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Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
1
Meadows Mental Health Policy Institute
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative
Care – March 2016
DepressioncostsU.S.employersapproximately$187.8billionayear.1,2Thistotalincludes
annualcostsof$134billioninhealthcare(healthandmentalhealthcombined),$20.9billionin
absenteeism,and$32.9billioninlostproductivity.Despitethegrowingbodyofresearch
demonstratingtheeffectivenessofdepressiontreatment,manyemployeesandtheir
dependentsdonotgetthetreatmenttheyneed,unnecessarilyraisingemployers’healthcare
andproductivitycosts.Implementing“CollaborativeCare3”interventionscanaddressthis
problembycorrectinghealthcaredeliverysystemflawsthatpreventindividualsfromaccessing
andsuccessfullycompletingevidence-baseddepressiontreatment.Buttraditionalemployee
benefitsdonotcoverCollaborativeCareinterventionseventhoughtheycanbecost-effective.
Toensureemployeesandtheirdependentsreceiveeffectivedepressiontreatment,and
employersexperiencetheassociatedcostsavings,innovationinbenefitdesignanddelivery
systemstoincludeCollaborativeCareinterventionsisanecessarynextstep.
DepressionIsReal
IntheUnitedStates,oneinfiveadults(20%)willexperienceaclinicallysignificantformof
depressionintheirlifetime.4About7.5%oftheUSworkforcehasdepressioninanyyear.5
Depressionisaseriousillnessthatcanimpactanyone,includingthemostproductiveemployee
andtheyoung,rising-starexecutive.AstheNationalInstituteofMentalHealthnotes,
“Depressiveillnessesaredisordersofthebrain.Longstandingtheoriesaboutdepression
suggestthatimportantneurotransmitters—chemicalsthatbraincellsusetocommunicate—are
1
Mrazek,D.A.,Hornberger,J.C.,Altar,C.A.&Degtiar,I.(2014).Areviewoftheclinical,economicandsocietal
burdenoftreatment-resistantdepression1996-2013.PsychiatricServices,65(8).
2
Mrazeketal’scostanalysisincludedfouremployer/privatepayerclaimsdatabasesandoneMedicareclaims
database.Estimateswerebasedona12-monthprevalenceofdepressionin16,000,000adults;thepercentageof
peoplewithtreatmentresistantdepressionwas12%(conservatively);averagedirecthealthcarecostsforpeople
withtreatmentresistantdepressionwere$13,196annually;averagedirecthealthcarecostsforpeoplewith
treatmentresponsivedepressionwas$7,715;averageproductivity-relatedcostswere$6,924and$2,876,
respectively.
3
CollaborativeCareisatypeofintegratedcareinwhichtrainedprimarycareprovidersandembeddedbehavioral
healthprofessionalsprovideevidence-basedtreatments,supportedbyregularpsychiatriccaseconsultationand
treatmentadjustmentforpatientswhoarenotimprovingasexpected.AIMSCenter,AdvancedMentalHealth
Solutions.https://aims.uw.edu/collaborative-care.AccessedMarch11,2016.
4
Kessler,R.C.,etal.(2005).Lifetimeprevalenceandage-of-onsetdistributionsofDSM-IVdisordersintheNational
ComorbiditySurveyReplication.ArchivesofGeneralPsychiatry,62,593-603.Formajordepressionalone,the
chanceofhavingthediagnosisatsomepointinone’slifeisoneinsix.
5
Kessler,RC,Merikangas,R.&Wang,P.(April2008).ThePrevalenceandCorrelatesofWorkplaceDepressionin
theNationalComorbiditySurveyReplication.JournalofOccupationalandEnvironmentalMedicine,50(4):381–
390.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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outofbalanceindepression.”6Recentstudieshaveshownthatthesamebiologicaland
chemicalfactorsthattriggerdepressioncanalsoinfluenceheartdisease.
Theimpactofanemployee’sdepressionextendsbeyondtheindividualtoaffectfamily,friends,
coworkers,andeventually,thebottomline.Anindividualwithdepressionmaybewithdrawn
andirritable,causingrelationshipswithfamilymembersandfriendstobecomestrained.Ifthe
employeeisoneofthe15%ofindividualswithseveredepressionwhocommitssuicide,family
members’riskforextremeguilt,depression,physicalhealthproblemsanddivorceare
increased.Anemployeewithdepressionmayfrequentlycallinsick,missdeadlines,andappear
unabletoconcentrate,frustratingco-workersandsupervisorswhoresentpickinguptheslack.
