Contingency management - sometimes called CM - is one of the most controversial and little-known topics in the behavioral health field. We’ve spoken about it before on this blog.
Simply put, contingency management is a system of “positive reinforcements” that clinicians offer SUD patients for making progress on their treatment goals. Typically, in a CM program, treatment progress is measured in clean urinalysis results. The “positive reinforcements” a client receives for their treatment progress are typically gift cards.
Although this treatment approach is backed by decades of research, detractors of this unusual treatment modality bristle at the premise of “paying addicts to stay sober.”
In this post, we’ll discuss how contingency management works, why it’s so controversial and what the future of contingency management might look like in the behavioral health field.
Does contingency management work for addiction treatment?
Contingency management is a treatment approach for behavioral health conditions like Substance Use Disorder that functions on the principle of operant conditioning. Essentially, operant conditioning uses punishments and rewards - carrots and sticks - to condition a patient’s behavior. We can clearly see these principals at work in many child rearing techniques, as well as dog training systems.
In the case of contingency management for addiction treatment, patients are “paid to stay sober” and rewarded with financial incentives - oftentimes intermittent financial rewards - for displaying desired behaviors, such as abstaining from drugs of abuse or attending treatment sessions.
Research on the efficacy of contingency management is strong, particularly for high-risk populations with lower motivation for change. One study saw contingency management patients were 22% more likely to maintain sobriety after 24 weeks of treatment versus patients who used a different treatment approach.
What states currently use contingency management to treat SUD?
Contingency management programs are beginning to catch on around the United States. States like California, Montana and Washington are exploring Medicaid programs for people with SUD that incorporate contingency management principles. California’s program, the first in the nation to be covered by Medicaid, opened its doors in 2022.
If it works, why isn’t contingency management more widely used in the United States?
Contingency management is unique because it involves a transfer of money to the patient. While contingency management may be clinically effective and even cost-effective, no other modality incurs these types of costs and this makes it difficult to fit contingency management into pre-existing healthcare payer structures.
Anti-kickback laws and contingency management
Kick-back laws are also a legitimate hurdle for contingency management. As they are currently written, anti-kickback laws ban contingency management schemes because they blur the boundaries between kick-back payment (though they are not that) and legitimate treatment expenses. Contingency management is not typically covered by insurance, private or public, for this reason. Most payers won’t reimburse treatment costs that exist outside typical durable medical goods and clinical services. Contingency management “financial incentives” don’t fit neatly into either of these categories.
Public opinion, stigma and contingency management
Public opinion of contingency management also tends to be quite negative. Some individuals bristle at the suggestion of paying “addicts” for “what they should be doing anyways.” While opinions like these aren’t grounded in the current understanding of the disease model of addiction, the stigma and misunderstanding around the nature of addiction persists and, so, too, does the stimaga around contingency management.
Software, technology, EMRs and contingency management
Finally, many addiction treatment programs don’t have necessary technology needed to adequately track markers of treatment progress and produce the documentation necessary to justify the financial incentives of contingency management. An alarming number of behavioral health organizations in the United States still rely on paper charts and paper-based UA results. Others are still using legacy EHRs that don’t offer the kind of interoperability and customization required to handle contingency management.
What does the future hold for contingency management in the addiction treatment community?
It’s quite possible that regulations around anti-kickback laws and health plan obligations will change in the future to support wider adoption of contingency management in the addiction treatment community. As it is now, programs that use contingency management as a treatment modality cannot accept insurance reimbursements for this portion of their treatment plan.
Specifically, contingency management would likely take off in the United States if:
Anti-kickback laws were modified to allow for contingency management financial incentives in state-funded healthcare programs
Insurance payers revised their rules to include reimbursements for financial incentive payments
Or
Researchers discovered that social incentives or some other “free” incentive might fuel the same sort of behavior modification that we see with financial incentives, eliminating the need for any changes to reimbursement rules at all.
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