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Managing mental health: You might need training -- by an insurance company.

Primary care physicians increasingly are diagnosing and treating depression. Insurers are responding.

By Jonathan G. Bethely — Posted Jan. 23, 2006

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Even if you're not a psychiatrist -- especially if you're not -- you soon could be hearing from health plans about depression.

While employers and plans for years have developed disease management and behavioral health carve-outs that were supposed to manage mental illness costs, their efforts are getting more aggressive in the face of evidence that depression can exacerbate physical conditions, and vice versa, thereby costing employers and plans a lot of money.

Their efforts also are getting more aggressive in the face of evidence that in an overwhelming number of cases, it's a primary care physician who is diagnosing and treating depression.

So health plans are beefing up their disease management and behavioral health carve-outs, or even putting them together, as a means of coordinating care for depression. Plans are examining claims data, seeing if patients are following up a physician's recommended treatment. Plans also are combing through those data to identify patients who appear to have symptoms of depression but have not been diagnosed, and contacting primary care physicians to conduct a screening.

And at least one plan, Aetna, promises to pay extra for depression screenings, as long as doctors go through the plan's training program.

On one hand, primary care physicians are happy to see additional plan support and focus on depression. "It's a step in the right direction," said family physician Michael Klinkman, MD, who is director of primary care programs for the University of Michigan Depression Center in Ann Arbor and has studied how primary care physicians diagnose and treat depression.

On the other hand, primary care physicians see these moves as only a first step. Right now, physicians say, when it comes to insurance and mental health, they and their patients still struggle with a system that puts treatment and payment in a separate box.

A report released in December 2005 by the National Business Group on Health found "financial disincentives" in the insurance system that discouraged physicians from screening for depression and patients from seeking treatment.

One disincentive, even in Aetna's plan, Dr. Klinkman said, is the possibility that more depression screening might yet become merely another administrative hassle for already burdened primary care physicians. In Dr. Klinkman's experience, a patient needs a lot of explanation, taking more time than the usual office visit, as to why he or she is being screened and why that screening indicated depression. Patients often flat-out reject that initial diagnosis.

"My concern is that this step might be seen as sufficient, and it is clearly not," Dr. Klinkman. "It will preclude us from talking about how do we arrange to get the [managed care community] together so that we can create a single process."

Insurers are looking at primary care physicians for two reasons. First, the primary care physician often is going to be the treating physician. The National Business Group on Health, a coalition of large employers, in its report, titled "Employers' Guide to Behavioral Health Services," quoted previously published studies in the Journal of the American Medical Association in saying that 67% of psychotropic drugs are prescribed by primary care physicians. Cigna, citing its own research, says 80% of the estimated 122 million annual antidepressant prescriptions are written by primary care physicians.

The National Business Group on Health, in its report, also said 51.6% of patients treated for major depression are seen in the "general medical sector," defined as primary care physicians and other non-psychiatric physicians. The report quotes American Academy of Family Physicians research saying 42% of all clinical depression diagnoses are made by primary care doctors.

As early as 1996, the AMA House of Delegates had passed policy encouraging medical schools and other training programs to give all physicians the skills to diagnose and treat depression. Recently, primary care physicians, as well as doctors in other specialties, also have become more attuned to diagnosing depression because of studies showing it can co-exist with other morbidities and make these other conditions worse.

While the development and popularity of selective serotonin reuptake inhibitors is sometimes given as a reason that primary care physicians have gotten more involved in mental health care, doctors say that's only part of the picture.

"Most patients feel most comfortable going to their family physicians," said Trevor Stone, director of private-sector advocacy for the AAFP.

There are many estimates on how much depression costs American employers, anywhere from $24 billion to $78 billion per year. A study published in the June 18, 2003, JAMA placed the number at about $44 billion annually. But an overwhelming majority of the costs -- $35 billion -- was what the study termed "presenteeism," employees who were at work, but were less productive because of their depression.

Absenteeism also is a problem. A 1999 Health Affairs study said depressed employees were out 1.5 to 3.2 more days than their nondepressed colleagues, at a cost of $182 to $395 per day -- losses great enough to make it "cost-effective" for employers to increase mental health benefits.

Meanwhile, a study published in the December 2004 Psychiatric Services, a journal of the American Psychiatric Assn., suggested that effective depression treatment could reduce the high costs of job turnover. The study found that 14% of those with dysthymia were "new unemployed" [having lost their jobs in the previous six months], while 12% of those with major depression fit that category. The figure for rheumatoid arthritis patients, considered to have a high rate of work disability, was 3%.