Belowareexamplesofwhatdepressionanditseffectscanlooklikeintheworkplace:
• Billhasbeenworkingontheassemblylineatamanufacturingplantsincehewas23
yearsold.Aftertwentyyearsonthejob,hewasthinkingabouttakinganearly
retirementdealsohecouldtravel.Suddenly,withoutwarning,Billhadaheartattack.
Recoverywashard,makingBillfeelweakandvulnerable.Hehadlessandless
motivationtoexercise,followhisdiet,orkeeptrackofallhisdoctor’sappointmentsand
medications.WheneverBillwouldthinkaboutgoingbacktowork,hisheartwouldrace.
Convincedhewashavinganotherheartattack,Billendedupintheemergencyroom
overandoveragain.
• Sierraisa34-year-oldwomanwhoworkedherwayupfromasecretarialpositionto
becomeanExecutiveVicePresidentatatelecommunicationscompany.Sheisaborn
leaderandherdepartmentranunderbudgetforthefirstsixmonthsshewasincharge.
However,duringherrisetothetop,herhusbandbecameincreasinglydepressed.He
drankheavily,talkedaboutnothavinganythingtolivefor,andrefusedtogethelp.
Sierraworriedabouthimconstantly,especiallywhenhewashomealonewiththekids.
Sierrahadtroublesleepingatnightandcouldn’tconcentrateatwork.Shewasirritable,
causingpreviouslyloyalstafftolookforotherjobs.Attheendoftheyear,Sierranoticed
a$1,000,000errorinherannualbudget,forwhichshewouldlikelyloseherjob.
• Sagebecamepregnantaftertwoyearsoftrying.Hercoworkerscelebratedwithherat
herbabyshower,extractingpromisesfromherforlotsofbabypictureswhenshe
returnedtowork.Ashorttimelater,Sagegavebirthtoahealthybabygirl.Forthefirst
sixweeksafterthebirthofherdaughter,Sagewasinheaven.Shewastired,buthappy.
Aroundweekseven,Sagestartedtofeelstrange.Shefelt“nothing”whenshelookedat
herdaughteranddidn’twanttopickherupwhenshecried.Shewashavingintrusive
thoughtsthatmadeherworryshewouldhurtherdaughter.Shefeltlikeshewasgoing
crazy.SageandherhusbandfoughtallthetimebecauseSagewasunresponsivetoher
daughter’sneed.Shewastooashamedtotellanyoneatworkwhatwashappening.So
shebecameincreasinglyisolated,frequentlycallinginsicktowork.
6
WhatisDepression?NationalInstitutesofHealth.AccessedOctober27,2015.Retrievedfrom
http://www.nimh.nih.gov/health/publications/depression/index.shtml.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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•
At38,PhilipBurguiereswastheyoungestCEOevertorunaFortune500company.But
hefeltempty.Hestartedtothinkthattheworldwouldbeabetterplacewithouthim.
Fearfulofthestigmaassociatedwithdepression,heprovidedhisBoardofDirectors
withadoctor’sletterindicatinghehadbrainchemistryproblemsthatrequiredasixmonthleaveofabsence.Thecompany’sstockfelltenpercentfollowingthe
announcementofhisdeparturefor“healthreasons.”
UntreatedDepressionIncreasesanEmployers’Costs
MedicalOutcomesandCosts:Untreateddepressioncanincreasethechancesthatsomeonewill
experienceamedicalcondition.Inaddition,individualswithdepressionandamedical
conditionexperiencegreaterdistress,increasedfunctionalimpairment,andarelessableto
followmedicalregimens.Asaresult,depressioncanincreasemedicalcostsandnegatively
affecttreatmentoutcomes.Forexample:
• Menandwomendiagnosedwithclinicaldepressionaremorethantwiceaslikelyto
developcoronaryarterydiseaseorsufferaheartattack.7Inaddition,thosewhohave
experiencedaheartattackarethreetimesaslikelytohaveacardiac-relateddeathif
theyalsohaveaco-occurringdepressivedisorder.8,9
• Depressionoccursin10to27%ofstrokesurvivors,andthosewithco-occurring
depressionwillhavea50%higherriskofmortality10inthenext29years.11
7
AmericanPsychologicalAssociation(n.d.).Mind/BodyHealth:HeartDisease.RetrievedNovember11,2015,from
http://www.apa.org/helpcenter/heart-disease.aspx.
