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Depression In Primary Care: Bringing Behavioral Health Care Into The Mainstream

Abstract

 
The Robert Wood Johnson Foundation’s national program, Depression in Primary Care: Linking Clinical and Systems Strategies, funds three related components to stimulate innovation in primary depression care. The incentives, value, and leadership components evaluate and implement strategies for financing and sustaining use of clinical best practices despite barriers created by economic and organizational structures that fragment behavioral and general health care. A challenge for policymakers is how to link depression care with the management of other chronic conditions, so that they are integrated into the quality improvement agenda of purchasers, payers, and providers without becoming submerged in health care’s mainstream.

The program also recognizes that (1) depression is a serious, often chronic disease that is commonly encountered in primary care patients but often unrecognized or treated in ways that are inconsistent with evidence-based practice; (2) although models for chronic illness care have been shown to be effective in treating depression in primary care settings, systemic barriers at multiple levels operate against implementing and sustaining these models; and (3) integrating these models into everyday practice requires a multilevel clinical and systems strategy that engages all stakeholders, including patients, providers, practices, plans, and purchasers.

Depression in Primary Care will determine whether such a coordinated approach is feasible and effective and will provide a template of best practices for other organizations to follow. The program also will assist in determining and documenting the value of treating depression in primary care and will lay the groundwork for training a new generation of primary care providers to break down the traditional mind-body barriers in public, private, and research environments.

Depression And Key Barriers

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
Depression affects ten to fourteen million Americans every year, exerting a detrimental impact on quality of life, functioning, and work productivity.³ Models of recognition, treatment, and follow-up for depression in primary care settings have recently been developed, tested, and found effective.⁴ These models, along with major advances in pharmaceutical and psychotherapeutic treatments, hold great promise for improving outcomes. But this promise has yet to be realized for most patients with depression who seek help in a primary care setting. The reason is the confluence of clinical, organizational, economic, and policy barriers that impede the recognition and treatment of depression across multiple stakeholder groups in primary care.⁵

Depressed patients often encounter cultural stigma, deny the presence of depressive symptoms, and experience debilitating hopelessness. These factors can create a formidable barrier to seeking appropriate care. The somatic symptomatology of depression is often similar to that of other medical illnesses, thereby making differential diagnosis of the depressive disorder more difficult.

Primary care providers typically have minimal behavioral health care training, and practical tools for use in primary care settings have only recently become available. But even if these providers were adequately trained and equipped to recognize and treat depression, they face multiple competing demands for their attention and receive little or no financial incentive to manage depression.

Health care practice arrangements also create barriers to effective depression treatment. Most clinical practices and delivery systems are set up to deliver health care for acute conditions, whereas chronic conditions such as depression require different strategies. There is also wide variation in how primary care practices are organized to care for people with behavioral health problems and are linked to mental health specialty support, with high levels of ambiguity about which practice (the primary care practice or the mental health practice) is responsible for care. The current split between the provision of pharmacotherapy and psychotherapy in the specialty mental health sector exacerbates the limited communication and teamwork between primary care and mental health practices.

Health plans that carve out behavioral health services have shifted incentives for coordination and communication between primary care and specialty practices and providers, compounding the ambiguity inherent in caring for patients with depression. The existence of a risk-bearing managed behavioral health care organization (MBHO), in conjunction with another health plan’s capitation for primary care services only, establishes a potent motivation for primary care doctors to refer behavioral patients to the MBHO. MBHOs do not share any rewards or risks for more efficient management of depression in the primary care setting, nor do they receive any benefit from the reduced costs associated with improved pharmacy or medical/surgical use by members seeking treatment for their mental condition in the primary care setting. "As a result," according to Harvard health economist Richard Frank, "the primary care physician is less likely to view mental health care as his or her responsibility and may exert too little effort in follow-up of patients in treatment."⁶

Public and private purchasers wield enormous, although often indirect, power in the design of the health care system. Purchasing decisions are amenable to systematic and quantitative analysis, but there is little evidence that such analysis actually takes place. Efforts have been made to expand purchasers’ motivation to monitor the performance of health plans, but implementation has been variable, and there is little evidence that purchasers incorporate mental health quality measures in their purchasing decisions. Further, despite recent analyses that behavioral health care costs, as a percentage of overall health care costs, have been stable or dropping and that the value of depression care has been increasing, a persisting general view that such costs are continually rising also negatively influences purchasers’ decisions to include behavioral health care in their benefit packages.⁷ Purchasers may also be uninformed about the sizable indirect costs of depression, such as the costs of absenteeism and disability.⁸

Description Of The Program

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
Depression in Primary Care evolved from the recognition that these barriers exist and that strategies must be designed to overcome them if high-quality primary care for depression is to be achieved.⁹ This five-year, $12 million program incorporates three components: demonstration projects on incentives, research projects on the value of improved care for depression in the primary care setting, and physician leadership development.

