NYBGH One Voice Initiative

A Regional Strategy to Integrate Depression Screening and Management into Primary Care

1

Overview

• • • • •

NYBGH & health care quality The burden of depression Challenges and barriers to improving depression screening & management in primary care An evidence based model for depression care The One Voice pilot

2

NYBGH is an employer-driven, non-profit coalition dedicated to improving the quality and efficiency of healthcare • • • • NYBGH represents 175 employers, unions, health plans, providers, and other healthcare organizations operating in NY, NJ, and CT Focus is on education and quality improvement Unique combination of stakeholders allows NYBGH to launch major quality initiatives requiring collaboration between health plans and local partners One of 56 business coalitions around the country

NYBGH Initiatives

• • • • • eValue8: Nationwide health plan performance initiative. Physician Performance Reports: Measures PCP performance in the areas of diabetes, heart disease, prevention, COPD, depression by aggregating health plan data Patient Experience with PCPs: Working with Aetna, Cigna and United to measure patient experience with primary care physicians

One Voice

Hospital Value Initiative: Working with plans, employers and hospitals to create payment models that reward best outcomes and increase value for the purchaser 4

Mental Health Task Force comprised of key players in behavioral health care management in NY metro area

Local Government

NYC Dept. of Health and Mental Hygiene

Health Plans

EmblemHealth Aetna Empire Cigna United Healthcare

PBM

Medco

Professional Societies

New York County Medical Society New York State Society for Clinical Social Work

Consumer Advocacy

National Alliance on Mental Illness

Mental Health Task Force

Chair: Mike Thompson, Principal, PricewaterhouseCoopers

Purchasers/Consultants

Pitney Bowes Mercer CBS Corporation Citi PricewaterhouseCoopers LLC Hewitt NYC Labor Health Alliance

Behavioral Health Plans

ValueOptions Lifesynch MHN MyExpertSolution TeenScreen Harris Rothenberg

Pharmaceutical Companies

AstraZeneca Lilly Pfizer

Untreated depression creates heavy burden of disease for patients, and generates substantial costs for employers

380,000 working-age New Yorkers suffer from depression, but their illness is underdiagnosed and undertreated

Prevalence (last 12 months): 7.5% among adults 20+ (9.4% among 20-39 yr olds)

3

Awareness (ever-diagnosed): 54.6% among adults 20+ (45% among 20-39 yr olds)

3

Treatment: 36.7% among adults 20+

3

• •

Depression impedes functioning in nearly all aspects of a patient’s life 1

– – – Co-occurs with other chronic mental and physical disorders 70% of the time 2 Physical comorbidities (heart disease, chronic pain, cancer, diabetes) become harder to manage Co-occurring mental disorders are often misdiagnosed or incorrectly treated

Depression costs employers ~$36.6 billion in excess productivity loss each year 2

– Absenteeism: 1/3 of costs, ~8.7 days/year 2 – Presenteeism (sub-obtimal performance at work): 2/3 of costs, ~18.2 days/year 2 – Health care costs may be up to 50% greater for depressed employees 1 1 Katon, Wayne. The Impact of Depression on Workplace Functioning and Disability Costs. American Journal of Managed Care, 2009. 15: S322-S327.

2 Position Statement: Depression in the Working Population. American College of Occupational and Environmental Medicine, Jan. 2009.

3 NYC Health and Nutrition Examination Survey (HANES), 2004.

NYC health care landscape poses unique challenges for improving depression care

– More than 7 major commercial health plans and nearly 10,000 primary care practice locations 1 – – Limited psychiatric participation in health plans Prevalence of solo practices (34%) challenging 1 makes team approach 1 NYC Primary Care Physicians by Setting. Center for Health Workforce Studies.