8
Sherrer,J.F.,Garfield,L.D.,Chrisciel,T.,etal.(2011).Increasedriskofmyocardialinfarctionindepressedpatients
withtype2diabetes.DiabetesCare,34(8):1729-34.
9
Majordepressionanddepressivesymptomsarepositivelycorrelatedwithcardiacproblems,moregenerally,and
increasingseverityofdepressionisassociatedwithearliermanifestationandgreaterseverityofcardiacevents.
Afteramyocardialinfarctionevent(heartattack),individualswithdepressionhavetwicetheriskofanother
cardiaceventwithintwoyearsofthefirstevent.Thisassociationcanbeexplainedbothbiologicallyand
behaviorally.Individualswithdepressionhavemorebiomarkersthatarecorrelatedwithheartproblems.
AccordingtoascienceadvisorygroupsponsoredbytheAmericanHeartAssociation,theseincludereducedheart
ratevariability,evidenceofhypothalamic-pituitary-adrenaldysfunction,plasmaplateletproblems,impaired
vascularfunction,andavarietyofothercirculatorysystemproblems.Behaviorallinksbetweendepressionand
heartdiseaseincludedietandexercise,tobaccouse,stress,isolation,andmedicationadherence.Seeamore
detaileddescriptionofthesefindingsin:Lichtman,J.H.,etal.(2008).Depressionandcoronaryheartdisease:
Recommendationsforscreening,referral,andtreatment:AscienceadvisoryfromtheAmericanHeartAssociation
preventioncommitteeofthecounciloncardiovascularnursing,councilonclinicalcardiology,councilon
epidemiologyandprevention,andinterdisciplinarycouncilonqualityofcareandoutcomesresearch:Endorsedby
theAmericanPsychiatricAssociation.Circulation,118(17),1768-1775.
10
Healthcarecostsinthelastyearoflifearemuchgreaterthaninotheryearsofaperson’slife.Seeforexample,
Tanuseputro,P.,Wodchis,W.P.,Fowler,R.,etal.(2015).Thehealthcarecostofdying:Apopulation-based
retrospectivecohortstudyofthelastyearoflifeinOntario,Canada.PLoSOne,10(3):e0121759.
doi:10.1371/journal.pone.0121759.
11
MentalHealthAmerica.(n.d.).Co-OccurringDisordersandDepression.RetrievedNovember23,2015,from
http://www.mentalhealthamerica.net/conditions/co-occurring-disorders-and-depression.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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Depressionoccursin25%ofpeoplewithdiabetes.12Patientswithsymptomsof
depressionarelesslikelytoadheretodietaryrestrictionsormedicalregimens,and
morelikelytousetheemergencyroomorinpatientsettings.13
• Depressionoccursin13to42%ofpatientswithrheumatoidarthritisandisassociated
withworsehealthoutcomes,includinganincreasedriskofmortality.14
• Depressionincancerpatientsisoftenattributedtochemotherapysideeffects,whenin
actualitydepressionismorelikelytocontributetoweightloss,fatigueanddepressed
mood.Studiesalsoshowthatdepressioniscorrelatedwithhighermortalityratesin
cancerpatients.15
• Nearlyone-thirdofpatientswithmajordepressivedisorderalsoabusealcoholor
drugs.16Individualswhoabusealcoholordrugshaveincreasedmedicalcostsanduse
expensiveformsofacutecaremoreoften.17
BusinessCost.Besidesincreasinghealthcareexpenses,researchshowsthatuntreated
depressionisasignificantcontributortoworkplacedisabilitycosts,reducedworkperformance
andpresenteeism,absenteeism,safetyissues,employeeturnoverandlegalcosts.Forexample:
• While17to20%ofallworkersexperiencesshort-termdisabilityoverayear’stime,
workerswithdepressionhavemorethandoublethatrate(upto48%)inanygiven12monthperiod.18
• Depressionwasnegativelycorrelatedwithoverallworkperformanceandproductivity,
proficiencyincompletingjobtasks,andvoluntarilytakingonleadershiprolestohelp
one’scoworkersorthecompanyinspecificways.19
•
12
Williams,M.M.,Clouse,R.E.,&Lustman,P.(2006).Treatingdepressiontopreventdiabetesandits
complications:Understandingdepressionasamedicalriskfactor.ClinicalDiabetes,24(2),79-86.
