Week 10 6351 Discussion 1

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A policy-oriented review of strategies for improving the outcomes of services for substance use disorder patients*add_3464 2058..2066

Keith Humphreys1 & A. Thomas McLellan2

Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA1 and University of Pennsylvania, Philadelphia, PA, USA2

ABSTRACT

Aims To inform policy makers on available options for improving the effectiveness of treatments for substance use disorders and to stimulate debate about treatment improvement strategies among public officials, clinical providers, care managers, service users, families and researchers. Methods We draw on the scientific literature and our public policy experiences in two countries (the United Kingdom and the United States) to give an overview of policies which may improve care for individuals with substance use disorders. We divide such policies into ‘process-focused quality improvement strategies’ that attempt to change some aspect of treatment (e.g. increased retention, greater use of evidence-based practices) and ‘patient-focused strategies’ that attempt to reward outcomes directly (e.g. contingency management for patients, payment by results for providers). Findings Many policies of both types are poorly devel- oped, have shown poor results, or both. The evidence is clear that process-focused quality improvement strategies can change what providers do and how treatment programs work, but such changes have thus far demonstrated only minimal impact on patient outcomes. Patient-focused strategies face challenges including treatment providers avoiding hard-to-treat patients or spending inordinate time relocating patients after treatment to assess outcome. However, policies that reward in-treatment outcomes and policies that allow the patient to purchase desired recovery support services show more promise. As policy makers go forward in this endeavor, they can do an enormous service to their countries and the field by embedding careful evaluation studies alongside new treatment outcome improvement initiatives.

Keywords Addiction treatment, payment by results, performance measurement, public policy, quality of care, treatment outcome.

Correspondence to: Keith Humphreys, VA Palo Alto HCS (152-MPD), 795 Willow Road, Menlo Park, CA 94025, USA. E-mail: [email protected] Submitted 16 November 2010; initial review completed 15 March 2011; final version accepted 31 March 2011

INTRODUCTION

Systemized efforts to improve the performance of complex service delivery systems have been part of the business world for over a century [1] and a feature of health, social care and criminal justice systems for several decades. Yet health and social services for people with substance use disorders have rarely been the subject of such initiatives, nor have the results of those efforts been assembled in a policy-oriented review. This paper strives to remedy this problem by providing policy makers with

an overview of system-level strategies than can improve the outcomes of services for substance use disorder patients. We draw on scientific literature but are also sub- stantially informed by our experiences designing, imple- menting, overseeing and advising on public policy in two nations, the United States and the United Kingdom (including the current national governments of both countries). The limits our personal experience imposes on the scope of the discussion will, we hope, be compensated for by the perspective we offer having been ‘on both sides of the table’ in the United States and United Kingdom.

*Authors’ note: Earlier versions of this paper were presented at a meeting of the UK Advisory Council on the Misuse of Drugs and at the 2010 Symposium of the Society for the Study of Addiction. This paper is heavily informed by the authors’ experience working with/for numerous government agencies in the United Kingdom and United States, but does not necessarily reflect the official views of any of those agencies.

FOR DEBATE doi:10.1111/j.1360-0443.2011.03464.x

For these reasons, we explicitly characterize our paper as a stimulus to discussion and debate rather than as a sys- tematic review of all available evidence in all countries.

We focus on the generic subject of how policies can improve outcomes rather than any of the specific labels under which this goal has been pursued, e.g. ‘payment by results’, ‘value-based purchasing’, ‘continuous quality improvement’ and ‘performance contracting’, to name only a few buzzwords. We focus our discussion further by not entering the rich debate about what outcomes society should expect from treatment in the first place, be it abstinence, human immunodeficiency virus (HIV) risk reduction, reduced crime, higher rates of employment or ‘recovery’. Rather, we address the generic situation of the policy maker who wishes to make services produce better outcomes, regardless of the term they use for that policy and the specific outcomes they and other stakeholders have chosen to pursue.

Because, until quite recently, care for substance use disorders was omitted from most discussions of how to increase the effectiveness of health care [2], we make use of examples outside the field where appropriate. We also attempt to describe the direct, intended effects of outcome improvement policies (that are usually assessed by any ensuing evaluation studies) as well as the unintended, indirect effects (that are often not assessed). As an illus- tration of the latter type of effect, consider the US Veter- ans Health Administration (VHA), which instituted a national system of measuring and incentivizing parti- cular clinical practices across a very large, integrated health-care system [3,4]. This approach created a broader culture of ‘league table competition’, in which more providers put more effort into becoming the best at a range of clinical practices, even clinical practices that were not incentivized [5,6]. Because effectiveness improvement policies involve changing complex organi- zations and not just individual providers and patients, any policy initiative can alter the culture and practices of a services system (for well or for ill) beyond its explicit remit. These changes include but are not limited to the practice of ‘gaming’, in which organizations try to over- state their performance [7].

