Impact of financial incentives on
waiting time and length of stay in
publicly funded addiction
treatment
Maureen T. Stewart, PhD
Institute for Behavioral Health
The Schneider Institutes for Health Policy
The Heller School for Social Policy and
Management, Brandeis University
Supported by grants from NIAAA (T32 AA007567) and NIDA (5F31 DA022822-02)
Acknowledgements
Supported by grants from NIAAA and NIDA.
Constance Horgan, ScD
Deborah Garnick, ScD
A. Thomas McLellan, PhD
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Background
♦ Performance contracting has been
identified as a way to improve quality of
AOD treatment (IOM 2006, 2008).
♦ 24+ existing pay-for-performance
programs in behavioral health (Bremer, 2008).
♦ Few programs have been evaluated.
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Previous Research
♦ DE PBC → “Immediate and sustained
improvements” in access to care and
attendance in treatment. No evidence of
selection of clients. (McLellan, et al, 2008).
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Study questions
♦ How did the PBC implemented in
Delaware affect waiting time for treatment
and length of stay?
♦ How did the PBC combined with NIATx
affect waiting time for treatment and length
of stay in Delaware?
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Design of DE performance contract
♦ Prior to PBC state used a global budget
♦ PBC implemented in 2001 for public
outpatient AOD treatment (n = 5-8
programs)
♦ Performance evaluated monthly
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Contract Measures
♦ Contract includes potential penalties and
bonuses
♦ Contract Measures:
– Program Capacity Utilization
– Client Active Participation
– Client Treatment Completion
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Measure definitions & payment scheme
♦ Capacity Utilization Treatment slots filled
Capacity
90%
80%
70%
60%
All treatment slots
Payment
100%
90%
80%
70%
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Measure definitions
♦ Active Participation:
# Days Client req Pgm target
0 – 30
2 visits/wk 50%
31 – 90 4 visits/mo 60%
91 – 180 4 visits/mo 70%
181+
2 visits/mo 80%
All AP measures
Bonus
1%
1%
1%
1%
1%
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Data & research design
♦ Client episode data from Delaware and
Maryland, 1998 – 2006
♦ Pre –post design with matched control
group selected from Maryland data
Pre
Post
PBC
PBC+NIATx
|
|
|
|
1998 2001
2004
2006
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Measures Studied
♦ Waiting time for treatment:
Number of days between initial contact
with treatment program and admission
♦ Length of stay:
Number of days from admission to
discharge
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Results: Change in waiting time
Dependent variable: Waiting time for outpatient AOD
treatment
Parameter
Estimate SE p value
State & Admission Year (Maryland 1998 – 2001)
DE PBC: 2002 – 2003
-13.27 2.36 <.0001
DE PBC + NIATx 2004– 2006
Delaware
Admission 2002 – 2003
Admission 2004 – 2006
-20.04
16.68
4.16
3.31
2.22
3.97
1.30
1.17
<.0001
<.0001
0.001
0.005
Model includes controls for client demographics, state & admission yr.
Adjusted for clustering of clients within programs. n = 21,351
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Results: Change in LOS over time
Dependent variable: LOS in outpatient AOD treatment
Parameter
Estimate SE p value
State & Admission Year (Maryland 1998 – 2001)
DE PBC: 2002 – 2003
14.80 9.35
0.11
DE PBC + NIATx 2004– 2006
Delaware
12.44 7.32
-19.31 7.70
0.09
0.01
Admission 2002 – 2003
Admission 2004 – 2006
-11.70 3.01
-5.71 3.34
0.00
0.09
Model includes controls for client demographics, state & admission yr.
Adjusted for clustering of clients within programs. n = 21,351
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Policy Implications
♦ Improvements are associated with the
performance contract.
♦ Additional improvements occurred with a
combination of financial incentives and
quality improvement tools.
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Policy Implications
♦ Some important characteristics of this
program appear to be:
– Timely feedback
– Significant penalties / rewards
– Provider buy-in
– SSA determination and willingness to
lose providers
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Future research
♦ How were client outcomes affected?
♦ How did the type and frequency of
services clients received change?
♦ How did clinician turnover change?
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Thank you
Contact information:
Maureen Stewart
mstewart @ brandeis.edu
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