13
Ciechanowski,P.S.,Katon,W.J.,&Russo,J.E.(2000).Impactofdepressivesymptomsonadherence,function,
andcosts.JAMAInternalMedicine,160(21).Retrievedfrom
http://archinte.jamanetwork.com/article.aspx?articleid=485556
14
Margaretten,M.,Julian,L.,Katz,P.,&Yelin,E.(2011).Depressioninpatientswithrheumatoidarthritis:
Description,causes,andmechanisms.InternationalJournalofClinicalRheumatology,6(6),617-623.
15
Pinquart,M.&Duberstein,P.R.(2010).Depressionandcancermortality:Ameta-analysis.Psychological
Medicine,40(11).
16
MentalHealthAmerica.(n.d.).Co-OccurringDisordersandDepression.RetrievedNovember23,2015,from
http://www.mentalhealthamerica.net/conditions/co-occurring-disorders-and-depression.
17
RobinE.Clark,R.E.,O’Connell,E.,&Samnaliev,M.(March2010).SubstanceAbuseandHealthcareCosts
KnowledgeAsset.SubstanceAbusePolicyResearchProgram.Retrievedfrom
http://saprp.org/knowledgeassets/knowledge_detail.cfm?KAID=21.
18
Goldberg,R.J.,&Steury,S.(2001).Depressionintheworkplace:Costsandbarrierstotreatment.Psychiatric
Services,52(12),1639-1643.Seealso:DepressionCenter,UniversityofMichiganHealthCenter.(n.d.).Depression
andLostProductivity.RetrievedNovember23,2015,fromhttp://www.depressioncenter.org/work/informationfor-employers/lost-productivity/.
19
Ford,M.T.,Cerasoli,C.P.,Higgins,J.A.,&Decesare,A.L.(2011).Relationshipsbetweenpsychological,physical,
andbehavioralhealthandworkperformance:Areviewandmeta-analysis.Work&Stress,25(3),185-204.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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•
•
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Inathree-monthperiod,individualswithdepressionmissedanaverageof4.8workdays
andhad11.5daysofreducedproductivity.20
Whencomparedtohealthyemployeesoremployeeswithrheumatoidarthritis,
employeeswithdepressionhadmoreabsenteeismandturnover.21
Dependingonthenatureandseverityofthedepression,aswellasthelevelofsupport
intheworkplaceforrecoveryfromdepression,jobturnoverratesrangedfrom25to
50%amongworkersexperiencingdepression.Thecosttotheemployer(inrecruitment,
trainingandotherorganizationalefforts)wasestimatedtobethree-quarterstooneand-a-halftimestheemployee’sannualsalary.22
Employeeswithdepressionaremoreaccident-pronebecauseofdepression's
interferencewithconcentrationandfocus.23
Therehasbeena56%riseindepression-basedworkplacediscriminationclaimsfiled
withtheEqualEmploymentOpportunityCommission(EEOC)between2003and2013.24
EffectiveDepressionTreatmentYieldsanAttractiveReturnonInvestment
ImprovedMedicalOutcomesandReducedMedicalCosts.Studiesshowthateffective
depressiontreatmentcanimprovemedicaloutcomesandreducemedicalcosts.Forexample:
• Patientswhoreceivedearlyantidepressanttreatmentafterexperiencinganischemic
strokehadsignificantlylowermortalityratescomparedtothosewhodidnotreceive
antidepressanttreatment.25
• HemoglobinA1clevelsinpeoplewithdiabeteswereloweredwhenco-occurring
depressionwastreated.26
• Antidepressanttreatmentofpatientswithasthmaresultedinareducedneedfor
corticosteroids.27
• Simplepsychosocialinterventionsdeliveredbyspeciallytrainedhealthworkersreduced
therateofpostpartumdepressioninwomen.28Totalcostsover12monthsforat-risk
20
Valenstein,M.,Vijan,S.,Zeber,J.E.,Boehm,K.,&Buttar.(2001).A.Thecost-utilityofscreeningfordepressionin
primarycare.AnnalsofInternalMedicine,134,345-360.
21
Lerner,D.,Adler,A.,Chang,etal.(2004).Unemployment,jobretention,andproductivitylossamongemployees
withdepression.PsychiatricServices,55(12),1371-1378.
22
Cocker,F.,Nicholson,J.M.,Graves,N.etal.(2014,September).Depressioninworkingadults:Comparingthe
costsandhealthoutcomesofworkingwhenill.PLoSONE,9(9):e105430.Doi:10,137/journal.phone0105430.
