Cash for clean urine tests. Prizes for attending recovery meetings.
If it sounds to you more like insurance fraud than treatment, you wouldn’t be the first to have that thought.
Contingency Management is a treatment modality that intermittently rewards clean time and program participation with cash or prizes. While some have moral objections to “paying an addict to get sober,” others point to the fact that, unlike a lot of treatments for meth, cocaine and stimulant abuse, Contingency Management (CM) actually works.
Case in point: the VA has been using CM to get veterans clean for years. The data they’ve collected on their program serves as another reminder that CM is perhaps the most successful form of treatment available for people with SUD, particularly those, like stimulant abusers, for whom there is no pharmacological alternative.
Detractors of CM, on the other hand, have moral and practical concerns about the treatment modality.
Today, we’ll look at CM, learn more about what it is, how it works, and why CM might be coming to your addiction treatment center sooner than you think.
What is Contingency Management and How is it Used at Addiction Treatment Centers in the United States?
Contingency management is a treatment for SUD that is based on operant conditioning principles. Studies have shown that it is perhaps the most effective treatment option available for SUD - eclipsing the success of standard CBT treatment and even the success rate of MAT options like methadone.
According to the National Institute on Drug Abuse, contingency management comes in two flavors: voucher-based and prize-based.
With voucher-based CM, patients receive vouchers for things like food or movie tickets. The vouchers start low in dollar value and increase as clean time increases. A positive urine test resets the vouchers to their initial level of value.
With the prize-based CM system, patients who provide negative urine tests draw slips of paper with prizes or simple affirmations on them. Prizes vary in value from $1 to $100. At the beginning of treatment, patients may only draw one slip. As clean time accumulates, the number of slips they are allowed to draw also increases. Again, a positive urine test resets the numbers of slips back to one. In some programs, the prizes are actually just cash that is loaded onto a debit card.
Why Isn’t Contingency Management More Widely Used at Addiction Treatment Centers in the United States?
There are three major barriers to accessing CM in the United States.
1 - Public opinion. Many critics of CM see the system as immoral and unethical. Some don’t believe people with SUD should be compensated for improving their health and fighting their disease. Others worry that the cash prizes will enable irresponsible purchases fueled by addiction. Still others argue that the element of chance in some CM schemes will increase gambling problems in a population that is already vulnerable to compulsive gambling.
2 - It’s not covered by insurance. Aside from a few pilot programs in the country and a few academic studies, the only patients who receive CM in the United States are veterans at the VA, due to the unique funding structure of that organization. Neither publicly funded programs, like Medicaid, nor private insurance companies, cover CM.
3 - It’s illegal. Programs that receive federal or state funding are currently barred from offering CM because the prizes and vouchers are not allowed under anti-kick back laws designed to protect the health care system from fraud, waste and abuse. The Centers for Medicare and Medicaid Services (CMS) currently puts a cap on annual incentives at $75. Studies show that CM programs need to budget between $400 and $600 in incentives per patient per year in order to be effective.
In order for CM to be used more widely in the United States, both state laws and CMS policies banning CM would need to change.
California Recently Passed a Law Permitting Contingency Management Programs, Pushing Feds to Change CM Laws
This summer (2021), California passed SB 110, which legalizes contingency management in the state and authorizes Medi-Cal, the state’s public health insurance organization, to add CM to its list of insurable addiction treatment services.
On June 1, the California Senate unanimously passed SB 110, which declares contingency management a legal practice and authorizes its funding by adding it to the list of drug treatment services offered through Medi-Cal.
However, without the go-ahead from the federal government, or the Centers for Medicare and Medicaid Services, more specifically, California will not see contingency management programs begin in the state.
Could Contingency Management Be the Next Big Thing in Addiction Treatment?
These are interesting times for the addiction treatment community.
With the shift towards value based care, the renaissance in psychedelics research and now the push towards contingency management, it’s hard to know what the future will hold for our industry. When and if CMS responds to this most recent California bill, we’ll have more information about what to expect from contingency management moving forward.
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