Incentives. The goal of the incentives component is to plan, implement, and evaluate projects that combine clinical best practices in the primary care treatment of depression with economic and nonfinancial incentives to reorganize systems of primary care. Primary care practices (the providers of care) and health plans (the payers) have formed partnerships to implement organizational changes that better align clinical and systems approaches to care. Clinical best practices include the principles of the chronic illness care model (for example, evaluation of patients’ preferences, adherence to evidence-based guidelines and protocols, longitudinal follow-up by a care manager, and mental health specialty support). Changes in the incentives include implementing new rules about which types of services for which behavioral diagnoses will be reimbursed and providing additional time to primary care practitioners to care for depressed patients.

Value of improved care. Through awarding large and small research grants, the value component of the program supports analyses of barriers to treatment and the development of strategies for improving the quality of care. The grants’ purpose is to assess the "value" of improved primary depression care as defined by the key stakeholder groups (patients, health care providers, office practices and delivery systems, health plans, and public and private purchasers) and to demonstrate how that value can be best achieved, documented, and sustained. For example, the program funded a Blue Cross/Blue Shield initiative in Michigan to measure the impact of benefit changes allowing nonpsychiatric physicians to bill for psychiatric treatment.

Physician leadership. The leadership component of the program is intended to identify and develop future leaders in primary care who will commit to improving the treatment of depression in their settings (such as academic institutions, managed care organizations, clinical practices, and public and private agencies) where they will become visible role models and new thought leaders. Talented, early-career primary care physicians, linked with senior mentors of their choice, are conducting specific research projects that advance the overall goals of this RWJF program.

Program support. All of these components are supported by the National Program Office (NPO), which provides ongoing technical assistance to the projects, monitors their progress, assimilates lessons learned, and works closely with the RWJF to disseminate information related to the adoption and sustainability of programmatic innovations.

Progress To Date

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
Incentives demonstrations. Eight ethnically and geographically disparate sites across the country have implemented demonstration projects designed to analyze and restructure local clinical, economic, and systemic barriers in the way of improved primary depression care. The sites vary greatly by the number and types of primary care practices involved, the populations served, and the prevalent payer mix that must ultimately sustain the innovations when RWJF funding terminates in 2005. For example, the sites in Vermont, Colorado, Massachusetts, and Oregon work with Medicaid populations, while the sites in California, Utah, Maine, and Michigan work with commercially insured populations. Several combinations of relationships between purchasers, plans, and providers are represented. For example, some local partnerships include MBHOs (for example, United Behavioral Health in San Francisco and Massachusetts Behavioral Health Partners in Boston), general medical insurers (such as Anthem in Portland, Maine, and Blue Shield in northern California), primary care group practices (for example, federally qualified health centers in Vermont, Maine Health’s group practices, and Intermountain Health Care’s primary care clinics in Utah), and, in some cases, corporate purchasers (such as Ford Motor Co.) or state Medicaid programs (for example, the Massachusetts Division of Medical Assistance).

The complexity and multiplicity of the partnering groups provide continuous challenges to evaluating the extent to which these evolving programs can achieve the objective of providing sustainable high-quality depression care in a primary care setting. Evaluations of their impact occur separately at each site and across sites via an external appraisal conducted by a team of Johns Hopkins University researchers. A wide array of qualitative and quantitative data are collected, including information obtained from interviews with stakeholders, patient registries and surveys, and medical and administrative records. Analyses and publication of these data are beginning.

The NPO provides technical assistance to the sites through two teams (clinical and economic) comprising national experts in the subject matter. A clinical expert and an economic expert are assigned to each site, along with a quality improvement consultant. The technical assistance provided includes monthly teleconferences, quarterly reports, topic-specific conference calls, technical assistance workshops, an active e-mail discussion list, an annual meeting, and periodic site visits with each demonstration team.

Value research grants. Following two consecutive rounds of calls for small and large research proposals, twenty-six value research grants have been awarded to date under the national program. Of these, twelve larger projects are collecting primary data; examining innovative alternative models that combine clinical and economic strategies for treating depression in the primary care setting; or assessing existing barriers and devising strategies for overcoming them. Projects in this category cover a range of important topics, including (1) creating employer demand for improved depression care; (2) building links to school-based health centers for use by depressed adolescents; (3) developing methods to reward physicians for high-quality depression care; and (4) implementing employer-led efforts to improve depression care.