23
Jacob,I.(2006,October).Depression’simpactonsafety.OccupationalHealthandSafety.
24
Dunning,M.(2014,December).Depressionintheworkplaceremainsproblematic,costsemployersbillions.
BusinessInsurance.http://www.businessinsurance.com/article/20141207/NEWS03/312079961.
25
Mortesnsen,J.K.,Johnsen,S.P.,Larsson,H.&Andersen,G.(2015).Earlyantidepressanttreatmentandall-cause
30-daymortalityinpatientswithischemicstroke.CerebrovascularDiseases,40(1-2).
26
Penclofer,S.,etal.(2014,March).Stateofthescience:DepressionandType2Diabetes.WesternJournalof
NursingResearch,1-25.
27
VanLieshout,R.J.,&MacQueen,G.M.(2012).Relationsbetweenasthmaandpsychologicaldistress:Anoldidea
revisited.ChemImmunolAllergy,98,1-13.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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womenreceivingtheinterventionwere10%lowerforthedepressioninterventionthan
withroutinecare,eventhoughthedepressioninterventionaddedtasksforhealth
workers.
ReducedBusinessCosts.Studiesalsoshowthatwhenpeoplewithdepressionreceiveeffective
treatment,theyhaveanaverageof17fewerannualdisabilityleavedayscomparedtothose
withdepressionwhodonotreceivetreatment.29Onestudyfrom2007showedthatindividuals
whoreceivedtreatmentfordepressionhad23%lessabsenteeismandonlyonethirdasmany
misseddaysofwork.30Thisstudywentontoreportthateffectivedepressiontreatmentledto
aneconomicbenefitof$1,982associatedwithimprovedproductivityatworkand$619per
personduetoreducedabsenteeism,31amountsthatarehigherintoday’sdollars.
BarrierstoEmployeeUseofBenefitstoObtainTreatmentforDepression
Althoughmorethan80%ofpeoplewithdepressioncanbetreatedsuccessfullywith
medication,psychotherapy,oracombinationofboth,lessthan22%receiveadequatecare.32
Nearly74%ofAmericanswhoseekhelpforsymptomsofdepressiongotoaprimarycare
physician(PCP)ratherthanamentalhealthprofessional.Unfortunately,adiagnosisof
depressionismissed50%ofthetimeinaprimarycaresetting.Evenwhendepressionis
diagnosedandaddressedbyaPCP,halfofpatientsprematurelystoptakingprescribed
medicationsandmanydonotfollowthroughwithaspecialtyreferral.
Forpatientswhoacceptamentalhealthorsubstanceusedisorder(MH/SUD)treatment
referral,nearlyhalfofthemdropoutoftreatmentagainsttheirtherapist’sadvice.33Lackof
awarenessofdepressivesymptoms,personalembarrassment,concernsaboutjobimpact,
stigma,medicationsideeffects,psychiatristshortages,unrealisticexpectationsabouthowfast
symptomswillgoaway,andtheburdenofweeklyclinicvisitspreventmanyindividualsfrom
gettingthetreatmenttheyneedfordepression.
28
Morrell,C.J.,Warner,R.,Slade,P.etal.(2009).Psychologicalinterventionsforpostnataldepression:Cluster
randomizedtrialandeconomicimpactevaluation(ThePoNDERtrial).HealthTechnologyAssessment,13(30):1153.
29
Donohue,J.M.,&Pincus,H.A.(2007).Reducingthesocietalburdenofdepression:Areviewofeconomiccosts,
qualityofcareandeffectsoftreatment.Pharmacoeconomics,25(1),7-24.
30
Ibid.(Seealso:Langlieb,A.M.,&Kahn,J.P.(2005).Howmuchdoesqualitymentalhealthcareprofit
employers?JournalofOccupationalandEnvironmentalMedicine,47(11),1099-1109.)
31
Ibid.
32
Kessler,R.etal.(2003).Theepidemiologyofmajordepressivedisorder:ResultsfromtheNationalComorbidity
StudyReplication(NCS-R).JournaloftheAmericanMedicalAssociation,289(23),3095-3105.
