funded Rewarding Results grant program funded by RWJF and California Healthcare by RWJF and California Healthcare Foundation, and administered by the Foundation, and administered by the Leapfrog GroupLeapfrog Group
Impact of Private Sector P4P Impact of Private Sector P4P Programs Programs (35-36)(35-36)
Financial incentives motivate change – provided they Financial incentives motivate change – provided they are large enough to make a difference.are large enough to make a difference.Non-financial incentives also can make a difference.Non-financial incentives also can make a difference.Engaging physicians is a critical activity – they must Engaging physicians is a critical activity – they must be brought in early as collaborators to ensure that the be brought in early as collaborators to ensure that the goals are clinically meaningful.goals are clinically meaningful.There is no clear picture yet of return on investment.There is no clear picture yet of return on investment.
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Impact of Private Sector P4P Impact of Private Sector P4P Programs Programs (35-36)(35-36)
Public reporting is a strong catalyst for Public reporting is a strong catalyst for providers to improve care.providers to improve care.Providers need feedback on their Providers need feedback on their performance.performance.Providers need to be better educated Providers need to be better educated about P4P.about P4P.Data integrity is important.Data integrity is important.
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Impact of Private Sector P4P Impact of Private Sector P4P Programs Programs (35-36)(35-36)
P4P is not a magic bullet – it is one of a P4P is not a magic bullet – it is one of a number of activities that can work to number of activities that can work to improve healthcare quality and change the improve healthcare quality and change the way it is delivered and financed.way it is delivered and financed.
MedVantage P4P SurveyMedVantage P4P Survey2008 2008
N = 62 P4P Program ResponsesN = 62 P4P Program ResponsesWhat Results do you attribute to P4P?What Results do you attribute to P4P?
84% - Performance on clinical measures improved84% - Performance on clinical measures improved66% - Improvement was statistically significant66% - Improvement was statistically significant
What changes do you anticipate making?What changes do you anticipate making?65% - Expand scope or number of measures used65% - Expand scope or number of measures used53% - Change performance domains or relative 53% - Change performance domains or relative weighting of measuresweighting of measures0% - Discontinue the program0% - Discontinue the program
Connecting Payment and Connecting Payment and Performance in SA DisorderPerformance in SA Disorder
TreatmentTreatment
Personal PurchasingPersonal Purchasing
What do you do when buying a new:What do you do when buying a new:Car, Computer, Appliances, etc.Car, Computer, Appliances, etc.
Compare models, features, priceCompare models, features, price
Consider quality, performance and Consider quality, performance and reliabilityreliability
State As PurchaserState As Purchaser
State sets the expectations:State sets the expectations:Based on science/research/proven practiceBased on science/research/proven practiceDefines the expectations and resultsDefines the expectations and results
Who can best provide what I want?Who can best provide what I want?Contracts and pays for performance and Contracts and pays for performance and results.results.SA treatment provider = seller – how can SA treatment provider = seller – how can they convince state to buy what they are they convince state to buy what they are selling?selling?
Overall Context for P4POverall Context for P4P
Need for new financing and funding models Need for new financing and funding models for healthcare and SA treatment:for healthcare and SA treatment:
Fee for service, grant and contract funding Fee for service, grant and contract funding do not reward performance and resultsdo not reward performance and resultsBundled care, networks and collaborativesBundled care, networks and collaborativesIncentives for resultsIncentives for results
P4P is not a stand-alone solution for P4P is not a stand-alone solution for performance improvement or achieving performance improvement or achieving better resultsbetter resultsGovernment precedentsGovernment precedents
Paying For PerformancePaying For Performance
Connecting payment to performance and Connecting payment to performance and results at a program or network levelresults at a program or network level
Not to individual practitionersNot to individual practitioners
Not to patients, clients – not contingency Not to patients, clients – not contingency management/motivational enhancementmanagement/motivational enhancement
Connecting payment to a few very specific Connecting payment to a few very specific targets that will improve service delivery targets that will improve service delivery and/or results:and/or results:
Examples - access, retention, continuing careExamples - access, retention, continuing care
Chronic/Adaptive CareChronic/Adaptive Care
Chronic not acute care treatment designChronic not acute care treatment design– System wideSystem wide– Individual treatment programsIndividual treatment programs
Disease management not program approachDisease management not program approach– Continuing careContinuing care– Recovery supportRecovery support– Self managementSelf management
Think/fund system of care not individual Think/fund system of care not individual programsprograms
P4P Design ImplicationsP4P Design Implications
Design system to require collaboration Design system to require collaboration among providers, including continuity of among providers, including continuity of care/maintenancecare/maintenance
Include rewards for collaboration – decide Include rewards for collaboration – decide where to place the incentives (push-pull)where to place the incentives (push-pull)
ExamplesExamples
Pay a % of base contract for providing Pay a % of base contract for providing agreed upon/contracted servicesagreed upon/contracted services– Pay remainder for achieving critical Pay remainder for achieving critical
performance targetsperformance targets
Pay incentives for meeting agreed upon Pay incentives for meeting agreed upon performance targets.performance targets.
