General Hospital Psychiatry 37 (2015) 368–371

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Letters to the Editor Further policy changes are needed to improve depression care

Depression is a highly prevalent disorder among primary care patients, particularly those with chronic medical disorders. Patients with depression use more medical care and have two-fold higher medical costs than patients without depression. Older adults with depression have high medical costs, frequently have multiple chronic illnesses, and are the focus of many payment reforms and healthcare redesign approaches. Depression is a risk factor for functional decline in aging populations, dementia, and mortality. There could be many long-term benefits for preventing the downstream sequelae of depression through evidence-based care, including improving adherence to prescribed medical regimens, decreasing caregiver burden, and potentially reducing premature mortality associated with depression. Primary care physician (PCP) antidepressant prescriptions have increased, yet extensive gaps in quality of care for depression remain. Many quality improvement efforts concentrate on PC settings, where most depressed adults receive care. However, current policies fall short of incentivizing comprehensive adoption of evidence-based integrated mental health care models. Although the Affordable Care Act (ACA) advances health reforms, including instructing the Centers for Medicare and Medicaid Services (CMS) to test new models such as Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs), additional policy reforms are needed to improve depression care. More recently, CMS announced its intention to increase the proportion of Medicare payments tied to quality or value through alternative payment models. However, we argue that additional policy changes needed to support further implementation of evidence-based treatment for depression. Presently, insufficient reimbursement and a lack of other financial incentives remain as obstacles in making this transition. Treatment targets and treatment length based on number of treatment episodes were first described in Agency of Health Services and Research Depression Guidelines in the 1990s, however, few depressed patients receive regular measurement-based assessments, and therapy length rarely matches patients’ clinical histories. Clinicians regularly assess blood pressure among hypertensive patients and HbA1c levels in diabetes patients, yet formal depression assessment is infrequent. Although multiple primary care systems have adopted the nine-item Patient Health Questionnaire (PHQ-9) for initial assessment, and some use it to gauge treatment success with two clinical targets (e.g., response as percent with ≥50% decrease in symptoms from baseline and remission as percent reaching PHQ-9 of b 5), the PHQ-9 is neither uniformly nor consistently applied in most healthcare systems. More people are taking antidepressants for longer time periods but fewer are receiving psychotherapy, and undertreating major depression and overtreating adjustment disorders and minor depression in primary care remain commonplace. The traditional behavior carve-out system where PCPs refer to mental health professionals working outside of primary care leaves most patients untreated. Almost half of the

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patients referred from primary care to specialty mental health do not follow through with referral or attend a minimal number of visits [1]. The lack of systematic assessment of patients for depression and regular measurement-based follow-up with a depression scale makes it impossible to assess whether depressed patients are getting better in realworld, population-based settings. This is in contradistinction to diabetes, where healthcare systems monitor and report HbA1c levels in diabetes patient populations. Collaborative care for depression is an evidence-based solution to gaps in quality of mental health care that achieves the triple aim of improving quality of care and outcomes, without increasing costs of care for individuals with depression, based on 79 randomized clinical trials [2]. Rarely is there such extensive evidence that so clearly demonstrates the effectiveness of a treatment model. It is important to note that collaborative care is a specific model for integrating behavioral health and primary care, with defining characteristics that distinguish it from other integration models (i.e., it is a term of art and not simply an umbrella term for referring to any program in which mental health providers work in some collaborative way with primary care). Benefits of this model have been shown across the lifespan, with promising results for pediatric and adolescent populations, as well as adult and geriatric populations. Research has also demonstrated the effectiveness of this model in the context of comorbid medical and psychiatric conditions, such as diabetes, heart disease, and anxiety respectively. Although many integration models exist in addition to collaborative care, some of these other models have been evaluated and generally found to be ineffective, and others have not yet been rigorously evaluated; therefore, their effectiveness is uncertain. All models need to be evaluated and held to common standards of evidence. The 2012 Institute of Medicine report on geriatric mental health workforce made several relevant recommendations: evaluate alternative methods for funding PC personnel providing evidence-based care models to older adults with mental disorders, including reimbursing care managers and psychiatrist supervision, and evaluate alternative payment methods to encourage effective workforce deployment for integrated mental healthcare [3]. It is time to address persistent yet modifiable barriers to widespread implementation of depression collaborative care. Despite substantial evidence documenting effectiveness of collaborative care, widespread dissemination and implementation has been limited and held back by current payment models. Collaborative care includes systematic screening with a validated instrument, evidencebased care management and stepped care that addresses treatment nonresponse, ongoing review of patient needs and treatment progress, a designated psychiatrist conducting weekly systematic supervision of all care management cases and recommending treatment changes that the care manager communicates to the PCP who evaluates recommendations and writes prescriptions, and continuous performance measurement and improvement [4]. Collaborative care addresses both acute care needs and focuses on continuation and maintenance treatment, which is crucial for effectively managing this frequently chronic and relapsing condition.

