Pay for Performance in Behavioral Health

Objective: Pay for performance is a rapidly expanding strategy intended to improve the quality and value of health care in the United States. The application of this strategy for behavioral health has not yet been systematically examined. This article presents the results of a targeted national effort to identify pay-for-performance programs in behavioral health and describe their core components. Methods: The authors describe pay-for-performance programs currently being implemented in the mental health and substance abuse treatment fields. On the basis of responses from 109 screening informants who were identified as being likely to have knowledge of existing pay-for-performance programs, the authors identified 24 specific pay-for-performance programs and interviewed 28 individuals associated with these programs. The semistructured interview protocol consisted of 36 questions assessing the core program components. Results: Thirteen programs targeted behavioral health specialists or substance abuse treatment providers. Eleven programs targeted primary care providers. Depression was the most common of the behavioral health conditions targeted. Financial incentives offered in behavioral health pay-for-performance programs were often small. Many programs struggled to obtain accurate and valid data on quality and outcomes of care, and the public reporting of results was not widespread. On the basis of this analysis, the authors recommend a number of actions to improve the implementation and impact of behavioral health pay-for-performance programs on quality of care. Conclusions: The authors reaffirm the finding identified by the Leapfrog Group's "Rewarding Results" initiative-that is, pay for performance is not a magic bullet that alone will improve quality and control costs. Although pay-for-performance programs hold promise for advancing the overall performance of the U. S. health care system, more intensive efforts aimed at strengthening the quality infrastructure in behavioral health will be required. (Psychiatric Services 59: 1419-1429, 2008)