Addressing Depression in “Medicare Health Support”

1. Addressing Depression in “Medicare Health Support” Michael Schoenbaum June 27, 2005

2. Collaboration between RAND, University of Washington, University of Pittsburgh • Harold Pincus (co-PI) • Jürgen Unützer • Wayne Katon • Funded by • National Institute of Mental Health (1 R01 MH75159-01) • John A. Hartford Foundation • Robert Wood Johnson Foundation

3. Introduction • Medicare Modernization Act of 2003 (Section 721) created “Chronic Care Improvement Program” • New care management benefit under FFS Medicare • Phase 1 is 3-year pilot program • Complex diabetes and/or congestive heart failure • Medicare risk score of “moderate” or higher • 9 sites - each set up as randomized control trial • Up to 20,000 intervention & 10,000 control patients • Participation is voluntary

4. 9 Sites in Phase 1 • Florida (Central) – Humana & Pfizer Health Solutions • Tennessee - XLHealth Corp. • Illinois (Chicago) - Aetna Health Management • Oklahoma - Lifemasters Supported SelfCare • Mississippi - McKesson Health Solutions • Georgia - CIGNA HealthCare • Pennsylvania (Western)- Health Dialog Services Corp. • Maryland & Washington DC - American Healthways • New York (Queens & Brooklyn) - Visiting Nurse Service of New York Home Care & United HealthCare Services

5. Introduction (cont.) • Organizations develop & apply own disease management protocols • Who to target • What services to provide • CMS can’t mandate content • CMS will judge organizations based on • Cost: total Medicare costs must be <95% of usual care • Performance indicators, e.g., HbA1c, flu vaccine, depression screening

6. Why focus on comorbid depression? • Prevalent in CCIP population • Up to 25% in Medicare patients with diabetes/CHF • Associated with higher costs & worse outcomes • >2x health costs • ~2x mortality • More diabetes & CHF complications • Higher disability • Impairs compliance with treatment • Lower medication adherence • Less likely to improve diet, exercise, smoking cessation

7. Diagnosis Care manager Proactive tracking & reminders Benchmarking & stepped care Patient education Behavioral activation Medication management Brief psychotherapy Psychiatric consultation How to address depression • Usual care for depression not effective or cost-effective • Effective strategies exist, based on “collaborative care” model

8. Our project • Technical assistance to organizations, to help them • Manage and track depression in their patient populations • Provide web-based “depression toolkit” • Craft a customized depression care program • Train their staff • Evaluate effectiveness • Work with CMS to evaluate • Role of depression as moderator of program effectiveness • Value-added of specific strategies to address comorbid depression

9. Timeline