Payment by results
Paying incentives to improve performance is not a new idea for business or for health care. It has yet to be used successfully with substance misuse services – an attempt to do so in the UK, known as Payment by Results, is to be rolled out in April 2013. The schemes for alcohol and for drugs are very different – the former devised by the Department of Health and the latter by the National Treatment Agency. ‘Gaming’ and ‘cherry picking’ has been a weakness of incentive schemes and seems likely to be a weakness of the UK plan. A better solution to incentivise providers would be to spread the triggers for additional payments across a broad base of achievements. Payments linked to treatment should be for performance in-treatment as opposed to post-treatment – the longer after treatment that outcomes are assessed the less confidence that treatment rather than social factors is responsible for the outcome.
The question arises as to which outcome measures might be used in-treatment. A mix of what are called generic, dimension, condition specific, and societal impact measures should be selected on the basis of how well the scale properties have been validated and how well the measures reflect the work of the service. Substance use itself is in a sense a condition specific measure and also the measure that service users, friends and family, and the public are most likely to endorse as meaningful. Other suitable measures are the generic scale EuroQol5D (EQ5D), and the dimension scales Leeds Dependence Questionaire (LDQ), Clinical Outcomes in Routine Evaluation (CORE-10), and Social Satisfaction Questionaire (SSQ). These scales have been shown to measure single constructs and be independent of each other. All have general population data and can be used to calculate clinically significant change, the gold standard of outcome.