Increasing the Impact of Interventions Incentivizing Psychiatric Treatment Engagement: Challenges and Opportunities

Financial incentives have been shown to increase several components of psychiatric treatment engagement, including the target behavior itself (e.g., abstinence from substance use, adherence to psychiatric medications) and engagement with mechanisms that lead to behavior change (e.g., treatment attendance and completion of treatment goals) (3). Most research on incentive-based programs has focused on the effectiveness of providing financial incentives for abstinence among individuals with substance use disorders, an intervention called contingency management. Many studies have also incentivized health behaviors, such as exercising, losing weight, and controlling chronic conditions (e.g., HIV). Overall, these interventions result in medium effect sizes and are cost effective in the long term (3–5). Additionally, certain intervention characteristics increase the effectiveness of these programs (e.g., providing greater incentives and delivering them immediately after the behavior is completed) (3). Recently, studies have found that incentives can increase psychiatric treatment engagement more broadly, including outcomes such as treatment attendance, medication adherence, and completion of homework or other treatment goals. Although these studies have been conducted largely among individuals experiencing substance use disorders, emerging evidence shows that incentives can also improve treatment engagement among individuals with other psychiatric conditions (6–8).

Evidence that providing financial incentives for abstinence is highly effective prompted the VA to initiate a nationwide effort in 2011 to increase access to contingency management (9). This effort is the largest-scale initiative by a health care system to implement an incentive program supporting abstinence or other forms of psychiatric treatment engagement. By 2018, 126 VA medical centers had implemented contingency management for veterans with substance use disorders, with clinical outcomes comparable to those from studies conducted in community clinics (9, 10). The success of this initiative can be attributed to various factors, some of which we review below (9, 10).

First, program costs are reduced through the use of a probability-based prize system that distributes coupons provided by the Veterans Canteen Service, a business within the VA. Second, the VA provided support for initial training and continues to support ongoing implementation, including input from subject matter experts who encourage providers to implement programs that use evidence-based strategies. Third, providers and administrators are motivated to participate in contingency management through social and organizational incentives. Monthly e-mails with program success stories and buy-in from team leaders offer social incentives for provider participation. Additionally, disbursal of coupons to medical centers is contingent on their exclusive use for contingency management and provider participation in coaching designed to ensure treatment fidelity. Finally, medical centers receive hospital system performance credit for offering this treatment.

The VA’s implementation of contingency management has been nationally successful in reaching patients and producing outcomes comparable to those of clinical trials of this treatment. Although other health care systems have not yet systematically implemented financial incentives for psychiatric treatment engagement, comparable incentive programs have been implemented to encourage general medical health (e.g., employee wellness programs) and to reimburse providers on the basis of performance (e.g., pay-for-performance programs) (11). Renewed efforts to implement evidence-based, patient-centered treatments for psychiatric disorders, along with a growing body of research highlighting the efficacy and acceptability of incentive-based interventions, suggest that other health care systems should consider implementing these programs. Both the VA and other health care systems hoping to benefit from incentive-based interventions can increase their impact in four key ways.

Certain features of incentive-based interventions present challenges to implementation that can be addressed with additional research, training, or advocacy. First, because the effects of incentives on behaviors tend to diminish once incentives are withdrawn, research is needed to determine ways to maintain treatment gains over time. Second, providers and administrators may hesitate to buy in to incentive-based interventions because of concern that they are coercive or will change the patient-provider relationship. These concerns can be addressed by adapting intervention features (e.g., not having the patient’s main provider deliver incentives), training providers and allowing them to observe the intervention’s effectiveness, and motivating providers to implement these interventions through social or organizational incentives, as described above. Third, although concerns about the widespread abuse of financial incentives are not supported by research (17), they can lead to policies that limit the effectiveness of incentive-based interventions. For example, recent policy changes by the U.S. Department of Health and Human Services may constrain the amount of financial incentives that federally funded treatment providers can offer patients (18). This policy, together with research showing that low reward amounts are typically ineffective (19), present a significant barrier to implementation. Those advocating for the removal of this policy have noted that any potential for abuse can be reduced by providing gift cards for specific items or stores or smart debit cards that prohibit cash withdrawals and high-risk purchases (e.g., liquor).

In sum, the VA is an example of a health care system that has successfully implemented a financial incentive program aimed at improving psychiatric treatment engagement. This success can be attributed in part to the attention paid to motivating providers to implement these programs, support for training and implementation, and partnership with a business that helps provide sustained funding for incentives. Health care systems, including the VA, interested in implementing these interventions can increase their impact in the four key ways described. Although implementation challenges remain, they can be addressed through research, training, and advocacy.