Abstract
BackgroundPay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs).MethodsBuilding on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes.ResultsAt trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191–$16,171).ConclusionThis study provides experimental evidence supporting P4P as a cost-effective implementation strategy.Trial registrationNCT01016704.
Highlights
Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care
Relative to treatment organizations assigned to the IAU condition, treatment organizations assigned to the IAU+P4P condition had a significantly higher average number of months that therapists demonstrated Adolescent Community Reinforcement Approach (A-CRA) competence (IAU = 8.62; IAU+P4P = 18.64; p < 0.001; 116% increase) and a significantly higher average number of patients who received target A-CRA (IAU = 2.27; IAU+P4P = 9.64; p < 0.001; 325% increase)
The IAU+P4P condition had a significantly higher average Training & Coaching Cost (IAU = $18,844; IAU+P4P = $23,483; p < 0.001; 24.6% increase), and a significantly lower average treatment cost (IAU = $44,073; IAU+P4P = $39,838; p < 0.001; 9.6% decrease) per organization. When these costs were combined with P4P costs, which averaged $2935 (SD = $3103) for the treatment organizations assigned to the IAU+P4P condition, the total cost per organization was significantly higher for the IAU+P4P condition (IAU = $62,917; IAU+P4P = $66,256; p = .034; 5% increase)
Summary
Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. In 2007, as part of a broad effort to improve the quality of care delivered within the USA (including greater implementation of EBTs), the Institute of Medicine recommended pay-for-performance (P4P) as a promising strategy to improve implementation of high-quality care [11] This recommendation, combined with the limited empirical research evidence supporting P4P as a method to improve quality of care, motivated an experimental test of the effectiveness and cost-effectiveness of P4P as a strategy to improve the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA)—an EBT shown to be effective and cost-effective in treating SUDs for adolescents [12,13,14,15,16,17,18]. The rationale for using a cluster randomized trial design was that primary interest was to examine P4P as an organizational-level strategy, as well as that validity threats are possible from the randomization of patients within therapists (e.g., contamination) or of therapists within treatment organizations (e.g., compensatory rivalry and resentful demoralization)
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