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

LETTERS

and use of such technologies. Participants were recruited from

two programs: the Prevention and Early Intervention Program
for Psychosis at the Douglas Mental Health University Institute
and the Prevention and Early Intervention Program for Psychosis at McGill University Health Centre. Between December 2013 and October 2014, a total of 67 individuals
(mean6SD age525.665.1) completed the survey, which was
developed in collaboration with young adult service users
and mental health clinicians. The Ethics Review Board at
McGill University provided approval, and all participants
provided consent.
The majority of participants had access to a cell phone
(N559, 88%), most of which were smartphones. Most (N547,
70%) had access to a laptop computer, and a little over half
(N535, 52%) had access to a desktop computer in their home.
Only some (N511, 16%) owned a tablet, whereas several
(N527, 40%) owned an MP3 player (for example, an iPod). In
descending order, the ten most popular reported uses of these
devices among a list of possible activities were listening to music,
watching videos, e-mailing, searching for information, social
networking, text messaging, taking pictures, using maps, playing
games, and banking. The ve most popular types of information
searched online in the past year among a list of topics were news,
work, transportation, school, and mental health. The three
most commonly visited social media sites were YouTube
(N563, 94%), Facebook (N550, 75%), and Skype (N530, 45%).
Many participants were active users of social media, particularly YouTube and Facebook, highlighting the importance of leveraging social media in the context of mental
health services. Yet, at the time of the study, neither of the
recruitment sites had a social media presence. It is also noteworthy that a portion of cell phone users (N513, 19%) did not
have a smartphone that would provide them with access to the
Internet and the use of apps; moreover, a few participants
(N58, 12%) did not have access to any type of cell phone.
To our knowledge, this is the rst reported survey
on access to and use of technology among young adults

Psychiatric Services 66:7, July 2015

receiving FEP services. A larger sample would help us better

understand how access and use varies in relation to gender,
age, socioeconomic characteristics, and geographical settings.
As the trend toward technology-enabled mental health service delivery is increasing, it is important to understand
youths preferences and priorities. For example, knowledge
of the types and features of technology-enabled services that
youths would nd engaging and be amenable to receiving
(for example, peer support, medication reminders, online
counseling, and management of personal mental health information) can help prioritize efforts to develop, implement,
and evaluate new technologies and online strategies.
REFERENCES
1. Lal S, Adair CE: E-mental health: a rapid review of the literature.
Psychiatric Services 65:2432, 2014
2. Lal S, Malla A: Service engagement in rst episode psychosis: current issues and future directions. Canadian Journal of Psychiatry, in
press
Shalini Lal, Ph.D.
Jennifer DellElce, B.A.
Ashok K. Malla, M.B.B.S., F.R.C.P.C.
Dr. Lal is with the School of Rehabilitation, University of Montreal, and the
Douglas Mental Health University Institute, Montreal, Quebec, Canada.
Ms. DellElce is with the School of Physical and Occupational Therapy,
McGill University, Montreal. Dr. Malla is with the Department of Psychiatry,
McGill University, and the Douglas Mental Health University Institute, Montreal.
Preliminary results from this study were presented at the International Early
Psychosis Association biannual conference, Tokyo, November 1719, 2014.
Dr. Lals work on this project was partly funded the Canadian Institutes of
Health Research (CIHR) and a postdoctoral stipend from the CIHR Interdisciplinary Capacity Enhancement Grant in Health Disparities (HOA80072). Dr. Malla is supported by the Canada Research Chair Program. The
authors thank the survey participants, as well as clinicians, research assistants, and patient and family representatives for feedback during survey
development.
Dr. Malla has received research grants or honoraria from BMS, Janssen-Ortho
(Canada), Lundbeck, Otsuka, Pzer, and Roche. The other authors report no
nancial relationships with commercial interests.
Received December 21, 2014; revision received March 4, 2015; accepted
March 30, 2015.
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