We now review two broad classes of strategies for improving the outcomes of substance use disorder treat- ment (see Table 1). The first class, process-focused quality improvement strategies, attempts to manipulate aspects of the care system that are expected to translate into better patient outcomes (indeed, there is no justification for investing resources in this strategy if it does not ulti- mately accomplish this) [7]. The second class of strategies focuses on patients and their outcomes more directly, without specifying which clinical and organizational practices are to be used to attain those outcomes. This would include, for example, paying for care based partly

or entirely on the basis of how much improvement patients make, or creating publically available ranking systems of program success rates. A system could use multiple strategies within each broad class, as well as hybrids across both. We describe them here separately for ease of presentation.

PROCESS-FOCUSED QUALITY IMPROVEMENT STRATEGIES

Research has documented substantial deficits in the quality of substance use disorder care in the United States and the United Kingdom [8,9]. These problems include an excess of paperwork, insufficient time spent with patients, demoralized staff, a lack of medically trained staff and dysfunctional organizational dynamics. Treat- ment programs also tend to underutilize scientific evidence [10].

The immediate objective of process-focused quality improvement strategies is to change organizational, financial and clinical practices. These improvements in treatment quality, in turn, are hoped to translate into better patient outcomes, but this cannot be assumed [11]. As chronic conditions with powerful behavioral and environmental components, substance use disorders are influenced profoundly by concurrent life context [12]. An individual patient may therefore receive high-quality care, but live in an environment (e.g. working in a pub, living on skid row) which undermines long-term out- comes. Similarly, a patient may receive low-quality care but have a major life event (e.g. becoming a mother, mar- rying someone who is in recovery, landing a dream job) that facilitates a good long-term outcome. In general, the longer the time between receipt of services and outcome measurement, the less likely the outcome can be taken as proof of the quality or lack of quality of those services. We develop this point further in the ensuing discussion of evidence.

Table 1 Strategies for improving the outcomes of health and social services for substance use disorder patients.

Process-focused quality improvement strategies Increasing licensure/credentialing requirements Measuring and/or incentivizing evidence-based clinical

practices Improving managerial capacity and business practices Embedding substance use disorder care in a higher-quality

care network Patient-focused strategies

Rewarding providers for post-treatment outcomes Rewarding providers for in-treatment outcomes Rewarding patients for attaining specific outcomes Making the patient a customer with purchasing power

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Process-focused quality improvement strategy no. 1: increasing licensure/credentialing requirements

Most US addiction treatment programs have no physi- cians or nurses [9]. In the United States and to a lesser, but still significant, extent in the United Kingdom, many counselors in the field have the primary credential of being in recovery from addiction themselves rather than having earned a particular educational degree or com- pleted a particular sequence of courses in counseling techniques. It therefore seems logical at face value that increasing credentialing requirements for staff will improve quality of treatment, which will in turn improve patient outcomes. Matters are not so simple, however.

First, the low status of careers in substance use dis- order treatment frequently makes it difficult to hire and retain staff. By definition, an increase in entry require- ments will exacerbate this problem unless it is accompa- nied by some inducement that makes a career in the field more attractive [for example, during a period when the National Health Service (NHS) was struggling to hire mental health professionals it offered a more generous pension scheme for new hires, allowing retirement at age 55 years]. Second, credentialing has become an entrepreneurial activity, with countless organizations developing and selling certificates and licenses. Although amusing as a story, it is disturbing from a policy perspec- tive that a man was able to purchase a doctorate and numerous psychotherapy credentials for his housecat over the internet [13]. It is a rare policy maker, and an even rarer consumer of services, who can tell which certificates on a wall truly reflect clinical competence. This problem is not particular to addiction treatment or even to health care: how many customers know what the certificates on the wall at a restaurant, beauty shop or in an accountant’s office actually mean?

Finally, although it comes as unwelcome news to pro- fessional guilds, evidence from hundreds of clinical trials shows that the outcomes of psychological counseling— one of the staples of substance use disorder treatment— are not predicted at all by the counselor’s type or level of educational degree [14]. This is less surprising than it may at first seem, as having a degree in medicine from Oxford or Cambridge, for example, does not ensure the ability of a physician to make an emotional connection to a drug-addicted homeless patient or an alcoholic army private who suffers from post-traumatic stress disorder.

Legitimate credentialing and licensure could help weed out truly destructive individuals (e.g. someone who has a criminal record for violence). Some credentials also allow particular clinical activities that could otherwise not be done, such as prescribing medication or drawing a blood sample. Further, there is evidence that more educated staff are particularly receptive to the use of

evidence-based practices [15]. Beyond these rather gross indicators of value, new credentialing policies are a weak lever for improving the outcomes of substance use dis- order treatment systems. One might temper this pessi- mistic conclusion by saying that credentialing might matter more if it shifted focus to demonstration of specific clinical competencies rather than particular coursework or hours of training.

