1. Addressing Depression in “Medicare Health Support” Michael Schoenbaum June 27, 2005

2. 27Jun05, Slide 2 Collaboration between RAND, University of Washington, University of Pittsburgh –Harold Pincus (co-PI) –Jürgen Unützer –Wayne Katon Funded by –National Institute of Mental Health (1 R01 MH75159-01) –John A. Hartford Foundation –Robert Wood Johnson Foundation

3. 27Jun05, Slide 3 Introduction Medicare Modernization Act of 2003 (Section 721) created “Chronic Care Improvement Program” New care management benefit under FFS Medicare Phase 1 is 3-year pilot program –Complex diabetes and/or congestive heart failure –Medicare risk score of “moderate” or higher 9 sites - each set up as randomized control trial –Up to 20,000 intervention & 10,000 control patients –Participation is voluntary

4. 27Jun05, Slide 4 9 Sites in Phase 1 Florida (Central) – Humana & Pfizer Health Solutions Tennessee - XLHealth Corp. Illinois (Chicago) - Aetna Health Management Oklahoma - Lifemasters Supported SelfCare Mississippi - McKesson Health Solutions Georgia - CIGNA HealthCare Pennsylvania (Western)- Health Dialog Services Corp. Maryland & Washington DC - American Healthways New York (Queens & Brooklyn) - Visiting Nurse Service of New York Home Care & United HealthCare Services

5. 27Jun05, Slide 5 Introduction (cont.) Organizations develop & apply own disease management protocols –Who to target –What services to provide –CMS can’t mandate content CMS will judge organizations based on –Cost: total Medicare costs must be <95% of usual care –Performance indicators, e.g., HbA1c, flu vaccine, depression screening

6. 27Jun05, Slide 6 Why focus on comorbid depression? Prevalent in CCIP population –Up to 25% in Medicare patients with diabetes/CHF Associated with higher costs & worse outcomes –>2x health costs –~2x mortality –More diabetes & CHF complications –Higher disability Impairs compliance with treatment –Lower medication adherence –Less likely to improve diet, exercise, smoking cessation

7. 27Jun05, Slide 7 How to address depression –Diagnosis –Care manager –Proactive tracking & reminders –Benchmarking & stepped care –Patient education –Behavioral activation –Medication management –Brief psychotherapy –Psychiatric consultation Usual care for depression not effective or cost-effective Effective strategies exist, based on “collaborative care” model

8. 27Jun05, Slide 8 Our project Technical assistance to organizations, to help them –Manage and track depression in their patient populations –Provide web-based “depression toolkit” –Craft a customized depression care program –Train their staff –Evaluate effectiveness Work with CMS to evaluate –Role of depression as moderator of program effectiveness –Value-added of specific strategies to address comorbid depression

9. 27Jun05, Slide 9 Timeline Dec. 2004Organizations selected by CMS We submitted grant application to NIMH Jan.-June 2005Contract negotiations Grant was approved (May 2005) Summer 2005CMS selects patient samples, contacts beneficiaries July-Oct. 2005Organizations finalize program content, train staff Sept. 20051 st cohort of organizations goes live Oct./Nov. 20052 nd /3 rd cohort of organizations goes live