Fourteen smaller projects are using case-study data to test the early effects of newly implemented policy changes; analyzing data collected under existing larger projects in which critical questions arise afterward; or adding to existing studies a specific component that is directly related to the national program objectives. Projects in this category cover such topics as (1) assessing the validity of the Health Plan Employer Data and Information Set (HEDIS) indicators to measure the quality of depression care; (2) identifying health plan tactics associated with improving depression care outcomes; (3) demonstrating the impact of an integrated employee assistance program (EAP)–primary care program for depression on employees’ productivity; and (4) evaluating performance-contingent incentives for improving depression care results.

Leadership grants. The national program has granted awards to four young faculty physicians for support of their research and experiential learning in areas related to primary care for depression. The leadership grantees and their faculty mentors come from the University of California, Los Angeles (UCLA); University of California, San Francisco (UCSF); Oregon Health and Science University; and University of Washington. They are exploring a range of critical issues including barriers and facilitators of referral to behavioral health specialty care and follow-up in primary care; delivery system innovations to increase patients’ treatment motivation and social support; and improvement of depression care for specific populations, such as women who have been abused.

Early Lessons Learned

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
Although these projects are still under way, observations of the work to date highlight important lessons that may become broadly generalizable. Behavioral health care is in many ways different from, but at its core similar to, the rest of health care. Centuries of stigma surrounding mental health conditions, Cartesian dualism that splits the mind and body, and separate silos of care delivery and financing have led to clinical and systems fragmentation and perverse incentives. However, the clinical and policy challenges for improving behavioral health care quality mostly mirror those for general health care.

For example, the chronic illness care model can be readily adapted for behavioral disorders and is a powerful tool for changing clinical systems.¹⁰ With local initiative and expert technical assistance, each of the model’s elements—patient self-management, decision support, delivery system redesign, clinical information systems, and linkage to community resources—can be implemented to reorganize care for depression to be similar to chronic care for diabetes, asthma, or congestive heart failure. But because of inherent differences in behavioral health care, the chronic illness care model must be customized to local contexts of purchasers (public and private), plans and payers, practices, providers (behavioral health and primary care), and patients. Specifically, a complementary economic intervention is needed to align organizational and financing systems with clinical best practices. Inevitably, a successfully realigned and integrated chronic illness care model will force revision of financial incentives to rectify the fragmentation between general and behavioral health. The UCSF incentives project is evaluating a health plan (Blue Shield of California) and an MBHO (United Behavioral Health) jointly credentialing and reimbursing UCSF primary care providers to provide depression care.

Policy Implications

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
The multiple barriers that impede effective depression treatment in primary care and the best practices required for improving it highlight a number of generic policy issues related to improved behavioral health care.

Application of quality principles to behavioral health. A broader application of the influential Crossing the Quality Chasm report’s principles to behavioral health care more generally is required.¹¹ The Depression in Primary Care paradigm can be applied equally well to other behavioral disorders (such as alcohol and other substance abuse problems and attention deficit disorder). A new Institute of Medicine (IOM) committee is adapting the Quality Chasm report for behavioral health.¹²

Mainstreaming. Behavioral health care must penetrate more deeply into the mainstream of general health care. Given the high degree of co-occurring mental illness, substance abuse, and chronic medical conditions, greater treatment coordination and systems linkage across these areas is essential. This requires mutual alignment of information technology (IT), performance measurement, quality improvement efforts, decision making, and innovative financing (including pay-for-performance mechanisms) between traditionally disparate silos of health care. Also, the strategies and linkages must ensure that the severely mentally ill receive high-quality preventive and general medical care.

Adaptation. Because of the historical and structural separation, behavioral health care will, at least initially, need a "flotation device" to avoid drowning in the mainstream.¹³ Bridges across the current gaps between managed care organizations, MBHOs, pharmacy benefit managers (PBMs), and provider groups need to be developed to minimize clinical, systemic, organizational, and financing fragmentation. Behavioral health care providers will need financial assistance for capitalization of IT infrastructure and incentives to migrate toward coordinated group-practice models. Special efforts and dedicated resources to expand the knowledge base for improving the quality of behavioral health care are needed, as well as technical assistance centers that are closely linked to similar efforts in general health care (such as the Institute for Healthcare Improvement).

The long-term success of the program and its model depends on (1) the extent to which the program model meets the needs of and is acceptable to key stakeholders; and (2) clear, convincing evidence that its value is greater than and differentiated from other approaches as to cost-effectiveness, improved quality, good clinical outcomes, and user satisfaction.

Overall, the program provides stakeholders with a realistic template for accomplishing better synchronization of behavioral and medical services. We hope that improved outcomes, satisfaction, and efficiency resulting from this synchronization will become the economic motivation for consumer groups, purchaser coalitions, and health plans to negotiate shared-risk contractual coverage of behavioral health care with MBHOs and primary care practices.