Process-focused quality improvement strategy no. 2: measuring and/or incentivizing evidence-based clinical practices

In the US VHA, particular clinical practices were selected by national management and included in ongoing moni- toring throughout the system. Facility directors, chiefs of staff and other leaders were rewarded for augmenting the use of such practices, sometimes by financial incentives and sometimes by professional incentives (e.g. public ranking of medical centers’ success rates). Such clinical practices have included screening all primary care patients for drinking problems, recommending smoking cessation to psychiatric patients and retaining alcohol- and drug-dependent patients in specialty substance use disorder treatment for 3 months [16]. Outside the VHA, under the influence of quality improvement organiza- tions such as the Washington Circle [17], the National Committee for Quality Assurance [18] and the National Quality Forum [19], other public and private health-care systems in the United States have begun to monitor the proportion of patients whose substance use disorder is identified, the proportion who engage early in care and the proportion who are retained in care over time.

The VHA experience is that such incentives can lead to dramatic improvements in how often treatment pro- grams hit these process-of-care targets. The same has been found elsewhere, for example in the State of Dela- ware, which rewarded financially treatment programs that decreased the number of patients who dropped out of care quickly [20], and rewarded detoxification units and treatment programs who increased the rate of transition from the former care setting to the latter [21]. However, careful research on some of these measures has shown that achieving them bears at best a weak relationship to subsequent patient outcomes [22–24]. These disappoint- ing findings include studies of the 3-month retention in care process measure, which was used unsuccessfully for years in the US VHA and has now been adopted as a standard in the UK National Treatment Agency. The problem of weak links of process measures to outcomes is not unique to substance use disorders. For example, Medicare’s hospital quality measures for care of heart attacks and pneumonia explain a very small percentage of variation in patient outcome [25].

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A proponent of such approaches might argue that all a quality treatment system can be expected to do is provide care as close to practice guidelines and evidence as possible, not control everything that happens to the patient later. A more compelling point, we think, is that practice incentive strategies have demonstrated some- thing very important: provider behaviors respond to incentives [26]. It now remains for research to tell the health-care field which provider behaviors lead ulti- mately to better patient outcomes. Because research cannot yet predict reliably and strongly which care pro- cesses improve patient outcome, policy makers wanting prompt improvement in the effectiveness of treatments for substance use disorders will be understandably chary of this approach at the moment.

Before closing this section, we raise another question that is relevant to this strategy as well as some of those discussed in the ensuing sections: should anyone other than providers themselves be made aware of how closely they are following evidence-based practice guidelines? A recent clinical trial found that giving substance use dis- order treatment providers substantial feedback on their patients’ perceptions of the therapeutic alliance, satisfac- tion with care and level of current substance use had no effect whatsoever on clinical performance [27]. This finding resonates with others indicating that if there is no risk of reputational damage, information on one’s individual or organizational performance is generally dis- regarded [7]. Absolute and relative performance on mea- sured clinical practices is best made a public rather than private matter if the goal is to improve the outcomes of care.

Process-focused quality improvement strategy no. 3: improving managerial capacity and business practices

This strategy involves having expert consultants in busi- ness practices help treatment programs to improve their management skills, knowledge and capacity. Examples include teaching treatment programs how to pilot new procedures and make prompt use of data on their impact, engage with customers to discover their needs and wants, reduce excessive paperwork and other cumbersome bureaucratic processes, improve financial management and create an organizational culture that is professional and continuously educational for all involved. The highest-profile US-based efforts of this type are the Network for the Improvement of Addiction Treatment (NIATx) [28] and a follow-on project, Advancing Recov- ery [29]. Treatment programs applied competitively to join these projects, and those that were granted entry received a small amount of funds and access to exten- sive learning and consultation sessions. They were also brought together in conferences that allowed learning

from each other and also generated at least some spirit of healthy competition.

One intriguing business improvement strategy employed by NIATx is the ‘walkthrough’, in which program managers attempt to access care in their own programs from the patient’s point of view. For many managers, this was an eye-opening experience in poor organizational practice (e.g. telephones not being answered, messages being lost, unfriendly assessment staff) that helped to explain the low rates of treatment entry and retention in substance use disorder care. Other management practices taught in these initiatives include careful analysis and allocation of existing funding and better development of a business case for legislative and administrative bodies when advocating for new funding.

In two studies of the benefits of NIATx, participating programs reduced waiting time for treatment entry and increased retention in care [28,30]. These benefits remained in place after the intensive phase of organi- zational consultation had ended, suggesting that this approach is a sustainable strategy. The Advancing Recov- ery project generally improved its programs’ continuity of care and use of evidence-based pharmacotherapies [29].