33
DroppingOutofPsychotherapy,HarvardHealthPublications,HarvardMedicalSchool,October1,2005.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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RemovingBarrierstoEffectiveDepressionTreatment:TheCollaborativeCareModel
Researchshowsthatimplementingspecificinterventions(collectivelyreferredtoas
“CollaborativeCare”)thatpromotethedetectionofdepression,“in-place”treatment(no
referralneeded),andtreatmentadherencecansignificantlyimproveoutcomesbyincreasing
thenumberofindividualswhoaccessandsuccessfullycompletetreatmentfordepression.34
CollaborativeCareinterventionsincludestandardizeddepressionscreeninginprimarycare,
tailoredpatienteducation,caremanagement(e.g.,carecoordinationandtriage,telephonic
follow-up),andtechnology-enabledtreatmentplanmonitoring.Similartodiseasemanagement
programsfordiabetes,theseinterventionspromoteearlyidentificationofdepression,improve
treatmentengagement,andreducetreatmentdrop-outrates.Inaddition,integrating
psychiatricconsultationintomedicalsettings,withaccountabilityforoutcomesandcosts,
improvesmentalhealthandmedicaltreatmentoutcomeswhileultimatelyreducingthecostof
care.35Table1illustrateshowCollaborativeCareinterventionspromoteeffectivetreatmentfor
depression.
Table1
TraditionalDepressionTreatment
CollaborativeCareIntervention
50%PCPdepressiondetection
Automateddepressionscreeningincreases
detection
50%treatmentdrop-outrate
Proactivepatientmonitoring,prioritizationof
care,andfollow-upbycaremanagers
50%medicationadherence
Sideeffecteducationandmonitoring,
tailoreddosageadjustments,progress
measurementandfollow-up
Mentalhealthandmedicaltreatmentsilos
thatmayresultincontra-indicated
medicationinteractions,pooradherenceto
treatmentregimensandredundanthealth
carecosts
Professionalcollaboration,consultationand
treatmentplancoordination;
implementationofadherencestrategiesfor
medicalcare;identificationandtreatmentof
co-occurringMH/SUDconditions;
informationsharingviaelectronicrecords
ButCollaborativeCareinterventionsdonotfitneatlywithinthebenefitdesignscommonly
offeredbyemployers,andfewinsuranceplansreimburseforthesetypesofinterventions.
34
TheCollaborativeCareModelhasbeendescribedbytheAIMSCenterattheUniversityofWashington:
http://uwaims.org
35
SeetheWashingtonStateInstituteforPublicPolicyathttp://www.wsipp.wa.gov/BenefitCostforarecentreview
ofstudiesthatconcludedintegratedmentalhealth/physicalhealthcareinprimarycaresettingsiscost-effective.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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Employersandinsurersmustcollaborateandnegotiatetodevelopemployeebenefitplansthat
supportCollaborativeCare.
EmployerBenefitsandInsuranceCoverage
Fee-for-serviceinsurancereimbursementforoutpatientmentalhealthandsubstanceuse
disordertreatmentistypicallylimitedtoin-personvisitswithprofessionalsforpsychotherapy,
medication,ordeliveryofaspecifictreatment(e.g.,electroconvulsivetherapy[ECT]).
Administrationofdepressionscreeninginstruments,healthandbehaviorconsultsinthe
medicalsetting,telephonicinterventionwiththepatient,casemanagement,treatment
planning,psychologicalconsultswithoutthepatientpresent,progressmonitoring,andpatient
educationarerarelyreimbursed.Employerswhowanttomoreeffectivelyaddressdepression
mustpayprovidersorinsurerstodeliverCollaborativeCareinterventionstoreapmoreofthe
benefitsofeffectivetreatmentfordepression.
ExamplesofhowemployerscaninvestinCollaborativeCarefollow:
1. PayingforCollaborativeCareinterventionsthroughaninsureronacapitatedbasis(i.e.,a
peremployeepermonthfeetoprovideallorsomeoftheelementsofcollaborativecare).
Inthisapproach,theinsurerimplementsa“depressiondiseasemanagement(DDM)”or
“caremanagement(CM)”programinwhichcaremanagershiredbytheinsurerprovide
telephoniccasemanagementservices(e.g.,follow-upcalls,medicationchecks,care
coordination,patienteducation,triage),arrangeforpsychologicalconsults,andmake
recommendationsfortreatmentplanmodifications.Providerreimbursementfor
administrationofdepressionscreeningtoolsandprogressmonitoringinstruments,health
andbehaviorconsults,andmorethanoneprocedureinadayshouldalsobeincluded.This
approachisbestsuitedforinsuredpopulationswithaccesstoalarge-scaleprovider
network.DisadvantagesincludepatientrefusalstoparticipateintheDDMprogram,distrust
ofmanagedcare,andcomplicationsassociatedwithproviders’inabilitytoidentify
individualswhoseinsurancecoveragemakesthemeligiblefortheDDMprogram.
