It is no secret that the overwhelming majority of patients with major depression who are seen by primary care physicians never get screened for depression, much less treated. Statistics from the National Ambulatory Medical Care Surveys from 2003 to 2006 reveal that despite the high prevalence of depression in primary care (10% to 12%), the incidence of screening is extremely low, at 2% to 4% of visits.
In an effort to dramatically drive up those screening statistics, Medicare announced in October that it would pay for depression screening in primary care settings that have “staff-assisted depression care supports” in place to ensure accurate diagnosis, effective treatment, and follow-up. While this is an important development, there is no information on what the payment will be, and some important long-term follow-up issues, such as lack of access to mental health treatment in many areas, are not addressed.
Jürgen Unützer, MD, MPH, MA, Professor and Vice Chair, Department of Psychiatry and Behavioral Sciences, and Chief of Psychiatry, University of Washington Medical Center, said most primary care practices will be able to administer screening tools, which can be done quite well, he added, by a trained medical assistant, another allied health professional, or a physician. The next step, making an accurate diagnosis, is more complicated, and ensuring that a patient with major depression gets effective treatment is more complicated still. Unützer added that compensation for the screening is a “huge” question. “It needs to be high enough to get people’s attention and to incorporate this into their practices.”
Ellen Griffith, spokeswoman for the Centers for Medicare and Medicaid Services (CMS), was unable to say at what level screening reimbursement would be set.
Unützer also said that it will be important to expand access to mental health care. While some primary care practices will be able to provide effective treatment, others will not. Those that cannot may have trouble finding a mental health professional to whom they can refer patients. In one survey, two-thirds of primary care practices said referral doesn’t work for them, either because there are no mental health providers in their community or because the providers that are there refuse to take the patient’s insurance. Unützer noted that in the Pacific Northwest, there are entire counties without a single practicing psychiatrist.
Benjamin Druss, MD, MPH, Rosalynn Carter Chair for Mental Health, Department of Health Policy and Management, Rollins School of Public Health, Emory University, called the Medicare depression screening coverage decision a step in the right direction. He added, “It needs to be coupled with appropriate coverage for evidence-based depression services as well.”
Druss explained that Medicare still does not pay for many evidence-based components of team-based care, such as care management and provider-to-provider consultations. “New financing models, Medical Home demonstrations, for example, may help get around these financial barriers.”
To qualify for the payment, a provider must be practicing in a “primary care setting,” defined as one in which there is provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. Payment is not available for physicians practicing in emergency departments, inpatient hos-pital settings, ambulatory surgical centers, independent diagnostic testing facilities, skilled nursing facilities, inpatient rehabilitation facilities, and hospices. Moreover, psychiatrists are never eligible.
In addition to the primary care setting requirement, Medicare will demand that clinical staff be on premise (eg, nurse, physician assistant). The staff can advise a physician of screening results and can facilitate and coordinate referrals to mental health treatment. Griffith says the new benefit doesn’t say “who” in the primary care practice has to perform the screening. That presumably means the nurse or physician assistant can do it.
Glenn A. Weiglein, Vice President, Government & External Affairs, Takeda Pharmaceuticals North America, Inc, wanted the CMS to establish a minimum level of training required for support staff. “Takeda believes that it is more important for CMS to encourage the identification of widely recognized standards for training in depression screening and follow-up, and to ensure that practitioners who perform depression screening become appropriately credentialed through educational methods such as periodic training,” he said. In partnership with Lundbeck, Takeda is developing therapies for the treatment of depression.
The CMS decision to pay for depression screening in primary care settings was based on a 2009 recommendation from the US Preventive Services Task Force (USPSTF), which gave that screening a letter grade of “B,” meaning the Task Force recommends Medicare coverage and that “there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.” A “C” grade means the Task Force recommends against routinely providing the service. There may be considerations that support providing the service in an individual patient; however, there is at least moderate cer-tainty that the net benefit is small.
Just as it declined to set training requirements, the CMS also declined to endorse a specific screening tool. Again, it fell back on the USPSTF recommendation, which found little evidence to recommend one screening method over another. The Task Force stated that “clinicians may choose the method most consistent with their personal preference, the patient population being served, and the practice setting.”
In terms of what constitutes “staff support” in Medicare’s eyes, the agency once again referred back to the USPSTF, which cited a “lowest effective level” represented by a screening nurse “who advised resident physicians of positive screening results and provided a protocol that facilitated referral to behavioral treatment.” The “highest level” might include “institutional monetary commitment; staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; many materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for adherence to medication for those prescribed antidepressant medications; a visit with a trained therapist for cognitive-behavioral therapy; and a reduced copay for patients referred for psychotherapy.”
Medicare will apparently reimburse when staff support anywhere between the lowest and highest levels is available.