Technology Access
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Letters to the Editor The Three-Part Model to Pay for Early Interventions for Psychoses TO THE EDITOR: We read with interest Frank and colleagues’ column (1) [this issue] proposing a novel three-part payment model for early interventions for psychoses. The first part is a prospective per-case payment to cover the average cost of outreach, engagement, and retention per engaged client; the second is a per-service payment for clinical service delivery; and the third is an outcome-based component, intended to reward providers for improved outcomes. The three parts combined provide a sound framework to guide payment designs that ad- equately cover the costs of a coordinated service package but also align incentives with evidence-based early interventions. We raise a few issues toward refining the model. First, start-up funds may be needed to support building the early intervention team (2) and a financially viable caseload. Second, when operationalizing the per-case payment (part 1 of the model), it may be challenging to define “engaged clients.” Early intervention programs have high dropout and individually tailored services. Varying the definition of engagement may have substantial financial implications for providers and em- bedded incentives for evidence-based care. For example, de- fining engagement by at least one program contact would maximize provider payment but carry perverse incentives for retention; defining engagement as having had contacts with all provider types, on the other hand, is at odds with the per- sonalized nature of care, and providers may find it difficult to recover costs for clients who ultimately do not “engage.” Third are the challenges in designing the outcome-based component (part 3 of the model) to be both valid and reliable. Prognostic and psychosocial factors affect individual out- comes. The validity of a given measure—the extent to which it reflects the quality and evidence-based practice of the team—should be scrutinized in light of new data, such as from the RAISE studies (3). On the other hand, given the typically small caseload (20–30 cases) of the teams, any mea- sure is likely to be highly imprecise and unreliable, with a high risk of misclassifying teams (4). In light of these issues, we propose the addition of a start- up payment to support the initial operation of the team, to be made in installments conditional on achieving well-defined milestones (for example, recruitment of core team mem- bers). Our second proposal is to make the per-case payment periodic (for example, quarterly), contingent on evidence of client engagement; the payment rate, however, could be adjusted by special needs (for example, substance abuse) or intervention stage (for example, postcrisis versus maintenance) (5). Third, we propose an approach to the outcome-based payment whereby, rather than tying payment to a single outcome, providers get credit for each client who achieves a predefined goal in any key outcome domain, including hos- pitalization (a key cost driver), and recovery-oriented outcomes, such as work or school performance and functioning. The prominence of the outcome-based payment (relative to the other two components) should be gradually increased as teams ac- cumulate experience. These proposals may contribute to fur- ther aligning the model with the delivery of evidence-based early interventions as evidence accumulates to inform con- tinuous refinement. REFERENCES 1. Frank RG, Glied SA, McGuire TG: Paying for early interventions in psychoses: a three-part model. Psychiatric Services 66:678–680, 2015 2. Heinssen RK, Goldstein AB, Azrin ST: Evidence-Based Treatments for First Episode Psychosis: Components of Coordinated Specialty Care. Bethesda, Md, National Institute of Mental Health, 2014. Available at www.nimh.nih.gov/health/topics/schizophrenia/raise/ nimh-white-paper-csc-for-fep_147096.pdf 3. RAISE Project overview. Bethesda, Md, National Institute of Mental Health. Available at www.nimh.nih.gov/health/topics/schizophrenia/ raise/index.shtml. Accessed Feb 12, 2015 4. Adams JL: The Reliability of Provider Profiling. Santa Monica, Calif, RAND Corp, 2009 5. Bao Y, Casalino LP, Ettner SL, et al: Designing payment for Colla- borative Care for Depression in primary care. Health Services Re- search 46:1436–1451, 2011 Yuhua Bao, Ph.D. Harold Alan Pincus, M.D. Dr. Bao is with the Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City. Dr. Pincus is with the Department of Psychiatry, Columbia University, and New York-Presbyterian Hospital, New York City. Psychiatric Services 2015; 66:764; doi: 10.1176/appi.ps.660701 Technology Access and Use Among Young Adults With a First Episode of Psychosis TO THE EDITOR: It is increasingly recognized that the Inter- net, social media, and mobile technologies can complement, augment, or extend mental health care (1) and enhance ser- vice engagement, particularly among young people (2). Un- derstanding how young people receiving psychiatric services access and use these technologies can inform the develop- ment or uptake of technology-enabled mental health inter- ventions and supports. Toward this end, we recently conducted an in-person survey among young adults receiving specialized services for a first episode of psychosis (FEP) about their access 764 ps.psychiatryonline.org Psychiatric Services 66:7, July 2015 LETTERS
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Technology Access and Use Among Young Adults With a First Episode of Psychosis psychiatric services july 2015
Transcript of Technology Access
Letters to the Editor
The Three-Part Model to Pay for EarlyInterventions for Psychoses
TOTHEEDITOR: We read with interest Frank and colleagues’column (1) [this issue] proposing a novel three-part paymentmodel for early interventions for psychoses. The first part isa prospective per-case payment to cover the average cost ofoutreach, engagement, and retention per engaged client; thesecond is a per-service payment for clinical service delivery; andthe third is an outcome-based component, intended to rewardproviders for improved outcomes. The three parts combinedprovide a sound framework to guide payment designs that ad-equately cover the costs of a coordinated service package butalso align incentives with evidence-based early interventions.
