Carrots and Sticks on Opposite Sides of the Atlantic: Integration Incentives for People With Serious Mental Illness in England

Commissioning for quality and innovation (CQUIN) is a payment framework that enables CCGs to reward excellence by linking a proportion of a service’s income to achievement of a national quality improvement target. Most CQUIN targets are set locally from a menu of centrally agreed goals, but there are four national indicators, each worth at least 1% of an MHT’s annual income, which can be increased further to 2.5% by local CCGs.

One national target covers the 20,000 adults with psychotic illnesses in psychiatric inpatient beds and the 5,000 in community-based early intervention in psychosis services (EIS). The target requires 90% of this population to have comprehensive cardiometabolic risk assessments, as judged by documented smoking status, lifestyle advice, BMI, blood pressure, glucose regulation, and blood lipids. These need to be completed at the start of an episode in EIS or on hospital admission. When indicated, individuals with abnormal results must receive appropriate treatment by specialist medical or primary care services, either “in house” or, more commonly, through affiliated providers.

CCGs can either withhold payment or request a proportionate return depending on the level of achievement (thus screening and appropriate follow-up for only 50% of the target population would reduce annual income by 75% of the total CQUIN amount). Each MHT has several eligible services (adult inpatient and community EIS) spread between a number of CCGs, leading to potential variability in achievement. However, poor achievement or unwarranted variability (as funding does not increase above the 90% screening threshold) would constitute a decrease in the MHT’s total income. Therefore, it is in the MHT’s interest to ensure that CQUIN targets are uniformly attained. Achievement of the general medical CQUIN is assessed through a record audit conducted by the Royal College of Psychiatrists and commissioned by NHS England. Results are shared with CCGs but have not yet been made publicly available.

GPs have a separate P4P mechanism (the Quality and Outcomes Framework) that rewards similar cardiometabolic monitoring for people with serious mental illness in primary care (9). The CQUIN is seen as a mechanism to link general medical health monitoring in primary care and specialist settings (10). It aims to foster closer working relationships between primary care and specialist behavioral health providers through sharing of diagnoses and treatment plans rather than a predetermined model of care. Good performance depends on concerted action and agreed pathways of care between providers.

The Primary and Behavioral Health Care Integration (PBHCI) program is a federally administered grant provided by the Substance Abuse and Mental Health Services Administration (SAMHSA) and intended to improve the general medical health of people with serious mental illness. It provides $400,000 per year for four years to specialist behavioral health clinics to allow them to provide primary care services. The initiative began in 2009 and had awarded 189 grants by 2015, with an average of 250 enrollees per grantee. The program has four core features: screening for and treatment of general medical conditions, developing a registry or tracking system for all primary care needs, case management, and prevention and well-being support services.

Early assessment by the RAND Corporation suggested that the scheme has been successful in building integrated multidisciplinary teams and making available a much greater array of primary care to those in the program compared with those not in the program (11). More recent evaluations have suggested that the grant improves some general medical outcomes but not all (12) and may reduce hospitalization costs in clinics where integration has been established longer (13).

Both the United States and England have used financial incentives to attempt to motivate providers to integrate care for people with serious mental illness. Whereas the United States has made new money available for implementation of integrated care in behavioral health settings (“carrot”), England has used a disincentive to ensure that providers carry out general medical screening and referral (“stick”). It is difficult to accurately calculate the amount of funding represented by the general medical CQUIN, but the minimum 1% of all English MHTs’ income is estimated to be $165 million annually. This covers about 25,000 patients with psychotic disorders. SAMHSA awarded $40 million to 60 PBHCI grantees in 2015, covering about 15,000 enrollees.

Whereas the PBHCI grant produces new services according to a preconceived model, the CQUIN incentivizes existing services to improve care in a more sustainable manner on a national scale. Although SAMHSA has recently started requiring successful applicants to develop sustainability proposals, grantees have found it difficult to maintain integration efforts beyond the grant. The grant is a start-up fund to implement a package of integrated care, which should be replaced through other funding mechanisms—for example, Medicaid Health Homes or the recently proposed Certified Community Behavioral Health Centers. Thus sustainability depends largely on the availability of other federal, state, or local funding streams. In contrast, CQUIN funding is awarded on a rolling annual basis and mandated centrally. However, it is potential money (that is, the threat of income being withheld) rather than actual funding to put integration structures and processes in place. Nevertheless, funding is tied to achievement of outcomes in the CQUIN, whereas PBHCI grants are not awarded for achieving high-quality care. Instead, funding is based on addressing an identified need.

Both programs have led to key improvements, including raising national awareness, local and regional training programs, enablement of electronic health records, formation of best-practice networks, and significant engagement with local communities.