2. PayingforCollaborativeCareinterventionsonafee-for-servicebasisfornetworkproviders
approvedtoimplementthem.Thisapproachalsoworksforlarge-scaleprovidernetworks
andavoidstheproblemsassociatedwithmanagedcare.However,itrequiresprovider
selectioncriteriaandCollaborativeCaretrainingresources,withincentivesthatencourage
individualswithdepressiontoutilizequalifiedproviders.ThetypesofCollaborativeCare
interventionsimplementedinthisapproachwilldependontheproviderdeliverysystem.
(SeeDeliverySystemStructurebelow).
3. Payingacontainedhealthcaresystem,suchasanHMO,ormultispecialtyprovidergroup
onacapitated,caserate(i.e.,payingafeetocoverCollaborativeCareforeachparticipant)
orfee-for-servicebasistodeliverCollaborativeCareinterventions.Inthisapproach,trained
CollaborativeCareprofessionalsareintegratedintothedeliverysystem,opportunitiesfor
collaborationandin-personinterventionareincreased,andefficiencyisincentivized.This
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016
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approachmaybegeographicallylimitedtotheregioninwhichthesystemorgroupis
located.
DeliverySystemStructure
Regardlessofthefundingmechanism,acontinuumofCollaborativeCareinterventionsmustbe
madeavailablesuchthatservicescanbetailoredtotheneedsofthepatientandseamlessly
providedwithinthedeliverysysteminwhichtreatmentissought.Forexample,telephonic
psychiatricconsultationandcaremanagementmaybebestsuitedtosupportaPCPwho
practicesinasmallgrouporruralsetting,whileanonsitebehavioralhealthprofessional
availableforconsultationand“warmhandoffs”fromPCPs(introducingthepatientin-personto
amentalhealthprovider)mayprovideoptimalassistancetoamultispecialtymedicalclinic.For
individualswithseveresymptomsofdepression,moreintensive,specializedtreatmentat
centersofexcellencethatimplementCollaborativeCareinterventionsshouldbeavailableand
accessible.
Additionally,providersdeliveringCollaborativeCareinterventionsmustbequalifiedand
adequatelytrained.Treatmentprofessionalsmustlikelyaddnewskillstotheirrepertoire,
includingtheabilitytoregularlytrackandreviewelectronicpatientdata,engagewithpatients
betweensessions,triageandprioritizecare,delivershort-terminterventionsasneeded,and
providespecificandconciseconsultationwhileparticipatingasamemberofafast-paced
medicalteam.
Tofullytransformabehavioralhealthpracticeand/ortrainclinicianstoprovidethefullrangeof
CollaborativeCareinterventions,start-upfundingmayberequired.Investmentsinscreening
andoutcomemeasurementtools,trackingsystems,electronicmedicalrecords,communication
systems,changestobillingsystems,transportationexpenses,andongoingprovidertrainingand
supervisionwillbeanimportantcomponentofthesuccessofanydeliverysystemthatincludes
CollaborativeCareinterventions.
CollaborativeCareisCost-Effective
CollaborativeCareinterventionsmakedepressiontreatmentmoreeffectivebecausethey
addresshealthcaresystemflawsthatpreventoptimaldeliveryofevidence-basedservices.And,
whileintheshort-runimplementingCollaborativeCareinterventionsaddstothecostof
depressiontreatment,theoveralleffectistolowercosts.