Editor's Notes

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 
Harold Pincus (pincusha{at}upmc.edu) is a professor and executive vice chair of the Department of Psychiatry at the University of Pittsburgh School of Medicine, in Pittsburgh, Pennsylvania. He is also a senior scientist and director of the RAND–University of Pittsburgh Health Institute, and he directs the Robert Wood Johnson Foundation national program that is this paper’s subject. Jeanine Knox Houtsinger is deputy director of that program. John Bachman is a communications consultant to the program. Donna Keyser is a research communicator with the RAND–Pitt institute.

The authors gratefully acknowledge the support of the Robert Wood Johnson Foundation (Grant no. 45529) and the National Institute of Mental Health (Grant no. MH30915), and the outstanding ongoing efforts of the Depression in Primary Care grantees and steering committee to improve the quality of patient care.

NOTES

Top Depression And Key Barriers Description Of The Program Progress To Date Early Lessons Learned Policy Implications Editor's Notes NOTES

 

1. The Depression in Primary Care Web site is located at www.depressioninprimarycare.org.
2. See the thematic issue on Providing Treatment to Persons with Mental Illness, Milbank Quarterly 72, no. 1 (1994); and D.A. Regier et al., "The de Facto U.S. Mental and Addictive Disorders Service System: Epidemiologic Catchment Area Prospective One-Year Prevalence Rates of Disorders and Services," Archives of General Psychiatry 50, no. 2 (1993): 85–94.[Abstract/Free Full Text]
3. R.C. Kessler et al., "The Epidemiology of Major Depressive Disorder," Journal of the American Medical Association 289 no. 23 (2003): 3095–3105[Abstract/Free Full Text]; and P.E. Greenberg et al., "Depression in the Work-place: An Economic Perspective," in Selective Serotonin Re-Uptake Inhibitors: Advances in Basic Research and Clinical Practice, ed. J.P. Feighner and W.F. Boyer (New York: John Wiley and Sons, 1996), 327–363.
4. A.J. Dietrich et al., "Re-Engineering Systems for the Treatment of Depression in Primary Care: Cluster Randomised Controlled Trial," British Medical Journal 329, no. 7466 (2004): 602–605[Abstract/Free Full Text]; J. Unutzer et al., "Collaborative Care Management of Late-Life Depression in the Primary Care Setting: A Randomized Controlled Trial," Journal of the American Medical Association 288, no. 22 (2002): 2836–2845[Abstract/Free Full Text]; and K. Wells et al., "Five-Year Impact of Quality Improvement for Depression: Results of a Group-Level Randomized Controlled Trial," Archives of General Psychiatry 61, no. 4 (2004): 378–386.[Abstract/Free Full Text]
5. H.A. Pincus et al., "Emerging Models of Depression Care: Multilevel (‘6 P’) Strategies," International Journal of Methods in Psychiatric Research 12, no. 1 (2003): 54–63.[CrossRef][Web of Science][Medline]
6. R.G. Frank et al., "Aligning Incentives in the Treatment of Depression in Primary Care with Evidence-based Practice," Psychiatric Services 54, no. 5 (2003): 682–687.[Abstract/Free Full Text]
7. M. Schoenbaum et al., "Exploratory Evidence on the Market for Effective Depression Care in Pittsburgh," Psychiatric Services 55, no. 4 (2004): 392–395.[Abstract/Free Full Text]
8. P.S. Wang et al., "Effects of Major Depression on Moment-in-Time Work Performance," American Journal of Psychiatry 161, no. 10 (2004): 1885–1891.[Abstract/Free Full Text]
9. H.A. Pincus et al., "Depression in Primary Care: Linking Clinical and Systems Strategies," General Hospital Psychiatry 23, no. 6 (2001): 311–318.[CrossRef][Web of Science][Medline]
10. E.H. Wagner et al., "Improving Chronic Illness Care: Translating Evidence into Action," Health Affairs 20, no. 6 (2001): 64–78[Abstract/Free Full Text]; and E.H. Wagner, B.T. Austin, and M. Von Korff, "Organizing Care for Patients with Chronic Illness," Milbank Quarterly 74, no. 4 (1996): 511–544.
11. Institute of Medicine, Crossing the Quality Chasm: A NewHealthSystemfortheTwenty-firstCentury (Washington: National Academies Press, 2001).
12. "Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders," www.iom.edu/project.asp?id=19405 (25 October 2004).
13. H.A. Pincus, "The Future of Behavioral Health and Primary Care: Drowning in the Mainstream or Left on the Bank?" Psychosomatics 44, no. 1 (2003): 1–11.[Free Full Text]

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