Addressing Depression in
“Medicare Health Support”
Michael Schoenbaum
June 27, 2005
• 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
27Jun05, Slide 2
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
27Jun05, Slide 3
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
27Jun05, Slide 4
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
27Jun05, Slide 5
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
27Jun05, Slide 6
How to address depression
• Usual care for depression not effective or cost-effective
• Effective strategies exist, based on “collaborative care”
model
– Diagnosis
– Behavioral activation
– Care manager
– Medication
management
– Proactive tracking &
reminders
– Benchmarking &
stepped care
– Brief psychotherapy
– Psychiatric
consultation
– Patient education
27Jun05, Slide 7
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
27Jun05, Slide 8
Timeline
• Dec. 2004
Organizations selected by CMS
We submitted grant application to NIMH
• Jan.-June 2005
Contract negotiations
Grant was approved (May 2005)
• Summer 2005
CMS selects patient samples, contacts
beneficiaries
• July-Oct. 2005
Organizations finalize program content, train
staff
• Sept. 2005
1st cohort of organizations goes live
• Oct./Nov. 2005
2nd/3rd cohort of organizations goes live
27Jun05, Slide 9