Researchonthecost-effectivenessofCollaborativeCareinterventionscomparedtothatof
treatmentfordepressiononitsownisrelativelynew,buttheresultsarepositive.The
WashingtonStateInstituteforPublicPolicy(WSIPP)foundthatCollaborativeCareinterventions
hadastatisticallysignificantimpactondepressionoutcomes,astatisticallyinsignificant
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016 10
increaseincostofcare,reducedlifetimehealthcareexpenses,andbetterlabormarket
outcomes(e.g.,turnover,unemployment),withnocombinationofassumptionsresultingin
CollaborativeCarefailingabenefitcosttest.36Severalstudiesevaluatingthecost-effectiveness
ofCollaborativeCareinterventionsrelativetoroutinecareinprimarycaresettings
demonstratedhealthcaresavingsovertime.37Agoodestimateoftheinvestmentinenhanced
treatmentis$1,000overtwoyearsperpersontreatedfordepression.38However,healthcare
savingsoverfouryearshavebeenestimatedtobeapproximately$3,300perperson;
productivityandabsenteeismsavingsinthefirsttwoyearshavebeenestimatedtobe
approximatelyanother$2,500perpersontreated.39
Inconclusion,thereturnoninvestmentinCollaborativeCarestrategiesisreducedhealthcare
costsovertime,improvedhealthcareoutcomes(forbothmentalhealthandphysicalhealth),
decreasedbusinesscostsrelatedtodisability,productivity,absenteeismandturnover,and
improvedqualityoflifeforemployeesandtheirfamilies.
HowtheMeadowsMentalHealthPolicyInstituteCanIncreasetheCost-Effectiveness
ofDepressionTreatmentthroughCollaborativeCare
TheMeadowsMentalHealthPolicyInstitute’s(MMHPI)roleinpromotingCollaborativeCareto
enhanceaccesstoeffectivetreatmentfordepressionincludesthefollowingthreecomponents:
1. WorkingwithEmployers:MMHPIwillidentifyandworkwithemployerswhoare
interestedinimplementingCollaborativeCare.MMHPIcanconsultwiththese
employersregardingbenefitdesign,assistwithrequestsforproposals(RFPs)for
insurersand/ormultispecialtyprovidergroups,anddesignpilotsorstudiestomeasure
cost-effectivenessoftheseprojectsfromtheemployer’sperspective,includingfactors
suchastotalhealthinsurancepremiums,laborproductivity,andlaborturnover.
36
WashingtonStateInstituteforPublicPolicy(December2015).Benefit-costresults:CollaborativePrimaryCare
forDepressionwithComorbidMedicalConditions.Olympia,WA:Author.
37
Grochtdrels,T.,Brettschneider,C.,Weggener,A.etal.(2015).Cost-effectivenessofcollaborativecareforthe
treatmentofdepressivedisordersinprimarycare:Asystematicreview.PLoSONE10(5):e0123078.
doi:10.1371/journal.pone.0123078.
38
InstituteforClinicalSystemsImprovement.(n.d.).TheValueofProvidingCollaborativeCareModelsforTreating
EmployeeswithDepression.Seealso“AnewdirectionindepressiontreatmentinMinnesota:DIAMONDprogram,
InstituteforClinicalSystemsImprovement,Bloomington,Minnesota,”APAAchievementAward(2010).Psychiatric
Services,61(10),1042-1044.
TheDIAMOND(DepressionImprovementAcrossMinnesota,OfferingaNewDirection)Projectchangeshowcare
forthepatientwithdepressionisdeliveredandpaidforinprimarycare.Itsscopeis“toassistprimarycarein
developingsystemsthatsupporteffectiveassessment,diagnosisandongoingmanagementofneworexisting
diagnosisofmajordepressioninadultsage18andover,andtoassistindividualstoachieveremissionof
symptoms,reducerelapseandreturntopreviousleveloffunctioning.”
39
Ibid.
Increasing the Cost-Effectiveness of Depression Treatment with Collaborative Care – 03/2016 11
2. HelpProvidersImplementCollaborativeCare:MMHPIwillcollaborativelyworktosecure
fundingforprovidergroupsornetworksinterestedindevelopingtheinfrastructureand
expertisenecessarytoprovidethefullcontinuumofCollaborativeCareinterventions.
MMHPIcanassistthesegroupswithtailoringtheirservicestotargetedmedicaldelivery
systemsbyfillingresourcegapswithintheservicearea,facilitatingintegrationwiththe
existingmedicalsystem(s),andbrokeringtraininginCollaborativeCarestrategies.
3. EvaluateandSupportCollaborativeCareSystemsOnceOperational:MMHPIcould
conductreadinessreviewsofhealthcaredeliverysystems,and/orauditsofCollaborative
Caredeliverysystemsorstrategiesaftertheyareoperational,toidentifytraining
opportunities,providecoachingincost-effectiveCollaborativeCareinterventions,and
secureevidenceofimprovedtreatmentofdepression,comorbidhealthoutcomes,and
reducedcosts.Datafromthesereviewscanpersuadeotheremployersaboutthe
importanceofofferingcoverageforCollaborativeCarestrategies.