However, NIATx and Advancing Recovery had a com- petitive entry process, meaning that better-organized and more motivated programs with stronger leadership were no doubt over-represented among participants. Effects would probably be less dramatic if such initiatives become national policy for the full universe of programs. Further, although both initiatives are currently trying to link implemented changes in care processes to long-term patient outcomes, this has not yet occurred. The same problem has bedeviled other, smaller-scale efforts to improve substance use disorder care through manage- ment consultation (e.g. the OpiATE Initiative) [31].

Process-focused quality improvement strategy no. 4: embedding substance use disorder care in a higher-quality care network

In its health-care reform legislation (the Affordable Care Act of 2010) and in the President’s National Drug Control Strategy [32], the Obama Administration consciously pursued a policy of medicalizing the care of substance use disorders [33], inspired in part by the UK’s example as well as by the few US systems that work on this principle (e.g. the VHA, Kaiser Permanante). The reasons for this decision were various, but one was the potential for improved quality. In the United States, sub- stance use disorder care is embedded in a clinical environ- ment of low resources and low quality, and in a financial environment (a set-aside public sector ‘block grant’) that pays for care with little consideration of effectiveness.

Through expanded funding for screening and brief intervention in primary care settings and changes in

Policies for improving treatment effectiveness 2061

public and private insurance, the Obama administration has begun the difficult process of transplanting substance use disorder care into general health care. This setting brings with it numerous features that may improve patient outcomes, for example the presence of medically trained individuals, availability of medications, a finan- cial reimbursement system that provides some incentives for quality, an electronic health record that promotes careful tracking and monitoring of patients, and a broad culture of careful inspections and monitoring (i.e. by the Joint Commission). Co-location should also improve the likelihood that substance use disorder patients needing supplemental medical services (e.g. psychiatric or infec- tious disease care) will be able to obtain it. Finally, and importantly, integrated care coordinated by one’s usual general practitioner/primary care physician may be more accessible and less stigmatizing than going to an ‘addic- tion treatment program’. In turn, this means that it may also be possible to engage patients with lower, more manageable levels of severity.

Although we have worked in our policy capacities to mainstream substance use disorder care, we are cogni- zant that quality improvement is not guaranteed by this approach. Some medical care systems could take the resources allotted for substance use disorder care and re-allocate them to other priorities. Care integration could also lead to some addicted individuals receiving treatment from providers who lack significant knowledge of addictive disorders (e.g. many general practitioners). Integration thus remains a promising idea in search of rigorous evidence rather than something that can be assumed effective.

PATIENT-FOCUSED STRATEGIES

We now turn to a distinct set of strategies focused on the patient’s actual outcome (e.g. reduction in substance use, psychiatric symptoms, high-risk behavior, un- employment, criminality) rather than any individual organizational and clinical practice (e.g. shorter waiting- times, longer retention in care). A common criticism of regulation in both the United States and the United Kingdom is that process is over-managed by central government without regard to whether it leads to any valued outcome. From this perspective, it is fair to charge some of the organizational quality improvement strategies just reviewed with failing to focus on what ultimately matters most: the patient’s outcome. Some weight is given to this perspective by the research just reviewed showing how changed care processes have often not translated into better patient outcomes, as well as by other research suggesting that negative side effects of process-focused quality improvement initiatives are possible [34].

The patient-focused approaches in this section have been implemented less frequently than have process- focused quality improvement strategies. We thus make more use in this section of examples from other disorders.

Patient-focused strategy no. 1: rewarding providers for post-treatment outcomes

In some areas of health care, providers are directly incen- tivized to produce specific long-term patient outcomes. For example, the refusal of Medicare to reimburse the costs incurred when a surgery patient returns for follow-up surgery to remove equipment left in the body (e.g. a glove or clamp that leads to infection or poor wound healing) is a financial penalty for those hospitals whose low-quality care leads to poor patient outcomes. Similarly, the majority of US State Medicaid programs have some variant of ‘value-based purchasing’, and the NHS has long had ‘payment by results’.

The UK government is now launching what we believe is the first payment-by-results program in drug depen- dence treatment [35]. In pilot sites around the country, patients will be assessed by an independent unit that will assign a ‘tariff’ (i.e. a specific amount of money) that treatment programs will earn if they produce long-term changes in the patient in various domains (e.g. drug use, employment, criminal behavior, health and wellbeing). The independent assessment unit will assess the patient again after care has concluded to determine whether the treating program should be rewarded the tariff. This stands as one of the more innovative performance improvement efforts in the addiction field, and it will be important to monitor whether it results in measurable improvements.

