Contingency Management for Substance Use Disorders

Contingency Management for Substance Use Disorders

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June 5, 2024
Contingency Management for Substance Use Disorders
Treatment for substance use disorders (SUDs) typically
obstacles to SUD treatment, such as requirements for
involves pharmacological or psychosocial therapies. For
frequent in-person visits.
instance, certain medications are used in treatment for
alcohol, tobacco, or opioid use. Meanwhile, for substances
Figure 1. Components of Effective Contingency
such as methamphetamine, cocaine, and marijuana, there
Management
are no comparable Food and Drug Administration (FDA)-
approved medications for treatment. Research shows that
psychosocial interventions are the most effective treatment
for stimulant use and marijuana use. More specifically, an
intervention known as contingency management (CM) has
thus far had the most empirical support for effectiveness.
This In Focus provides an introduction to CM, examples of
federal support for CM, and an overview of certain federal
fraud and abuse laws that may apply to CM programs.
Background
Contingency management is a behavioral intervention that
involves giving individuals tangible rewards to reinforce
desired behaviors. CM for SUDs comes in several forms,

Source: CRS, based on Sterling M. McPherson, Sara Parent, Andre
but all provide something tangible of value to participants
Miguel, et al., “Contingency Management is a Powerful Clinical Tool
for achieving a target behavior—usually participation in
for Treating Substance Use Research Evidence and New Practice
treatment, or reduction or elimination of substance use
Guidelines,” Psychiatric Times, vol. 39, no. 9 (September 9, 2022).
(often measured through urine screenings). Rewards
(known as motivational incentives, reinforcers, or
SUD treatment using CM does not have a prescribed time
contingencies) can include privileges, prizes, vouchers for
period. Many clinical evaluations of CM have followed 12-
goods or services, gift cards, or direct cash payments. Some
or 16-week schedules, though many patients may need
CM programs guarantee a reward—a set amount per
longer intervals to achieve desired outcomes. Practitioners
opportunity or an escalating schedule of increasing value as
can discontinue CM if participants stop responding to the
treatment progresses. Other CM methods provide chances
treatment. Participants can engage in a course of CM
for awards via pulls from a fishbowl containing incentives
treatment multiples times, as needed. CM is often used in
of varying value.
combination with other therapies and has been found to be
effective for diverse populations. For example, CM can be
One notable finding in the research is that higher monetary
paired with medication as an adjunctive treatment for
value and more frequent and immediate delivery of rewards
SUDs. Evaluations of CM have generally found it to be
are typically associated with a larger effect on behavior
cost-effective given the potential benefits of reduced
change (Figure 1). For example, one study found that
substance use. The long-term effects of CM on substance
immediate rewards increased steadily over the course of
use await further research.
treatment performed better than a single lump sum. Other
studies have found little difference between fixed versus
Federal Support for CM
varying amounts of rewards. Most studies have generally
Executive agencies responsible for SUD treatment—such as
found that higher rewards are more effective. Yet no
the Substance Abuse and Mental Health Services
consensus currently exists in the empirical literature on
Administration (SAMHSA), the National Institute on Drug
specific thresholds for incentives in CM. Generally, a total
Abuse (NIDA), and the Office of National Drug Control
maximum award of under $100 is considered low, while
Policy (ONDCP)—promote the use of motivational
treatments providing totals of over $1,000 are considered
incentives via CM to improve treatment outcomes for
high.
certain SUDs. For example, the Department of Veterans
Affairs (VA) has integrated CM into many of its intensive
Although most CM remains in person, new technologies
outpatient SUD treatment clinics for veterans since 2011.
have allowed for greater flexibilities in treatment delivery.
While some people may have moral or practical concerns
Digital therapeutics such as smartphone applications or
about paying substance users to reduce drug use (or
internet-based methods can provide remote monitoring and
concerns about fraud), federal programs have generally
incentive delivery. Technology-based CM interventions that
supported the use of CM.
allow patients to participate remotely avoid common
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Contingency Management for Substance Use Disorders
Federal financial support for outpatient SUD treatment
patients. Under this provision, civil monetary penalties may
comes in two main forms: (1) Medicare and Medicaid, and
be imposed against persons who offer or transfer
(2) discretionary grant programs, mostly administered by
remuneration to a federal health care program beneficiary
SAMHSA. For instance, in 2020, Congress added treatment
that the person knows or should know is likely to influence
for psychostimulants to the allowable uses of State Opioid
the beneficiary’s selection of a particular provider or other
Response (SOR) grant funds. The SOR Notice of Funding
entity for a reimbursable item or service under Medicare,
Opportunity (NOFO) explicitly permits CM as an allowable