Barriers in current system severely limit screening and management of depression in primary care

Barriers to integrating mental health with primary care are common

– Coverage challenges: Providers are not compensated for spending additional time with patients, consulting with colleagues, or screening for and treating mental health problems 1 – Provider resistance: Many PCPs feel they lack adequate decision support in managing mental illness, and have insufficient training in psychiatry 1 – Limited access to specialists: Providers report major challenges accessing mental health care services for their patients 2 – Patient resistance: Some patients may prefer to keep their mental health treatment separate from primary care, for privacy or care preference reasons 2 – Cultural barriers: Historical isolation of mental health providers from other health care practitioners creates disconnects in communication, relationships and knowledge 2 1 Cunningham, Peter. Beyond Parity: Primary Care Physicians’ Perspectives on Access to Mental Health Care. Project HOPE DataWatch, Apr. 2009.

2 Bazelon Center for Mental Health Law. Integration of Primary Care and Behavioral Health, 2005.

Integrating depression management into primary care leads to well-proven impact on treatment outcomes • •

RESPECT – MacArthur Initiative

Cluster randomized controlled trial 60% response to treatment and 37% remission at 6 months, compared to 47% and 27% in usual care practices 3 • •

IMPACT Study

Randomized clinical trial of collaborative care intervention for elderly patients Showed significant improvements in symptoms and functionality at 6 months, 12 months, and 2 years 1 • •

DIAMOND Initiative

Adapted IMPACT program for general population setting and studied outcomes 64% response to treatment and 44% remission at 6 months; 72% response and 52% remission at 12 months 2

Components of Collaborative Care Model

Patient Registry Care Manager Primary Care Provider Stepped Care Approach Relapse Prevention 1 The IMPACT Program: A team approach to depression care that gets dramatic results. John A. Hartford Foundation.

2 Jaeckels, N. and Trangle, M. DIAMOND: Origin, Context & Future. ICSI presentation, Oct. 2009.

3 Dietrich, A. et al., Re-engineering systems for the treatment of depression in primary care: Cluster randomised controlled trial. British Medical Journal, 2004. doi: 10.1136/bmj.38219.481250.55.

Screening/ Monitoring Consulting Psychiatrist

Cost-effectiveness studies show that collaborative care programs save money over the medium- to long-term • •

Health care costs will go up in the first year of the program

– IMPACT program cost $522/patient in the first year 1

Collaborative care programs begin to pay for themselves in the second year 2

Program Costs Outpatient Costs Patient Time & Transportation

Total Year 1

158 225 107

490 Year 2

130 -188 38

-20

• Extracted from Rost et al., Table 2: Enhanced Care Impact on Incremental Cost by Year

Enhanced treatment programs decrease total health care costs over the long-term

– Study of IMPACT costs showed that participants had lower mean healthcare costs over 4-year period than control group: $29,422 v. $32,785, representing a cost savings of nearly $3,500 per patient 1 1 Unutzer et al., Long-Term Cost Effects of Collaborative Care for Late-Life Depression. American Journal of Managed Care, Feb. 2008. Vol. 14, No. 2.

2 Rost et al., Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis. Annals of Family Medicine, Jan./Feb. 2005. Vo. 3., No. 1.

By adapting the collaborative care model to address those barriers we can improve depression screening & care in NYC • • • • Key features of clinical intervention – Three component model: Partnership between primary care provider (PCP), licensed clinical social worker (LCSW), and consulting psychiatrist – Integration of LCSW and consulting psychiatrist into PCP-based care team – Care management carried out by LCSW: Coordinating services and tracking progress Team members will be trained in care model, differential diagnosis, and medication management An evaluation will be conducted to assess clinical and financial impacts of the pilot

Goal: Demonstrate model to take to scale across NY metro area

Primary Care Provider LCSW

SCREEN

all patients for depression using the PHQ-2

ASSESS

all patients screening positive with the PHQ-9

DIAGNOSE

depression or other related condition if present

TREAT

patients as indicated

ADVISE PCP

on differential diagnosis and treatment plan

EDUCATE

patients

SUPPORT

self-management

ASSESS

progress with the PHQ-9

COORDINATE

referrals and care services Psychiatrist

CONSULT

by phone on difficult cases re: differential diagnosis and treatment plan

REVIEW

cases with team periodically

RECOMMEND

assessment by psychiatrist as indicated

Initiative will work with small set of providers to showcase and refine integrated care model for regional uptake • • • • • • Pilot will aim to enroll ~1,000 patients – adult working population Anticipate working with 2-3 large/group practices and 5-6 small providers Practices and providers will be selected based on interest and willingness to adapt their clinic systems, participate in training, and share data

