Costs and Utilization for Low Income Minority Patients with Depression in a Collaborative Care Model Implemented in a Community‐Based Academic Health System

Abstract

Research ObjectiveThe collaborative care model (CoCM) is effective in treating patients with common behavioral health conditions in primary care settings and improving clinical outcomes. As health care reform efforts move toward model sustainability and scalability, more information is needed to assess its potential impact on costs and utilization. In a community‐based academic health system, serving primarily Medicare and Medicaid recipients with significant racial and ethnic diversity, we examined cost and major health care utilization metrics for depressed patients enrolled in CoCM compared to a group that did not receive CoCM treatment.Study DesignThe community‐based academic health system has 23 primary care practices in an urban setting offering colocated behavioral health care access to a psychiatrist and social worker as part of “usual care.” Seven of these sites implemented the CoCM to enhance care quality through care manager support, psychiatric consultation, measurement‐informed care, and a patient tracking registry. Two types of analyses were conducted to examine cost and utilization metrics; a site‐level intention to treat (ITT) model and an analysis comparing CoCM patients to a matched cohort at all usual care sites using propensity score matching. Two timeframes were considered; the first and second year following an initial positive PHQ‐9 (>10 indicating clinically significant depressive symptoms).Population StudiedIndividuals were eligible for inclusion if they sought care at one of the 23 primary care sites, scored positive on the PHQ‐9, and were enrolled in Medicaid for at least nine months out of the year for both the baseline and analysis year. The outcomes of interest were cost and selected health care utilization metrics including emergency room, admissions, and office visits.Principal FindingsIn the first year, the CoCM patients (n = 4,315) demonstrated a statistically significant decrease in emergency room visits (OR = .95; OR = .91) and non‐BH specialty office visits (OR =. 92; OR = .93), and an increase in PCP visits (OR = 1.03; OR = 1.03) and behavioral health (BH) office visits (OR = 1.03; OR = 1.08) compared to the usual care patients (n = 3,061) for both the ITT and cohort match analyses (n = 1,873 in both groups). The trend in year two continued, with statistically significant decreased emergency room visits (OR = .89; OR = .88) and non‐BH specialty office visits (OR = .87; OR = .92) for CoCM patients (n = 2,623) compared to those in usual care (n = 1,838) for the ITT and cohort match analyses (n = 1,193). Total costs for both years were not significantly different between groups.ConclusionsFindings demonstrate CoCM treatment is associated with potentially positive outcomes, including decreased emergency room visits and improved continuity of primary care. Results indicate these outcomes are sustained for at least 24 months.Implications for Policy or PracticeWhen comparing CoCM treatment of depression with colocation care in a 2‐year analysis, more effective health care utilization was found for decreasing emergency room utilization and other medical specialty utilization, and increasing primary care continuity for patients receiving CoCM. As organizations continue to seek new opportunities to integrate behavioral health into primary care, consideration of health care utilization and costs will be helpful in determining model selection for integration.Primary Funding SourceCenters for Medicare and Medicaid Services.