Letters to the Editor

Collaborative care dissemination is growing, including the Depression Improvement Across Minnesota (DIAMOND) program in over 80 primary care clinics throughout Minnesota and the Washington state Mental Health Integration Program, in which major insurance companies agreed to implement and pay for collaborative care in over 100 community health clinics and 30 community mental health centers [5]. However, health policy changes will be necessary to widely implement this evidence-based model. Several recent policies could improve depression quality of care. These include mental health policies, such as the Medicare Improvements for Patients and Providers Act of 2008 [which eliminated by 2014 unequal copayments previously required for psychotherapy (50%) and other medical services in Medicare (20%)], the Mental Health Parity and Addiction Equity Act of 2008 (which prevents group health plans and health insurance issuers that provide mental health or substance use disorder benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits), and broader health policies included in the ACA: Medicaid expansion, employer mandate, health insurance exchanges with low income subsidies, PCMHs, Medicaid health homes, ACOs, and inclusion of mental health in essential benefits packages. Some policies have a greater likelihood than others to improve depression care. For example, mental health parity and insurance expansion alone are unlikely to solve the problem, as challenges with access to mental health services, which is already difficult, are likely to worsen (i.e., demand will increase but provider supply will not). However, some policy changes, such as credentialing requirements based on 2014 National Committee for Quality Assurance criteria for PCMH designation, incentivize integrated models with population-based requirements, CM requirements, and ways to better integrate mental health as key components to achieve level 3 credentialing, which will lead to better payments from many insurers. Demonstration models such as the Comprehensive Primary Care initiative provide financial incentives as well as educational opportunities and technical assistance to encourage integrated care practices. ACOs incentivize decreasing emergency room visits and hospitalizations, and people with comorbid mental and physical illness are disproportionately represented in these populations. Increasing evidence demonstrates that depression predicts 30-day rehospitalizations and ambulatory care-sensitive hospitalizations. CMS tracks and penalizes hospitals in the bottom 25% of 30-day rehospitalizations. CMS also recently finalized a separate payment, outside of a face-to-face visit, for managing care of Medicare patients with two or more chronic conditions (which could include depression) beginning in 2015. One might question how new policies could improve depression outcomes, particularly due to limited focus of broader policies on mental health conditions (e.g., only 1 of 33 ACO quality measures focuses on mental health with depression screening). However, strengths of recent policies may lie in encouraging more thoughtful applications of integrating evidence-based models to enhance depression treatment. These policies potentially incentivize a more nuanced, systematic, and integrated approach to depression management. Financial incentives provided by policies generate motivation for clinicians and healthcare systems to engage in the practice redesign work to identify which patients have depression, what treatments are needed, how treatments fit into overall treatment plans (rather than addressing mental and physical disorders separately), and provide increased intensity of care and systematic follow-up for patients with persistent symptoms. We recommend that to enhance integration of this evidence-based model, payers need to develop billing codes for care management contacts, including phone contacts and in-person contacts, codes for weekly psychiatrist systematic caseload review, and incentives for process measures tightly linked to depressive outcomes (e.g., changing ineffective treatments by 8 weeks) and improved outcomes (e.g., percent of patients reaching at least a 50% symptom reduction by 8 weeks and 6 months) [5]. Quality indicators or fidelity measures are needed to provide either a financial disincentive for systems that have attempted to


implement care managed with little fidelity to evidence-based models or to provide an incentive for systems implementing higher fidelity models. Incentives should also be provided for groups to participate in collaborative endeavors to improve the dissemination process and create more sustainable improvements. Both performance criteria and outcomes monitoring are important. Don Berwick said that the American system gets what it pays for by incentivizing high-cost procedures and tests rather than care quality and time with practitioners. It is time to change financial incentives to improve quality of care and outcomes for depression using evidencebased ways to deliver treatments. Kara Zivin, PhD Department of Veterans Affairs, Center for Clinical Management Research Ann Arbor, MI, USA Department of Psychiatry, University of Michigan Medical School Ann Arbor, MI, USA Corresponding author. University of Michigan North Campus Research Complex, 2800 Plymouth Road, Building 16, 228W, Ann Arbor, MI 48109-2800, USA. Tel.: +1-734-222-7417 E-mail address: [email protected] Wayne Katon, MD Department of Psychiatry, University of Washington Medical School Seattle, WA, USA Deceased, 3/1/2015

References [1] Grembowski DE, Martin D, Patrick DL, Diehr P, Katon W, Williams B, et al. Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms. J Gen Intern Med 2002;17:258–69. [2] Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:1–277 [CD006525]. [3] Institute of Medicine. The Mental Health and Substance Use Workforce for Older Adults: In Whose Hands? Washington, DC: The National Academies Press; 2012. [4] Sederer LI. What does it take for primary care practices to truly deliver behavioral health care? JAMA Psychiatry 2014;71:485–6. [5] Unützer J, Chan Y-F, Hafer E, Knaster J, Shields A, Powers D, et al. Quality improvement with pay-for-performance incentives in integrated behavioral health care. Am J Public Health 2012;102:e41–5.

Toward a theoretical model of misophonia To the Editor, Misophonia, literally translated into “hatred of sound” [1], is characterized by intense emotional responses to hearing specific sounds (i.e., triggers or auditory cues) as well as observing certain movements. Commonly reported triggers include chewing, breathing and sounds emitted from movements (e.g., foot or pen tapping) [2,3]. Those with misophonic symptoms often experience significant impairment across occupational/academic, familial/home-based and social functioning in response to the disgust, anger and distress caused by auditory cues [3]. The primary behavioral response to triggers is avoidance, although other behaviors have been reported [2,4]. Over the past several years, case studies have brought attention to the incidence of misophonic symptoms across certain clinical populations [5–8], but there have been few treatment studies or empirical reports that contribute to the development of a theoretical model for understanding misophonia and related phenomena, or its treatment. For future efforts to develop effective treatments for misophonic

Further policy changes are needed to improve depression care.

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