NYBGH has secured commitments from key partners

– – – 6 major NYC health plans have expressed interest and support Providers have demonstrated willingness to participate NYS Society of Clinical Social Workers supports the project Participatory planning process should minimize unexpected logistical or financial challenges during implementation

Goal of One Voice Initiative is to drive dissemination throughout region

–

Demonstrate results in NYC context

–

Refine model to optimize clinical and logistical methodologies

–

Produce materials for training, education, and clinical practices that can be reused

Timeline targets launch at 4-6 months from start, dissemination of results within 18 months T 0 : Funding identified 4-6 months

Planning Planning Phase

• Complete clinical protocols • • • Develop reimbursement guidelines Recruit practices, LCWS, psychiatrists Design training • Develop data tracking tools

Dissemination

1-2 months

X Launch x Launch Phase

• • • • Baseline data collection Set up data systems Training for PCP, LCSW Technical assistance for practices on model application 18-24 months

X Implementation x X Implementation Phase

• Ongoing training • • Ongoing technical assistance for practices Periodic meetings of participating practices, LCSWs • Project management and committee meetings

Evaluation & Dissemination

• • • Data collection and monitoring (ongoing) Data analysis and evaluation – measurement at key intervals, denoted by

X

Dissemination of results – toolkit production, publication, presentations, etc.

Evaluation will assess screening process, treatment process, impact on clinical outcomes, and measure costs

Screening Process

Does program improve frequency and accuracy of mental health screening?

Treatment Process

Does the program improve the quality of care provided, as measured by treatment initiation, adherence, and follow-up?

Clinical Outcomes

Does the program improve patients’ symptoms, achieve remission, and/or return normal functionality?

Financial Measures Evaluation Questions

Screening uptake Accurate Diagnosis Initiation of treatment Follow-up contact Medication adherence (acute phase) Medication adherence (continuation phase) Response to treatment Remission Improvement in functioning Improvement in vocational functioning Cost of healthcare services

Measures

Number of patients diagnosed with depression Number of patients referred to specialist for complex mental health conditions Percent of patients on antidepressant or in therapy within 1 month of diagnosis Percent of patients with follow-up contact within 3 months of starting treatment HEDIS antidepressant medication management indicator (84 days) HEDIS antidepressant medication management indicator (180 days) 50% decrease in PHQ-9 score PHQ-9 score less than 5 Decreased score on Item 10 of PHQ-9 Decreased score on vocational functionality assessment 12-month average total paid claims data

One Voice Initiative designed to not only demonstrate efficacy but take outcomes to scale: >15,000 patients by Year 5

Spread Strategies

• Develop technical support materials that can be reused locally and nationally • Training modules e.g. online medication management training for PCPs (with CME credit) • Training materials e.g. case management guidance for LCSWs • Technical assistance pool for practices • • Document the business case for plans and practices • Encourage plans to reimburse for LCSW, psychiatrist, training • Encourage plans to incentive providers to participate • Expand to other behavioral health issues, e.g. anxiety, weight management, addictions +64 practices

Partner with key dissemination agencies

• Medical societies, e.g. AAFP • Government agencies, e.g. DOHMH +32 practices • Share results at conferences +128 practices 4,000 patients 8,000 patients +16 practices 2,000 patients 8 practices 16,000 patients

Scale-Up in Years 1-5

1,000 patients

Thank You

For further information:

Laurel Pickering Executive Director NY Business Group on Health 61 Broadway, Suite 2705 New York, NY 10006 212-252-7440 x224 [email protected]

Joslyn Levy President Joslyn Levy & Associates 501 Fifth Avenue, Suite 1702 New York, NY 10017 212-867-8491 [email protected]