Letters to the Editor

The Three-Part Model to Pay for EarlyInterventions for Psychoses

TOTHEEDITOR: We read with interest Frank and colleagues’column (1) [this issue] proposing a novel three-part paymentmodel for early interventions for psychoses. The first part isa prospective per-case payment to cover the average cost ofoutreach, engagement, and retention per engaged client; thesecond is a per-service payment for clinical service delivery; andthe third is an outcome-based component, intended to rewardproviders for improved outcomes. The three parts combinedprovide a sound framework to guide payment designs that ad-equately cover the costs of a coordinated service package butalso align incentives with evidence-based early interventions.

We raise a few issues toward refining the model. First,start-up funds may be needed to support building the earlyintervention team (2) and a financially viable caseload. Second,when operationalizing the per-case payment (part 1 of themodel), it may be challenging to define “engaged clients.”Early intervention programshave highdropout and individuallytailored services. Varying the definition of engagement mayhave substantial financial implications for providers and em-bedded incentives for evidence-based care. For example, de-fining engagement by at least one program contact wouldmaximize provider payment but carry perverse incentives forretention; defining engagement as having had contacts withall provider types, on the other hand, is at odds with the per-sonalized nature of care, and providers may find it difficult torecover costs for clients who ultimately do not “engage.”

Third are the challenges in designing the outcome-basedcomponent (part 3 of themodel) to be both valid and reliable.Prognostic and psychosocial factors affect individual out-comes. The validity of a given measure—the extent to whichit reflects the quality and evidence-based practice of theteam—should be scrutinized in light of new data, such asfrom the RAISE studies (3). On the other hand, given thetypically small caseload (20–30 cases) of the teams, any mea-sure is likely to be highly imprecise and unreliable, with a highrisk of misclassifying teams (4).

In light of these issues, we propose the addition of a start-up payment to support the initial operation of the team, to bemade in installments conditional on achieving well-definedmilestones (for example, recruitment of core team mem-bers). Our second proposal is to make the per-case paymentperiodic (for example, quarterly), contingent on evidence ofclient engagement; the payment rate, however, could beadjusted by special needs (for example, substance abuse) orintervention stage (for example, postcrisis versusmaintenance)

(5). Third, we propose an approach to the outcome-basedpayment whereby, rather than tying payment to a singleoutcome, providers get credit for each client who achievesa predefined goal in any key outcome domain, including hos-pitalization (a key cost driver), and recovery-oriented outcomes,such as work or school performance and functioning. Theprominence of the outcome-basedpayment (relative to the othertwo components) should be gradually increased as teams ac-cumulate experience. These proposals may contribute to fur-ther aligning the model with the delivery of evidence-basedearly interventions as evidence accumulates to inform con-tinuous refinement.

REFERENCES1. Frank RG, Glied SA, McGuire TG: Paying for early interventions in

psychoses: a three-part model. Psychiatric Services 66:678–680, 20152. Heinssen RK, Goldstein AB, Azrin ST: Evidence-Based Treatments

for First Episode Psychosis: Components of Coordinated SpecialtyCare. Bethesda, Md, National Institute of Mental Health, 2014.Available at www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh-white-paper-csc-for-fep_147096.pdf

3. RAISE Project overview. Bethesda, Md, National Institute of MentalHealth. Available at www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml. Accessed Feb 12, 2015

4. Adams JL: The Reliability of Provider Profiling. Santa Monica, Calif,RAND Corp, 2009

5. Bao Y, Casalino LP, Ettner SL, et al: Designing payment for Colla-borative Care for Depression in primary care. Health Services Re-search 46:1436–1451, 2011

Yuhua Bao, Ph.D.Harold Alan Pincus, M.D.

Dr. Bao is with the Department of Healthcare Policy and Research, WeillCornell Medical College, New York City. Dr. Pincus is with the Department ofPsychiatry, Columbia University, and New York-Presbyterian Hospital, NewYork City.

Psychiatric Services 2015; 66:764; doi: 10.1176/appi.ps.660701

Technology Access and Use Among YoungAdults With a First Episode of Psychosis

TO THE EDITOR: It is increasingly recognized that the Inter-net, social media, and mobile technologies can complement,augment, or extend mental health care (1) and enhance ser-vice engagement, particularly among young people (2). Un-derstanding how young people receiving psychiatric servicesaccess and use these technologies can inform the develop-ment or uptake of technology-enabled mental health inter-ventions and supports. Toward this end, we recently conductedan in-person survey among young adults receiving specializedservices for afirst episode of psychosis (FEP) about their access

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LETTERS