The US VHA includes some outcomes in its perfor- mance monitoring system, including cholesterol levels for diabetic patients and blood pressure for hypertensive patients. In both these domains, VHA outperforms private and other public providers, as well as its own track record prior to the start of performance management [5]. We hasten to re-state, however, that what happens to a chronically ill individual after treatment becomes less linked to care quality over time. Setting the outcome measurement point too distant from treatment provision could lead to demoralization and subsequent lack of effort by clinical providers, as they are held accountable for things over which they have little control. There are also some risks that, in an outcome purchasing system, providers will ‘cream’ patients, i.e. not admit poor prog- nosis patients. Finally, the costs of locating and assessing patients after treatment can be considerable. When this work has been assigned to clinicians, it has resulted in poor follow-up rates, less time spent treating current patients and poor data [36]. It is therefore better for an

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independent outcomes monitoring team to follow-up patients, although this requires a continuing resource commitment [37].

Patient-focused strategy no. 2: rewarding providers for in-treatment performance

A different purchasing approach is to reward programs for outcomes attained during treatment. This resolves several problems with the just-mentioned strategy: finding the patient to assess them is easier, and what the provider does during the provision of care should have a stronger relationship to how the patient is doing at that moment. An experiment in the State of Maine initially generated enthusiasm about this strategy. Programs could obtain more funds by increasing the proportion of patients who achieved various outcomes (e.g. abstinent during the past 30 days of treatment, significant reduction in substance use since treatment intake) by their final contact with the program. Perfor- mance appeared to improve somewhat [38], but subse- quent analysis showed that programs began treating fewer severely troubled clients (creaming) after the performance contract was in place, implying that the apparent gains may have been illusory [39]. Further, the Maine system was entirely based on self-report, and patients may have been less candid in a system where treating clinicians are rewarded for reporting high abstinence rates. The Maine performance-contracting system was subsequently reviewed and updated to increase its effectiveness, but the most recent evaluation has again yielded disappointing results [40]. The Maine experience does not mean that this approach cannot work, but that performance contracts need to reward outcomes that are objective (e.g. urine testing) and case-mix-adjusted.

The Methadone Treatment Quality Assurance System implemented such an approach by having all participating methadone clinics fax in their urinalysis results to a central data monitoring unit, which then informed each program where it stood on case-mix- adjusted outcomes relative to a national sample [41]. This project demonstrated the feasibility of such a system, but because it did not attach any financial or reputational consequence to relative performance (clinic data were kept anonymous) there is no evidence that it changed clinical practice or improved patient outcomes.

Some clinicians would say that the in-treatment per- formance approach is not feasible as it requires regular monitoring of patients’ substance use. We are not sympathetic to this argument. Assessing a patient’s substance use at every single contact is as essential to good clinical practice as is an endocrinologist’s regular

measuring of blood sugar for diabetic patients or a car- diologist’s consistent monitoring of blood pressure for hypertension patients. Programs should assess patients’ substance use regularly whether or not there is an out- comes improvement contract in place.

Of the outcome improvement approaches described in this paper, we view purchasing in-treatment outcomes as among the most promising and feasible, not only because it could improve care but because it focuses clinicians’ attention on something for which they can and should be responsible throughout the care process. Research is still needed, however, to establish the strength of the relation- ship between in-treatment outcomes and longer-term, post-treatment outcomes.

Patient-focused strategy no. 3: rewarding patients for attaining particular outcomes

Multiple lines of evidence indicate that individuals with substance use disorders respond to incentives. Within the criminal justice system, for example, programs that put probationers and drink driving offenders in jail for a day immediately in response to a positive drug/alcohol test produce dramatic decreases in substance use [42,43]. Within health-care settings, contingency management programs have been shown to produce substantial behav- ioral changes when they reward abstinence or other out- comes with money, the chance at a prize or with greater privileges during treatment [44,45]. Housing provided contingent on abstinence also has been shown to reduce or eliminate substance use [46,47].

As a policy, however, paying patients to attain specific outcomes can run into resistance by the public and sometimes care providers as well, usually expressed in words to the effect that ‘they ought to change for free like everyone else’ or ‘why should we give goodies to baddies?’. These concerns can usually be somewhat mol- lified by using non-financial rewards; for example, by allowing methadone patients who stop using heroin to have extra take-home doses, and by emphasizing the public benefits of reward schemes, e.g. ‘the rewards to patients translate into rewards for everyone, such as safer neighborhoods’.

A different challenge is that behavior changes induced by an external reward sometimes deliquesce once the reward schedule is removed. This may come about through learning processes (e.g. the patient does not gain self-efficacy regarding the behavior change) or through disagreement about the purposes of treatment (e.g. the patient is interested in a different change than the one the system incentivizes). Policies of this sort may therefore affect long-term outcomes inconsistently, but may be useful in the early stages of treatment to encourage progress and engagement with care.