We raise a few issues toward refining the model. First,start-up funds may be needed to support building the earlyintervention team (2) and a financially viable caseload. Second,when operationalizing the per-case payment (part 1 of themodel), it may be challenging to define “engaged clients.”Early intervention programshave highdropout and individuallytailored services. Varying the definition of engagement mayhave substantial financial implications for providers and em-bedded incentives for evidence-based care. For example, de-fining engagement by at least one program contact wouldmaximize provider payment but carry perverse incentives forretention; defining engagement as having had contacts withall provider types, on the other hand, is at odds with the per-sonalized nature of care, and providers may find it difficult torecover costs for clients who ultimately do not “engage.”
Third are the challenges in designing the outcome-basedcomponent (part 3 of themodel) to be both valid and reliable.Prognostic and psychosocial factors affect individual out-comes. The validity of a given measure—the extent to whichit reflects the quality and evidence-based practice of theteam—should be scrutinized in light of new data, such asfrom the RAISE studies (3). On the other hand, given thetypically small caseload (20–30 cases) of the teams, any mea-sure is likely to be highly imprecise and unreliable, with a highrisk of misclassifying teams (4).
In light of these issues, we propose the addition of a start-up payment to support the initial operation of the team, to bemade in installments conditional on achieving well-definedmilestones (for example, recruitment of core team mem-bers). Our second proposal is to make the per-case paymentperiodic (for example, quarterly), contingent on evidence ofclient engagement; the payment rate, however, could beadjusted by special needs (for example, substance abuse) orintervention stage (for example, postcrisis versusmaintenance)
(5). Third, we propose an approach to the outcome-basedpayment whereby, rather than tying payment to a singleoutcome, providers get credit for each client who achievesa predefined goal in any key outcome domain, including hos-pitalization (a key cost driver), and recovery-oriented outcomes,such as work or school performance and functioning. Theprominence of the outcome-basedpayment (relative to the othertwo components) should be gradually increased as teams ac-cumulate experience. These proposals may contribute to fur-ther aligning the model with the delivery of evidence-basedearly interventions as evidence accumulates to inform con-tinuous refinement.
REFERENCES1. Frank RG, Glied SA, McGuire TG: Paying for early interventions in
psychoses: a three-part model. Psychiatric Services 66:678–680, 20152. Heinssen RK, Goldstein AB, Azrin ST: Evidence-Based Treatments
for First Episode Psychosis: Components of Coordinated SpecialtyCare. Bethesda, Md, National Institute of Mental Health, 2014.Available at www.nimh.nih.gov/health/topics/schizophrenia/raise/nimh-white-paper-csc-for-fep_147096.pdf
3. RAISE Project overview. Bethesda, Md, National Institute of MentalHealth. Available at www.nimh.nih.gov/health/topics/schizophrenia/raise/index.shtml. Accessed Feb 12, 2015
4. Adams JL: The Reliability of Provider Profiling. Santa Monica, Calif,RAND Corp, 2009
5. Bao Y, Casalino LP, Ettner SL, et al: Designing payment for Colla-borative Care for Depression in primary care. Health Services Re-search 46:1436–1451, 2011
Yuhua Bao, Ph.D.Harold Alan Pincus, M.D.
Dr. Bao is with the Department of Healthcare Policy and Research, WeillCornell Medical College, New York City. Dr. Pincus is with the Department ofPsychiatry, Columbia University, and New York-Presbyterian Hospital, NewYork City.
