Keith Humphreys A. Thomas McLellan Veterans Affairs and

Keith Humphreys A. Thomas McLellan Veterans Affairs and Stanford University Medical Centers Palo Alto, California USA Treatment Research Institute and University of Pennsylvania Philadelphia, Pennsylvania USA g n i t

c Outcome Monitoring tr a n o C ce n a m r o f Value Per

-b ased P4P To Im tal Q pr ov uali em ty en t purch

a C h t l a e H asing t n e m e

g na a M y t i l a re Qu Clinical Practice Incentivization Process-focused quality improvement

Patient outcome focused strategies N.B. Both share the same ultimate goal, but differ in how they approach it Many U.S. programs lack medicallytrained staff

Credentials do allow certain activities But. Must include reputational or economic consequences to work Succeeded in changing practice in U.S. VHA and individual U.S. States

BUT as with other areas of health care, changed practice has weak relationship to outcome Consultation model used by NIATx and Advancing Recovery Director walkthrough, fiscal advice, customer engagement, staff education

Has greatly reduce patient waiting times and early dropout and increased adoption of MAT BUTno documented relationship to outcome Some evidence of impact with hypertension and diabetes, never with substance use disorder

Tracking patient after treatment problematic Linking long-term outcome to care quality also problematic Probably works best when done in treatment Ample evidence of effect on contingency

management treatment literature Also shown effective in certain therapeutic jurisprudence interventions (24/7 Sobriety) BUTsubstantial political resistance to rewards AND serious questions about sustaining post-reward gains Radically different approach, started under G.W.

Bush Administration and expanded under Obama Uses usual market forces to drive quality Patients purchases aids to recovery, including dental care, education, transitional housing, resume assistance, baby sitting, work equipment and clothing Shown to increase employment and treatment

retention Most policies are poorly developed, have weak evidence, or both We can change care processes, but need research linking these changes to outcomes Patient outcome focused strategies may

be more powerful, though they too require more development Thank you for your attention!