Aims: The newly elected coalition government in the U.K. and the Obama Administration in the U.S. are both entertaining numerous policy proposals that are intended to improve the care of people who have substance use disorders. This paper surveys and organizes the range of current proposals and reviews the scientific literature to assess what is known about their likely impact.
Methods: Information on current policy proposals was gathered through consultation with elected officials, senior civil servants, academics and thought leaders in the U.K. and the U.S. Assessment of the likely effects of each policy was conducted by a literature review.
Results: Proposals to improve the effectiveness of care can be divided into those that focus on improving the quality of organizational and clinical processes, and, those that attempt to directly purchase particular patient outcomes. Research shows that the first type of policy can change organizations which provide care but that such changes do not necessary produce better outcomes in substance use disorder patients. Direct purchasing of outcomes is vulnerable to “creaming of caseloads”, but may work in those cases where an outcome is assessed and rewarded while the patient is still in care.
Conclusions: We in most cases do not know a great deal from science how to create policies that improve care. Science must do a better job of showing which organization and clinical practices predict patient outcomes, and policy makers must balance enthusiasm for change with humility about how much we don’t know.
Keith Humphreys and A. Thomas McLellan
Work carried out at: Veterans Affairs and Stanford University Medical Centers, Palo Alto, California, USA, and the University of Pennsylvania, Philadelphia, PA.
Conflicts of Interest: The authors had a principal role in the Obama Administration (2009-2010) in designing some of the policies they discuss. The senior author is providing ongoing policy consultation to the UK Parliament, the Home Office, and the City of London. This paper is not an official statement by any government agency in other country.
Address correspondence to: Keith Humphreys, VAPAHCS (152-MPD), 795 Willow Road, Menlo Park, California 94025 USA. Email: knh@stanford.edu Phone: +01 650 617 2746 FAX: +01 650 617-2736
