LETTERS

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 rst 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 adequately cover the costs of a coordinated service package but
also align incentives with evidence-based early interventions.
We raise a few issues toward rening the model. First,
start-up funds may be needed to support building the early
intervention team (2) and a nancially viable caseload. Second,
when operationalizing the per-case payment (part 1 of the
model), it may be challenging to dene engaged clients.
Early intervention programs have high dropout and individually
tailored services. Varying the denition of engagement may
have substantial nancial implications for providers and embedded incentives for evidence-based care. For example, dening engagement by at least one program contact would
maximize provider payment but carry perverse incentives for
retention; dening engagement as having had contacts with
all provider types, on the other hand, is at odds with the personalized nature of care, and providers may nd it difcult 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 outcomes. The validity of a given measurethe extent to which
it reects the quality and evidence-based practice of the
teamshould be scrutinized in light of new data, such as
from the RAISE studies (3). On the other hand, given the
typically small caseload (2030 cases) of the teams, any measure 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 startup payment to support the initial operation of the team, to be
made in installments conditional on achieving well-dened
milestones (for example, recruitment of core team members). 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)
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(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 predened goal in any key outcome domain, including hospitalization (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 accumulate experience. These proposals may contribute to further aligning the model with the delivery of evidence-based
early interventions as evidence accumulates to inform continuous renement.
REFERENCES
1. Frank RG, Glied SA, McGuire TG: Paying for early interventions in
psychoses: a three-part model. Psychiatric Services 66:678680, 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 Proling. Santa Monica, Calif,
RAND Corp, 2009
5. Bao Y, Casalino LP, Ettner SL, et al: Designing payment for Collaborative Care for Depression in primary care. Health Services Research 46:14361451, 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 service engagement, particularly among young people (2). Understanding how young people receiving psychiatric services
access and use these technologies can inform the development or uptake of technology-enabled mental health interventions and supports. Toward this end, we recently conducted
an in-person survey among young adults receiving specialized
services for a rst episode of psychosis (FEP) about their access
Psychiatric Services 66:7, July 2015