Using Population-Based Data to Estimate Treatment Gaps in Depression and the Impact of Physician Incentives Joseph H Puyat, MA (Psychology), MSc, PhD Centre for Health Evaluation & Outcome Sciences Providence Health Care 29 November 2016

Outline 1) Background 2) Gaps and variations in depression care 3) Impact of physician on depression care 4) Conclusions For more info: jpuyat@cheos.ubc.ca https://www.researchgate.net/profile/Joseph_Puyat

What is Depression? Mood Disorder > 5 symptoms from the following Sleep changes Interest (loss of) Guilt (feelings of) Energy (lack of) Cognition (substantial changes in) Appetite (loss of) Psychomotor (irritability or depressed mood) Suicidality

How Prevalent is Depression? CCHS 2012, Canada

How Prevalent is Depression? NSDUH 2014, US

How is Depression Treated?

Treatment Gap How Many Have Untreated Depression? 16% 84% 54%

Depression costs the economy CAD$32.3B/year So What? Global Burden of Disease Study Depression is the leading cause of disability worldwide (1990, 2000, 2010, 2020) Depression costs the economy CAD$32.3B/year

Data Canadian Community Health Survey Medical Services Payment (MSP) Data Mental Health Services Data File Hospital Discharge Database PharmaNet Database

Treatment Gap Statistics Canada, CCHS 2012

Gap in Minimally Adequate Treatment Overall Results 108,101 Diagnosed with MD in BC 13% 48% 53% 47% MACP MAAT MAT Inadequately Treated Puyat JH, Can J Psychiatry, 2016

Real Gap in Minimally Adequate Treatment Overall Results Real Gap in Minimally Adequate Treatment 63% 37% Treated by health care professionals Untreated MAT 33% 67% Puyat JH, Can J Psychiatry, 2016

Sex and MAT Disparities by Gender Puyat JH, Can J Psychiatry, 2016

Age and MAT Disparities by Age Puyat JH, Can J Psychiatry, 2016

Disparities by Residence Location and MAT Disparities by Residence Puyat JH, Can J Psychiatry, 2016

BC Mental Health Initiatives (2008) Mental Health Incentives http://evidencenetwork.ca/archives/4970 BC Mental Health Initiatives (2008) Mental Health Incentives MH Planning Fee ($100/yr) Increased billable counselling sessions from 4 to 8 per year ($53.31 – $79.97) Up to 5 tel/email follow-up fees/18 months ($15) Up to conferencing fees ($40/15min) CDM fee if patient has CPC ($120/year) Training modules (diagnosing and managing mental disorders) $2,900 compensation By 11/2012, 42% enrolled, 67 of whom completed the program. What the rest of Canada can learn from BC “Provinces have been attempting ambitious and far-reaching reforms with new impetus over the last decade. Ontario, Quebec and Alberta have largely embraced  structural reform, changing how services are delivered, creating community health clinics or family health teams with other allied health professionals like nurse practitioners, and putting doctors on salary or other payments models rather than traditional fee-for-service payments… British Columbia, has chosen a different route, opting to focus on operational reforms rather than structural reforms, through an active dialogue with physicians, patients, and other stakeholders to better align physician reimbursement with the provision of care to patients with complex health conditions and by supporting family doctors (also called General Practitioners or GPs) to feel better equipped both clinically and practically to do their job.”

Interrupted Time Series Analysis

Impact: Psychological Therapy Percent 2005 2006 2007 2008 2009 2010 2011 2012 2013 53 55 57 59 61 Yr 5 = 3.3 Mean = 2.2 Puyat JH, Med Care, 2016

Impact: Antidepressant Therapy Percent 2005 2006 2007 2008 2009 2010 2011 2012 2013 54 56 58 60 62 Mean = -2.8 Yr 5 = -4.5 Puyat JH, Med Care, 2016

Impact: Minimally Adequate Psychological Therapy Yr 5 = 1.8 Percent 2005 2006 2007 2008 2009 2010 2011 2012 2013 8 10 12 14 16 Mean = 1.0 Puyat JH, Med Care, 2016

Impact: Minimally Adequate Antidepressant Therapy Percent 2005 2006 2007 2008 2009 2010 2011 2012 2013 54 56 58 60 62 Mean = -1.7 Yr 5= -2.2 Puyat JH, Med Care, 2016

Impact: GP Continuity of Care (Mental Health) Average 2005 2006 2007 2008 2009 2010 2011 2012 2013 77 79 81 83 85 Yr 5 = 4.4 Mean = 2.4

Summary Reliable data are available and can be used to estimate gaps in treatment and examine the impact of policies Gaps and disparities in depression care and treatment adequacy continue to persist Physician incentives can influence depression care patterns, but the overall impact is modest

Implications Improve mental health services to everyone in general Examine how younger adults and men access mental health care Accelerate efforts to promote team-based approaches to mental health service delivery and not rely mainly on operational reforms Expand public coverage for psychological therapies

Thank You! References Puyat JH, Kazanjian A, Wong H, Goldner EM. Is the Road to Mental Health Paved With Good Incentives? Estimating the Population Impact of Physician Incentives on Mental Health Care Using Linked Administrative Data. Medical Care. 2016 Sep 14; Puyat JH, Kazanjian A, Goldner EM, Wong H. How Often Do Individuals with Major Depression Receive Minimally Adequate Treatment? A Population-Based, Data Linkage Study. Canadian Journal of Psychiatry. 2016 Jul 1;61(7):394–404.