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Patient-focused strategy no. 4: making the patient a customer with purchasing power

During the G. W. Bush Administration, a radically differ- ent approach to improving the outcomes of substance use disorder care was created. Individuals early in the recovery process were given vouchers with which they could purchase whatever services they thought would further their recovery. Examples included community college classes, transportation to work or to self-help group meetings, transitional housing, dental care, work training and clothes for job interviews. The services were provided by a range of organizations which the state cer- tified for quality and, as in any market, there was pressure to serve the customer well because he or she could always take the voucher somewhere else. This was an innovative attempt to break down the culture that can emerge in the public sector in which patients are viewed as people ‘who have nowhere else to go’; or people who should be told what is good for them. One of the basic dilemmas of public sector services is that they are insulated from most of the mechanisms that drive efficiency and product quality in a free market [7]. Giving patients vouchers creates a miniature free market inside the public sector that should, theoretically, bring some of these mecha- nisms into play.

Access to Recovery, as the program is called, expanded both the number of organizations providing services and the number of people receiving them. More importantly, a study of more than 7000 substance use disorder out- patients in the State of Washington found that patients who received vouchers remained in treatment longer and were more likely to be employed than were comparable patients who did not receive a voucher [48]. This study did not, unfortunately, capture data on substance use outcomes, but the higher rate of employment might incline one to suspect better outcomes in that domain as well as being significant in itself. The Obama Administra- tion embraced Access to Recovery and indeed proposed a large budget increase for it [33].

Some UK think-tanks and elected officials have taken note of the success of Access to Recovery and bruited similar ideas. Although not a voucher program per se, the ‘personal health budgets’ being piloted for health and social care in the NHS are analogous in that they give patients a form of purchasing power. In consultation with a health professional, individuals with chronic illnesses (e.g. obstructive pulmonary disease, psychiatric disorders) are given a fixed pool of funds from which they can buy a range of services, assembling a care package tailored to their needs [49,50]. The extension of such budgets to people with addictions has been a subject of active discus- sion within the government, but it is not clear at this writing whether this will lead to a pilot effort of this sort.

CONCLUSION

Public policy makers can use a range of strategies to improve the outcomes of substance use disorder treat- ment. Many are poorly developed at this point, have weak empirical support, or both. Incentives for particular clini- cal practices can definitely change what systems do, but it is less clear which of those system changes translate into better patient outcomes. Some initiatives to incentivize care processes (including some in which we have been personally involved) have proved literally worse than doing nothing. Cases discussed in this paper in which care utilization was incentivized but outcomes did not change are particularly troubling, in that money was spent on care that was apparently not needed, and this may have affected adversely other people’s wellbeing (e.g. if waiting-lists grew longer due to requirements to retain patients beyond the point where it was making a difference).

Despite the small evidence base, the logic of bringing market forces for quality and effectiveness into treatment systems—including directly rewarding outcomes—has significant practical and logical appeal. We are particu- larly optimistic about such initiatives when they focus on in-treatment performance rather than long-term post-treatment outcome. The experience of vouchers for recovery support services that give patients’ purchasing power is also promising, and we hope the purchasing power concept will be extended for substance use disorder patients in other contexts, for example through the NHS personal health budget programme.

The extent to which our discussion here generalizes outside the UK and US contexts is something we are candidly not qualified to judge. How treatment systems are structured, organized, staffed and supported fiscally varies enormously throughout the world, such that a service improvement strategy that works well in one country may be ineffectual in another. Indeed, even within a single country some humility is warranted. To take a vivid example of intracountry diversity, the US VHA has more in common with the UK NHS than it does with the fee-for-service private sector of treatment ser- vices in its own country.

We close by advocating that as they make their strat- egy choices, policy makers serve themselves and this area by embedding careful, realistic evaluations in place alongside any new initiatives. The most common way in which performance enhancement schemes have been evaluated has been through retrospective study of various policy experiments. The most common data sources have been administratively available data not intended for research. An embedded evaluation would bring in program evaluators from the very first, allowing them to help decide how proximal and ultimate outcomes

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will be measured, and to complete the work in a time interval that might actually inform what to do next year, rather than what should have been done 5 or 10 years ago. The investment and level of collaboration required to do this is substantial, but given the potential payoff in knowledge about how to enhance care for a life- threatening group of disorders, we have no doubt that the up-front costs to policy makers and researchers are very well justified.

Declarations of interest

The authors advised on or were involved in a number of the policy initiatives described in this paper.

Acknowledgements

Dr Humphreys’ work on this paper was supported by a VA HSR&D Senior Research Career Scientist award. We are grateful to Gwyn Bevan, Joe Francis, Alex H. S. Harris, Francis Keaney, John Marsden, Dennis McCarty and two anonymous reviewers for comments on earlier drafts of this paper.

References

1. Taylor F. W. Principles of Scientific Management. New York: Harper; 1911.

2. Institute of Medicine. Improving the Quality of Health Care for Mental and Substance-Use Conditions: Quality Chasm Series. Washington, DC: Author; 2005.

