Pam Pietruszewski, M.A., a health care consultant at the Institute for Clinical Systems Improvement's (ICSI) Professional Partnerships division, explains how a program in Minnesota is changing the way depression care is delivered and paid for.
ICSI brought together medical groups, health plans, employers and patients to discuss barriers to establishing a collaborative approach for patients with depression. More than 40 randomized controlled trials identified a better way to manage depression in the primary care setting. Not all aspects of that care are traditionally reimbursed, however. DIAMOND is unique because it changes the way depression care is delivered and paid for.
In the new reimbursement model, health plans provide a monthly payment to certified medical groups for a bundle of services offered as part of the program. This includes contact with a care manager who monitors depression symptoms and severity, discusses barriers to treatment adherence, and provides education and coordination with other services, as well as strategies for self-management, weekly psychiatrist caseload review and treatment recommendations.
To date, more than 9, 500 patients have participated in Minnesota, and the program has gained traction in other states, including Michigan, Hawaii and Pennsylvania. Locally, follow-up at 6 months shows a 66% response rate (PHQ-9 reduced by half) and a 49% remission rate (PHQ-9 < 5). Follow-up at 12 months finds a 70% response rate and a 52% remission rate. These outcomes are greatly improved from usual care, where remission typically ranges 5-30%.
Key Challenges
Currently, only about one third of eligible patients are participating, and the primary reason cited for opting out is financial. While we were successful in getting all the major health plans in the state to come together to support DIAMOND, Medicare/Medicaid does not currently reimburse for DIAMOND services. Some physicians do not refer patients to the program because consistent coverage is lacking, or they are used to referring patients directly to behavioral health providers without first trying primary care interventions and coordinating care with specialists.
ICSI is the Principle Investigator for a recently awarded $18 million CMS Innovation Challenge grant to coordinate the implementation of an integrated care management model with seven partner organizations throughout the U.S. This award recognizes and further validates the work we have implemented and expanded through the DIAMOND program. It also provides the opportunity to influence national redesign of care and payment models that are needed to accelerate the Triple Aim.
Lessons Learned
DIAMOND required the collaboration of a critical mass of payers and providers, made possible because of ICSI's reputation as a neutral, trusted convener. Removing economic barriers was necessary in order to deliver evidence-based care. A lack of previous success in "usual care" created the awareness of a gap and the urgency for change. The development process was more than just having access to guidelines and protocols. Success was driven by culture change, leadership commitment and a focus on fair process. Reportable outcomes were aligned with state reporting requirements as well.
Next Steps
The CMS Innovation Challenge is a three-year cooperative agreement to fund the implementation of a care management model for primary care adult patients with depression plus diabetes and/or cardiovascular disease, with an option to address risky substance. Additionally, ICSI's Professional Partnerships group continues to take proven solutions and services and make them available to health care organizations and stakeholders nationwide.
Links for More Information
The DIAMOND ProgramICSI Professional Partnerships Organization Overview: The mission of the Institute for Clinical Systems Improvement (ICSI) is to champion the cause of health care quality and to accelerate improvement in the value of the health care we deliver to the populations we serve. ICSI‘s vision is to be a collaboration that is deemed essential by its members for the improvement of health care and deemed essential by the community as a trusted voice for quality in health care.
Bio: Pam Pietruszewski, M.A., is a health care consultant at ICSI‘s, Professional Partnerships division. She works with health organizations seeking to improve care for depression and substance use and implement care management for multiple chronic conditions. She is a trainer and facilitator for the DIAMOND Initiative, a depression care management program that received the 2010 Gold Award from the American Psychiatric Association. Pam was one of 13 national experts to author the American College of Physicians‘ Depression Care Guide. Pam holds a master's degree in counseling and psychological services from St. Mary's University in Minnesota.
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