Back to table of contents Previous article Next article Health Care EconomicsFull AccessExperts Outline Costs, Barriers To High-Quality Depression TreatmentKate MulliganKate MulliganSearch for more papers by this authorPublished Online:1 Aug 2003https://doi.org/10.1176/pn.38.15.0001aResearchers tackled a big issue about the treatment of depression at the June meeting of AcademyHealth in Nashville.In the session titled “Integrating Behavioral Health and Medical Care: What Does it Take?,” they addressed clinical and economic strategies that promote or inhibit effective treatment of depression in primary care settings.“It’s a win-win situation when high-quality treatment for depression pays for itself,” Kathryn Rost, Ph.D., said. But, she added, previous studies have not demonstrated a cost offset for health plans that fund high-quality depression treatment, despite many experts’ belief that such treatment reduces medical costs for comorbid physical disorders.Rost is a professor in the department of family medicine at the University of Colorado Health Sciences Center at Fitzsimons. AcademyHealth is the professional organization for health services researchers, policy analysts, and practitioners and a resource on health research and policy.Rost’s study focuses on costs to health plans only. A recent survey found that employers are losing an estimated $44 billion a year in lost productivity directly related to depression (Psychiatric News, July 15).Rost and her colleagues developed an intervention to encourage the delivery of high-quality depression treatment and tested it at 12 primary care clinics across the country from 1996 to 1999. With funding from the National Institute of Mental Health and the MacArthur Foundation, the intervention trained care managers to assess depression, educate patients about effective treatment, and monitor their responses over two years.All patients met DSM-IV criteria for major depression.Rost said, “Depressed patients who recognized and acknowledged that they had psychological problems in the initial consultation were much more likely to improve as a result of treatment than those who only complained of physical symptoms.”There were no statistically significant differences between the two groups in terms of severity of symptoms of depression or socioeconomic factors such as level of education.Rost said, “Of course, we want to be able to help everyone who has been diagnosed with depression, but it is also important to be able to identify groups who offer good potential for cost savings, so that we can make a strong case that treatment for depression can save health plans money. Our findings also suggest that we may need different kinds of interventions to be successful with patients who do not initially acknowledge symptoms associated with depression.” The study is under journal review.Substantial Treatment BarriersDaniel E. Ford, M.D., M.P.H., took the opposite approach to the problem when he told the audience about barriers to effective treatment. He said that primary care physicians perceive that there is less access to “high-quality” specialty mental health services than to other high-quality medical services and that access to mental health services is negatively affected by the number of managed care contracts held by the primary care physician.Ford is a professor of medicine, psychiatry, and health policy and management at Johns Hopkins University School of Medicine. His initial comments were based on a study he helped write, “Managed Care Organizational Complexity and Access to High-Quality Mental Health Services: Perspective of U.S. Primary Care Physicians,” published in the May-June General Hospital Psychiatry.The authors speculated that for primary care physicians, the impact of organizational complexity, such as multiple contracts, mental health carvein and carveout clauses, and gatekeeper requirements, would impact access to mental health specialty providers.They used data from the Community Tracking Study Physician Survey, conducted by the Center for Studying Health System Change, collected between 1996 and 1997.Ford said primary care physicians ranked access to high-quality mental health services much lower than access to other specialty medical services (28 percent; 95 percent confidence interval [CI] versus 81 percent, 95 percent CI).Perceived access to high-quality mental health services was inversely related to the number of managed care contracts held by the physician. The highest perceived access was for physicians with no managed care contracts (38 percent access, 95 percent CI). The lowest was for practices with 25 or more contracts (24 percent access, 95 percent CI).Gatekeepers Affect PerceptionsThe effect of gatekeeper requirements on the perceived availability of high-quality mental health services was more complicated. Gatekeeping requirement was defined as the percentage of patients within a practice subject to managed care gatekeeping requirements.Physicians with practices in which 41 percent to 60 percent of patients had gatekeeper requirements reported the lowest perceived access. Physicians who had no patients subject to gatekeeper requirements and physicians with practices in which all patients were subject to gatekeeper requirements reported the highest perceived access.Ford speculated that the reason for this surprising finding might be that if a high percentage of the patients within a practice had gatekeeper requirements, the physician would be more likely to learn how to deal with those requirements than if the practice had a mixture of patients.He told the audience that barriers also result from the number of stakeholders involved in health care delivery and their different expectations and needs from the system (see diagram).Coordination of mental health care or of mental health with primary care will not become a high priority for payers until it can be shown to reduce costs and result in fewer complaints from health plan enrollees. The result is that family members, particularly in cases of serious mental illness, frequently become de facto care coordinators. ▪ ISSUES NewArchived
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