Paying Drug Addicts to Get Clean?

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What would it be worth to you in cold, hard cash to kick smack? Would you stay clean for $50 a day plus expenses? Get a job pushing paper for $100? Live in a drug-free house for $200?

Pay-for-performance is all the rage in health-care policy as the US and other nations struggle to cut runaway costs and waste. The new approach organizes services from doctors, hospitals, and other providers around the health outcome for the patient. Where the current system, fee-for-service, rewards providers to pile on the tests and treatments, pay-for-performance incentivizes—at least in theory—providers to achieve the best possible result at the least possible expense. Although this model is viewed by virtually the entire health-care industry as not only innovative but inevitable, the Republican Party slammed it as “rationing,” which helped the GOP win by a landslide in the 2010 midterm elections.

Britain is far ahead of the US in its application of the reward-for-outcomes approach. The Brits are already testing it in efforts to prompt recipients of welfare to return to work and to prevent ex-cons from returning to prison. Now the government is expanding these experiments to include the drug-treatment industry. A new governmental agency called the Public Health Service is unrolling pilot projects at eight organizations and companies that provide methadone and other services to people recovering from heroin or cocaine use. This marks the first time that any nation has directly linked payment to drug-free outcomes.

As with most social policy, the new approach to drug treatment is as much a result of politics as anything else. The recently elected coalition government has ushered in an age of austerity after both its far-right Tories and center-right Conservatives campaigned against Labor, long the ruling party, for its supposed wasteful tax-and-spend policies. Labor’s harm-reduction approach to drug addiction, once applauded as enlightened, was roundly denounced by conservatives for “parking” junkies on methadone—and the dole—for months and even years.

Britain currently has an estimated 230,000 users of heroin, crack, and other substances in drug treatment, double the number a decade ago—an achievement for which Labor has claimed credit. Yet drug use remains high in the UK, at least relative to the rest of the European Union. Both right-wing parties assailed the high cost that drug abuse and addiction exact in the health-care and criminal-justice systems, more than 25 billion a year according to a government tally. That includes some $3 billion paid out to the 400,000 Brits who are unable to work due to their dependence on alcohol or drugs.

The watchword for the new policy is “recovery”—the Conservative’s compromise between the Tories’ “abstinence” and Labor’s “harm reduction.” "There are no quick fixes," says James Brokenshire, the minister of drug policy. “Simply focusing on reducing the harms caused by illicit drug use is no longer enough—we must focus on recovery as the most effective route out of dependency.”

The drug-treatment industry has responded to the new policy with guarded optimism, but was still quick to point out three potentially serious wrinkles:

1. So far the government has left “recovery” undefined and avoided spelling out the successful outcomes upon which a treatment program’s payment will depend. With the status quo—detox plus methadone maintenance—now presumably ineligible, what will replace it? Abstinence, employment, and housing are the most likely targets, but it will be up to the local recovery shops to work out the details.

2. Given that most goals take fairly long to achieve, and that relapse is a common feature of recovery, making payment contingent on these lofty goals means that treatment programs will receive funding only on a long-term and unpredictable basis. Most of Britain’s recovery centers are too small to sustain themselves under these terms. Their only option is to become subcontractors to the large drug-treatment firms that tend to implement a one-size-fits-all approach, which typically has less success than personalized programs.

3. As with all pay-for-performance schemes, no matter what service is being delivered, providers will be strongly tempted to reduce their risk by cherry-picking clients, serving only those judged as most likely to hit the mark. Tougher customers are left out in the cold.

Says Martin Barnes, CEO of DrugScope: “Although a truism, the devil really is in the detail….We welcome the commitment to piloting and the recognition of the need to avoid unintended consequences, such as the ‘cherry picking’ of service users and disadvantaging smaller providers.”

One thing is certain: Addicts themselves will not be exchanging weekly urine samples for pound notes. What they will get, however, is “inspiration,” in the form of so-called recovery champions, “people who have recovered from their drug dependency and will take on a mentoring role to others seeking help,” says Andrew Lansley, the secretary of state for health.

They will also get a kick in the pants to fill up the nation’s newly incentivized recovery centers: The new drug policy makes all government benefits claimed by the 400,000 Britons who cannot work because of alcoholism or drug addiction contingent on being enrolled in a treatment program. Whether this "payment" will turn these alcoholics and addicts into sober, hard-working homebodies remains to be seen. It will, however, give Tories and Conservatives a record of being “hard on drugs” to run on in the next elections.