Medicaid, or other federal health care programs. However,
use of funds. SAMHSA has historically limited each
pursuant to a 2016 OIG policy statement, the agency does
incentive to a value of $15 (not cash), and the total amount
not deem gifts of “nominal value” (i.e., retail value of no
per patient to $75 per year.
more than $15 per item or $75 in the aggregate per patient
on an annual basis) to be enforceable violations of the
Most states report that Medicaid is their largest public
statute. Notably, by statute, an arrangement permissible
funder of SUD treatment. Some states have leveraged their
under the Anti-Kickback Statute or its safe harbor
Medicaid programs to support the use of CM. For example,
regulations is generally excepted from the Beneficiary
California is piloting a Medicaid program that rewards CM
Inducements CMP.
participants with up to $599 a year for reduced substance
use. (The maximum reward is just below the Internal
OIG Actions and CM Incentives
Revenue Service’s [IRS’s] $600 threshold for providers to
Federal statutes and regulations do not squarely address the
report payments to participants via the issuance of an IRS
full extent to which CM incentives may be provided to
1099 form as part of the federal tax filing process.)
health care program beneficiaries without violating the
fraud and abuse laws. Although OIG has indicated that CM
SAMHSA has encouraged clinics with CM programs that
incentives that are a part of a covered service under a
exceed federal incentive limits to solicit in-kind donations
federal health care program would not violate the Anti-
or use volunteers to supplement costs. Some localities, such
Kickback Statute or the Beneficiary Inducements CMP
as San Francisco, have relied on philanthropic funding to
because “the coverage includes the incentive itself,” other
implement innovative CM programs above public funding
CM incentives given to program beneficiaries may violate
limits.
these statutes.
Federal Fraud and Abuse Laws
As part of a 2020 rulemaking, OIG addressed CM
One alleged obstacle to more expansive use of CM is the
incentives as part of the creation of a new patient
potential application of certain fraud and abuse laws to
engagement and support safe harbor from the fraud and
these programs. Some health care providers have raised
abuse laws. This new safe harbor protects the provision of
concerns about possible liability under laws such as the
remuneration to health care program beneficiaries, in part to
federal Anti-Kickback Statute (42 U.S.C. §1320a-7b) and
foster certain value-based care and coordinated care
the Beneficiary Inducements civil monetary penalties
arrangements. In creating the safe harbor, OIG allowed for
provision (Beneficiary Inducements CMP, 42 U.S.C.
in-kind goods and services (such as health-related
§1320a-7a), collectively referred to here as fraud and abuse
technology and monitoring tools) to be given to
laws, particularly with respect to monetary or other rewards
beneficiaries, but it declined to extend the safe harbor to
provided to patients that participate in health care programs
include explicit protection for cash, cash-equivalent
such as Medicare or Medicaid.
payments, or gift cards, due to concerns over a “heightened
fraud and abuse risk.” The safe harbor also included a $500
Background
annual cap on acceptable tools and supports.
The basic thrust of the Anti-Kickback Statute is to limit
health care provider actions that are improperly influenced
In the preamble to the 2020 final rule, OIG addressed CM
by a profit motive, and to protect federal health care
incentives and application of the federal fraud and abuse
programs from unnecessary costs. Under this criminal
laws. It also clarified that the agency’s 2016 policy
statute, it is a felony for any person to knowingly and
statement concerning gifts of nominal value does not
willfully offer, pay, solicit, or receive “remuneration” (i.e.,
impose a $75 annual limit on CM incentives. Additionally,
monetary compensation or nonmonetary items of value) in
OIG stated that the agency would examine CM programs
return for a patient referral or other generation of business
that do not meet the patient engagement and support safe
reimbursable under a federal health care program. Given
harbor (or another safe harbor) on a case-by-case basis.
the broad scope of the Anti-Kickback Statute and its
potential application to legitimate business arrangements,
More recently, the Consolidated Appropriations Act, 2023
the statute authorizes the Department of Health and Human
(P.L. 117-328), directed OIG to review whether to establish
Service’s (HHS’s) Office of Inspector General (OIG) to
a safe harbor for “evidence-based contingency management
issue regulatory safe harbors to the statute. OIG has also
incentives” and “the parameters for such a safe harbor,” and
said that the safe harbor provisions do not indicate the only
to provide recommendations to Congress regarding the
acceptable business arrangements, and arrangements that do
issue by December 29, 2024. In a November 2023 report,
not fall within a safe harbor are not necessarily in violation
HHS noted that its consideration of a potential safe harbor
of the statute.
was ongoing.
A separate provision, the Beneficiary Inducements CMP,
Johnathan H. Duff, Analyst in Health Policy
expressly applies to financial or other incentives given to
Jennifer A. Staman, Legislative Attorney
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Contingency Management for Substance Use Disorders

IF12681

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