3. Francis J. The Veterans Health Administration: lessons learned from implementing performance measurement, electronic health records, and evidence-based practice. In: Magnabosco J. L., Manderscheid R., editors. Outcomes Mea- surement in the Human Services: Cross-Cutting Issues and Methods, 2nd edn. Silver Spring, MD: NASW Press; 2011, in press.

4. Jha A. K., Perlin J. B., Kizer K. W., Dudley R. A. Effect of the transformation of the Veterans Affairs Health Care System on quality of care. N Engl J Med 2003; 348: 2218–27.

5. Oliver A. The Veterans Health Administration: an American success story? Millbank Q 2007; 85: 5–35.

6. Oliver A. Public sector health-care reforms that work? A case study of the US Veterans Health Administration. Lancet 2008; 371: 1211–3.

7. Bevan G., Hamblin R. Hitting and missing targets by ambu- lance services for emergency calls: effect of different systems of performance measurement within the UK. J R Stat Soc Ser A 2009; 172: 161–90.

8. Best D., Day E. What treatment means in practice: an analysis of the delivery of evidence-based interventions in criminal justice drug treatment services in Birmingham, England. Addict Res Theory 2009; 17: 678–87.

9. McLellan A. T., Carise D., Kleber H. D. Can the national addi- ction treatment infrastructure support the public’s demand for quality care? J Subst Abuse Treat 2003; 25: 117–21.

10. McGlynn E. A., Asch S. M., Adams J., Keesey J., Hicks J., DeCristofaro A. et al. The quality of health care delivered to adults in the United States. N Engl J Med 2003; 348: 2635–45.

11. McLellan A. T., Chalk M., Bartlett J. Outcomes, performance, and quality—what’s the difference? J Subst Abuse Treat 2007; 32: 331–40.

12. Moos R. H., Finney J. W. The expanding scope of alcoholism treatment evaluation. Am Psychol 1983; 38: 1036–44.

13. Eichel S. K. D. Credentialing: It May Not be the Cat’s Meow. 2002. Available at: http://www.dreichel.com/ articles/dr_zoe.htm (accessed 19 May 2011; archived by Webcite at http://www.webcitation.org/5ykjQfsyZ).

14. Smith M. L., Glass G. V., Miller T. L. The Benefits of Psycho- therapy. Baltimore: Johns Hopkins University Press; 1980.

15. McCarty D., Fuller B. E., Arfken C., Miller M., Nunes E., Edmundson E. et al. Direct care workers in the national drug abuse treatment clinical trials network: characteris- tics, opinions, and beliefs. Psychiatr Serv 2007; 58: 181–90.

16. Humphreys K., Harris A. H. S., Kivlahan D. Performance monitoring in the Department of Veterans Affairs. Am J Drug Alcohol Abuse 2009; 35: 123–7.

17. McCorry F., Garnick D. W., Bartlett J., Cotter F., Chalk M. Developing performance measures for alcohol and other drug services in managed care plans. Jt Comm J Qual Improv 2000; 26: 633–43.

18. National Committee for Quality Assurance. HEDIS 2006 Volume 2: Technical Specifications. Washington, DC: Author; 2006.

19. National Quality Forum. National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. Washington, DC: Author; 2007.

20. McLellan A. T., Kemp J., Brooks A., Carise D. Improving public addiction treatment through performance contract- ing: the Delaware experiment. Health Policy 2008; 87: 296– 308.

21. Haley S. J., Dugosh K. L., Lynch K. G. Performance contract- ing to engage detoxification-only patients into continued rehabilitation. J Subst Abuse Treat 2011; 40: 123–31.

22. Harris A. S., Humphreys K., Bowe T., Kivlahan D., Finney J. W. Measuring the quality of substance use disorder treatment: evaluating the validity of the VA continuity of care performance measure. J Subst Abuse Treat 2009; 36: 294–305.

23. Harris A. S., Humphreys K., Bowe T., Finney J. W. HEDIS initiation and engagement quality measures of substance use disorder care: impacts of setting and health care spe- cialty. Popul Health Manag 2009; 12: 191–6.

24. Harris A. S., Humphreys K., Bowe T., Tiet Q., Finney J. W. Does meeting the HEDIS substance abuse treatment engage- ment criteria predict patient outcomes? J Behav Health Serv Res 2010; 37: 25–39.

25. Werner R. M., Bradlow E. T. Relationship between Medicare’s Hospital Compare performance measures and mortality rates. JAMA 2006; 296: 2694–702.

26. Chassin M. R., Loeb J. M., Schmaltz S. P., Wachter R. M. Accountability measures—using measurement to promote quality improvement. N Engl J Med 2010; 363: 683–9.

27. Crits-Cristoph P., Ring-Kurtz S., McClure B., Temes C., Kulaga A., Gallop R. et al. A randomized controlled study of web-based performance improvement system for substance abuse treatment providers. J Subst Abuse Treat 2010; 38: 251–62.