Psychiatric Services 2015; 66:764; doi: 10.1176/appi.ps.660701
Technology Access and Use Among YoungAdults With a First Episode of Psychosis
TO THE EDITOR: It is increasingly recognized that the Inter-net, social media, and mobile technologies can complement,augment, or extend mental health care (1) and enhance ser-vice engagement, particularly among young people (2). Un-derstanding how young people receiving psychiatric servicesaccess and use these technologies can inform the develop-ment or uptake of technology-enabled mental health inter-ventions and supports. Toward this end, we recently conductedan in-person survey among young adults receiving specializedservices for afirst episode of psychosis (FEP) about their access
764 ps.psychiatryonline.org Psychiatric Services 66:7, July 2015
LETTERS
and use of such technologies. Participants were recruited fromtwo programs: the Prevention and Early Intervention Programfor Psychosis at theDouglasMentalHealthUniversity Instituteand the Prevention and Early Intervention Program for Psy-chosis at McGill University Health Centre. Between De-cember 2013 and October 2014, a total of 67 individuals(mean6SD age525.665.1) completed the survey, which wasdeveloped in collaboration with young adult service usersand mental health clinicians. The Ethics Review Board atMcGill University provided approval, and all participantsprovided consent.
The majority of participants had access to a cell phone(N559, 88%),most ofwhichwere smartphones.Most (N547,70%) had access to a laptop computer, and a little over half(N535, 52%) had access to a desktop computer in their home.Only some (N511, 16%) owned a tablet, whereas several(N527, 40%) owned an MP3 player (for example, an iPod). Indescending order, the ten most popular reported uses of thesedevices among a list of possible activitieswere listening tomusic,watching videos, e-mailing, searching for information, socialnetworking, text messaging, taking pictures, using maps, playinggames, and banking. The five most popular types of informationsearchedonline in the past year among a list of topicswere news,work, transportation, school, and mental health. The threemost commonly visited social media sites were YouTube(N563, 94%), Facebook (N550, 75%), and Skype (N530, 45%).
Many participants were active users of social media, par-ticularly YouTube and Facebook, highlighting the impor-tance of leveraging social media in the context of mentalhealth services. Yet, at the time of the study, neither of therecruitment sites had a social media presence. It is also note-worthy that a portion of cell phone users (N513, 19%) did nothave a smartphone that would provide themwith access to theInternet and the use of apps; moreover, a few participants(N58, 12%) did not have access to any type of cell phone.
To our knowledge, this is the first reported surveyon access to and use of technology among young adults
receiving FEP services. A larger sample would help us betterunderstand how access and use varies in relation to gender,age, socioeconomic characteristics, and geographical settings.As the trend toward technology-enabled mental health ser-vice delivery is increasing, it is important to understandyouths’ preferences and priorities. For example, knowledgeof the types and features of technology-enabled services thatyouths would find engaging and be amenable to receiving(for example, peer support, medication reminders, onlinecounseling, and management of personal mental health in-formation) can help prioritize efforts to develop, implement,and evaluate new technologies and online strategies.
REFERENCES1. Lal S, Adair CE: E-mental health: a rapid review of the literature.
Psychiatric Services 65:24–32, 20142. Lal S, Malla A: Service engagement in first episode psychosis: cur-
rent issues and future directions. Canadian Journal of Psychiatry, inpress
Shalini Lal, Ph.D.Jennifer Dell’Elce, B.A.
Ashok K. Malla, M.B.B.S., F.R.C.P.C.Dr. Lal is with the School of Rehabilitation, University of Montreal, and theDouglas Mental Health University Institute, Montreal, Quebec, Canada.Ms. Dell’Elce is with the School of Physical and Occupational Therapy,McGill University, Montreal. Dr. Malla is with the Department of Psychiatry,McGill University, and the Douglas Mental Health University Institute, Montreal.Preliminary results from this study were presented at the International EarlyPsychosis Association biannual conference, Tokyo, November 17–19, 2014.
Dr. Lal’s work on this project was partly funded the Canadian Institutes ofHealth Research (CIHR) and a postdoctoral stipend from the CIHR In-terdisciplinary Capacity Enhancement Grant in Health Disparities (HOA-80072). Dr. Malla is supported by the Canada Research Chair Program. Theauthors thank the survey participants, as well as clinicians, research assis-tants, and patient and family representatives for feedback during surveydevelopment.
Dr. Malla has received research grants or honoraria from BMS, Janssen-Ortho(Canada), Lundbeck, Otsuka, Pfizer, and Roche. The other authors report nofinancial relationships with commercial interests.
Received December 21, 2014; revision received March 4, 2015; acceptedMarch 30, 2015.
Psychiatric Services 2015; 66:764–765; doi: 10.1176/appi.ps.201400580
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