BOX 3.2 The VA Model-Top-Down Incentives Model

For the past seven years, the VA has used an in-service program of education and training to integrate research-based treatments into its approach to substance dependent patients. This program has included national meetings for program leaders, interactive video teleconferencing for presentation of curriculum materials, the development of Centers of Excellence in Substance Abuse Treatment and Education as national education resource centers, quarterly conference calls with program leaders across the country, and small meetings to introduce technical treatments such as LAAM.

VA officials have learned that certain things do work in this process of change:

  • "money with strings attached" that is, funds made available on a competitive basis for improvement and innovation in care delivery;
  • strong medical and affiliated-health professional presence; Having well educated leaders "makes a big difference" in the ability of programs to adopt technological advances, but may not affect administrative change within the system;
  • good in-service education helps, but there is also a need for personal consultation, advice, "and hand-holding";
  • media reports of changes in the VA system generate public interest and can push professionals to participate in the change process; and
  • publications in the professional literature have little impact, but abstracting such literature to "separate the wheat from the chaff would be helpful.

Richard Suchinsky

Associate Chief for Addictive Disorders, Department of Veterans Affairs

Committee Workshop, July 27, 1997, Washington, DC

grams to the requirements of managed care programs, albeit against their wishes and desires, is an example of the power of this approach.

Top-down incentives were viewed by the committee as a powerful approach, but also a dangerous one. Money with dumb strings can lead to inappropriate actions and services, of which the committee heard several examples. The committee did agree that when top-down models are proposed, it must be with careful consideration of the potential negative consequences.


Knowledge exchange and the development of two-way communication between treatment personnel and researchers requires the development of trust. Trust takes time to develop. Trust between researchers and practitio-

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