28. McCarty D., Gustafson D. H., Wisdom J. P., Ford J., Choi D., Molfenter T. et al. The Network for the Improvement of Addiction Treatment (NIATx): enhancing access and reten- tion. Drug Alcohol Depend 2007; 88: 138–45.

Policies for improving treatment effectiveness 2065

29. Schmidt L., Rieckmann T., Abraham A., Molfenter T., Capoccia V., Roman P. et al. Advancing recovery: implementing evidence-based addiction treatment at the systems level. Report to the Robert Wood Johnson Foundation. Portland, OR: Health Sciences University; 2011.

30. Hoffman K. W., Ford J. H., Choi D., Gustafson D. H., McCarty D. Replication and sustainability of improved access and retention within the network for the improvement of addic- tion treatment. Drug Alcohol Depend 2008; 98: 63–39.

31. Willenbring M. L., Postier A. C., Kenny M. E., Hagedorn H. J. Innovative approaches to measuring outcomes and pro- viding feedback: the opioid agonist therapy effectiveness (OpiATE) Initiative. J Mainten Addict 2005; 3: 13–21.

32. White House Office of National Drug Control Policy. 2010 National Drug Control Strategy. Washington, DC: Executive Office of the President; 2010.

33. Humphreys K., McLellan A. T. Brief intervention, treatment and recovery support services for Americans who have sub- stance use disorders: an overview of policy in the Obama Administration. Psychol Serv 2010; 7: 275–84.

34. Wachter R. M., Flanders S. A., Fee C., Pronovost P. J. Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure. Ann Intern Med 2008; 149: 29–32.

35. National Treatment Agency for Substance Misuse. Payment by Results Update. 2011. Available at: http://www.nta.nhs. uk/payment-by-results-update.aspx. (accessed 19 May 2011; archived by Webcite at http://www.webcitation.org/ 5ykjbidhb).

36. Otilingam P. G., Ritsher J. B., Finney J. W., Moos R. H., Suchinsky R. Outcomes Monitoring for Patients with Sub- stance Use Disorders: V. Cohort 3 Patients’ Characteristics, Treatment and Treatment Outcomes. Palo Alto, CA: Program Evaluation and Resource Center; 2002.

37. Tiet Q. Q., Byrnes H. F., Barnett P., Finney J. W. A practical system for monitoring the outcomes of substance use disor- der patients. J Subst Abuse Treat 2006; 30: 337–47.

38. Commons M., McGuire T. G., Riordan M. H. Performance contracting for substance abuse treatment. Health Serv Res 1997; 32: 631–50.

39. Shen Y. Selection incentives in a performance-based contracting system. Health Serv Res 2003; 38: 535–52.

40. Brucker D. L., Stewart M. Performance-based contract- ing within a state substance abuse treatment system: a preliminary exploration of differences in client access and client outcomes. J Behav Health Serv Res; Epub ahead of print 20 January. DOI: 10.1007/s11414-010-9228-5.

41. Ducharme L. J., Luckey J. W. Implementation of the metha- done treatment quality assurance system. Eval Health Prof 2000; 23: 72–90.

42. DuPont R. L., Humphreys K. A new paradigm for long-term recovery. Subst Abuse 2011; 32: 1–6.

43. Hawken A., Kleiman M. A. R. Managing drug involved probationers with swift and certain sanctions: evaluating Hawaii’s HOPE. 2009. Report to National Institute of Justice, Washington, DC.

44. Lussier J. P., Heil S. H., Mongeon J. A., Basger G. J., Higgins S. T. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006; 101: 192–203.

45. Prendergast M., Podus D., Finney J., Greenwell L., Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. Addiction 2006; 101: 1546– 60.

46. Jason L. A., Olson B. D., Ferrari J. R., Lo Sasso A. T. Commu- nal housing settings enhance substance abuse recovery. Am J Public Health 2006; 96: 1727–9.

47. Milby J. B., Schumacher J. E., Raczynski J. M., Caldwell E., Engle M., Michael M. et al. Sufficient conditions for effective treatment of substance abusing homeless persons. Drug Alcohol Depend 1996; 43: 39–47.

48. Krupski A., Campbell K., Joesch J. M., Lucenko B. A., Roy- Byrne P. Impact of access to recovery services on alcohol/ drug treatment outcomes. J Subst Abuse Treat 2009; 37: 435–42.

49. National Health Service. Personal Health Budgets Update. 2011. Available at: http://www.personalhealthbudgets. dh.gov.uk/News/item/?cid=8206 (accessed 19 May 2011; archived by Webcite at http://www.webcitation.org/ 5ykjxcwCV).

50. Newbronner L., Chamberlain R., Bosanquet K., Bartlett C., Sass B., Glendinning C. Keeping Personal Budgets Personal: Learning from the Experiences of Older People, People with Mental Health Problems and Their Carers. London: Social Care Institute for Excellence; 2011.

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