Employers and insurers also have seen the studies saying that depression can make other conditions worse, as well as chronic illness leading to a case of depression. They've also seen the studies saying how much that can cost. For example, a March 2002 study in Diabetes Care, the journal of the American Diabetes Assn., concluded that health costs for a diabetic with depression were 4½ times greater than costs for a diabetic without depression.

Guiding the doctor

For a long time, mental health care was a carve-out -- something insurers sold to employers and managed separately from their other HMO and PPO products. That was the insurers' strategy of managing costs, but many studies, including one in the May 8, 2003, New England Journal of Medicine, showed what they often did was interrupt continuity of care.

The carve-outs aren't disappearing, but some plans are trying to integrate them or manage them like other disease management programs.

For example, on Jan. 1 Cigna began its Well Aware for Depression program. The program is designed to identify Cigna members who are being treated for depression or have "medical claim patterns that signal undiagnosed depression." The program has care managers and psychiatrists who work with patients to facilitate compliance with a physician's treatment plan, or to provide educational material, "coaching," and coordination of services. Cigna also will give physicians information about patients who might not be filling their prescriptions, or not taking them as directed.

One of the early goals is to keep patients on their medication, said Doug Nemecek, MD, Cigna's national medical director. Also, Cigna wanted to make it clear it will pay primary care physicians for depression treatment, he said.

"In the past, primary care physicians were afraid they wouldn't get reimbursed," Dr. Nemecek said. "We've made it clear so that the medical provider can bill simply for treating depression because we know it's being treated in the primary care setting."

Meanwhile, Aetna is piloting a program that it says will increase primary care physicians' depression-screening reimbursement by 30% to 40%. The program, available in Maryland, New Jersey, Oklahoma, Pennsylvania, Texas, Virginia and the District of Columbia, would reward those physicians who participated in the company's Depression Management program.

Physicians would need to be trained, and have their office staffs trained, in Aetna's system, which includes consulting with Aetna psychiatrists regarding treatment options. Similarly, Kaiser Permanente recently assigned a mental health aide to each of its salaried primary care physicians in Northern California.

Hyong Un, MD, Aetna's national medical director for behavioral health, said Aetna is not giving the green light for universal screening.

"This is not a program that's meant to be a screening for everyone," Dr. Un said. "We're asking physicians to screen patients that they have a suspicion for depression or if they have a chronic medical illness because we know they have a higher incidence of depression."

Dr. Klinkman, of the Michigan Depression Center, is encouraged by Aetna's move. But he said its benefit might be limited, particularly because of Aetna's requirements for reimbursement. Physicians will have to develop a different process for Aetna's depression program, which might not be worth the extra reimbursement for a doctor like himself, who has only 10% to 20% his patients carrying Aetna.

"It's OK that Aetna wants to take that on, but what they have provided so far doesn't help doctors get all the way through the process," Dr. Klinkman said. "Just giving somebody a [screening] moves you only one step along a difficult chain in trying to take care of people like this."

Darrel Regier, MD, MPH, education director of the division of research at the American Psychiatric Assn., said if Aetna's approach is successful, other plans might follow. The key to the success of any program, he said, is its ability to help move patients and primary care physicians through the often complicated web of mental health care. "The key is being able to sustain [care]."

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ADDITIONAL INFORMATION

The numbers behind depression

  • Estimated annual cost to employers in lost productivity: $44 billion
  • Amount of that lost productivity cost that's a result of depressed employees at work, but less productive: $35 billion
  • Health cost multiplier for patients with both diabetes and depression, compared with those who have diabetes alone: 4.5
  • Spending on antidepressants in 2005: $10 billion
  • Increase over 2004: 3%
  • Portion of monthly household income that patients are willing to spend for primary care-based depression treatment: 9%
  • Variance from what patients would pay for primary care-based treatment of other chronic illnesses: Nearly zero
  • Depression patients in primary care settings who first present with somatic symptoms: 67%
  • Patients who present in a primary care setting with "clinically significant" depressive symptoms: 20%
  • Depression patients who received long-term, full relief by taking a selective serotonin reuptake inhibitor: 30%
  • Patients who got no relief at all: 50%
  • Patients in drug-company tests who reported short-term relief from SSRIs: 25%-40%
  • Multiplier reflecting increase in mortality for patients with diabetes and minor depression over those who have diabetes alone: 1.67
  • For diabetes and major depression: 2.3

Sources: Journal of the American Medical Association, June 18, 2003; Diabetes Care, March 2002; various financial analysts' estimates; Journal of Clinical Psychiatry, Supplement 7, 2005; Psychiatric Services, March 2003; American Journal of Psychiatry, January; Diabetes Care, November 2005

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External links

"An Employer's Guide to Behavioral Health Services," National Business Group on Health, Center for Prevention and Health Services (link)

PHQ-9 form used by Aetna in its depression management program, in pdf (link)

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