Medicare Now Covers Depression Screening

Medicare Now Covers Annual Screening For Depression

Topics: Health Costs, Delivery of Care, Insurance, Marketplace, Quality, Medicare

By Michelle Andrews

Apr 03, 2012

Bette Davis, who had breast cancer and suffered a series of strokes before her death in 1989 at age 81, famously remarked that old age is not for sissies.

Many people assume that as health problems multiply and loved ones die, it’s inevitable that the elderly become depressed. Not true, say experts. Older people have lower rates of depression than younger groups.

But depression often goes undiagnosed in the elderly, who feel the stigma of mental illness more acutely than younger people and are often less likely to seek help. At the same time, older people are more likely to have multiple chronic conditions that consume their primary-care provider’s attention in the limited time available during a typical office visit.

The situation may be changing. In October, Medicare began to coverannual depression screening in primary-care settings with no cost sharing for beneficiaries.

Paying doctors to screen for depression — Medicare’s going rate is $17.36 per person — may well increase how often they do it, say experts. “Doctors are trying to do the right thing, but how do you prioritize what to do in 21 minutes with a complex person?” asks Ken Duckworth, medical director for the National Alliance on Mental Illness, an advocacy group. “If they get paid for it, they structure it into their practices.”

Medicare covers 60 percent of the treatment for mental health problems, including depression. (Under a 2008 law, that figure is scheduled to rise to 80 percent in 2014.)

A Rapid Test

Most primary-care practices that screen for depression use a tool called the patient health questionnaire. The PHQ-9, as it’s called, asks people to describe how frequently during the past two weeks they have felt down or hopeless or taken little interest or pleasure in doing things. It also asks about sleep patterns, appetite and concentration, among other things. Although the test can be taken in just a few minutes, a 2001 study indicated it identifies depression and pinpoints its severity nearly 90 percent of the time.

Nearly 17 percent of people will have a major depressive disorder during their lifetimes, according to 2007 data from the National Comorbidity Survey of mental health disorders. For people 60 and older, however, the lifetime prevalence is much lower, 10.7 percent. “It’s the survivor factor,” says Michael Friedman, an adjunct associate professor at Columbia University’s schools of social work and public health. “You’re more likely to die young if you have depression.”

The lower figures don’t tell the whole story, say experts. Older people are much more likely to suffer from chronic conditions such as diabetes and heart disease, which can complicate diagnosis and treatment of both depression and other medical problems.

“Depression worsens the effect of other illnesses,” says Charles Nemeroff, a geriatric psychiatrist at the University of Miami. “People with depression are more vulnerable to [disease], and once it happens, it’s worse.”

People with depression often don’t take very good care of themselves. They don’t exercise or eat right. They don’t take their medications or get their blood work done to make sure their blood pressure, blood sugar and cholesterol levels are under control. And people with multiple chronic conditions probably take multiple medications that may interact with each other.

In addition, diabetes and heart disease can actually cause a late-life form of depression called vascular depression, which may occur when blood vessels harden, reducing blood flow to the brain.

All of these factors present a challenge for primary-care providers. There’s no point in screening for depression, after all, if you don’t have the resources to help people get the treatment they need.

An Encouraging Trial

Mental health experts point to a model called collaborative care as one that has shown good results. In one trial conducted at 14 primary-care clinics in Washington state, patients who had poorly controlled diabetes and/or heart disease as well as depression received help from a nurse to improve their efforts to control their diseases over a 12-month period. The nurse worked closely with a psychiatrist, primary-care physician and psychologist to track patient progress and adjust medications as necessary.

Patients who received the intensive team approach showed significantly more improvement in both their depression and other medical conditions compared with patients who received usual care, according to a study published in the New England Journal of Medicine in December 2010 about the trial. Lead author Wayne Katon, a professor of psychiatry at the University of Washington School of Medicine, said the clinics saved an average of $600 per patient over a two-year period.

Most primary-care practices don’t provide that kind of comprehensive, coordinated care, Katon says.

But as policymakers and insurers increasingly offer incentives to primary care physicians to transform their practices into medical homes for their patients and reward providers for better disease control rather than simply running tests and doing procedures, the landscape should change.

Depressed people are more likely to receive diagnoses and be treated in primary-care settings than elsewhere. Research shows that elderly people, in fact, prefer to deal with their primary-care provider on mental health issues. In that context, coverage of depression screening may help more Medicare beneficiaries get the help they need.

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Majority Support medicaid Expansion

Majority of Americans support Medicaid expansion under Affordable Care Act
By Ashley Lopez Tuesday, April 03, 2012 at 5:11 am

One of the most contentious parts of the 2010 health care reform law — a requirement that states expand their Medicaid programs — is supported by a strong majority of Americans, according to a recent poll.
According to a Kaiser Family Foundation poll (.pdf) released last week, the Medicaid expansion provision in the Affordable Care Act has 70 percent approval from Americans. The poll also found that most provisions in the law have considerable support from the public, except for the individual mandate, which bottoms out with a 32 percent approval rating.
Last week, the U.S. Supreme Court heard oral arguments in the Florida-led legal challenge to the law. One of the main provisions Florida is fighting is the Medicaid expansion, which according to last week’s poll, found approval among 88 percent of Democrats, 69 of independents and 51 percent of Republicans.
During oral arguments last week, there was evidence that some Supreme Court justices, including Chief Justice John Roberts, were skeptical of claims made by the states challenging the Medicaid expansion. The 26 states argue that the law will impose an enormous financial burden.
Gov. Rick Scott has said many times that Medicaid is one of the big culprits for the state’s continued budget problems. Last week he said on Fox and Friends that the law would impact Florida greatly because it would add a “cost to [Florida’s] Medicaid program” that he says the state “cannot afford.” The federal government largely subsidizes Florida’s program, however. Scott’s claim that the law requires states to “dramatically expand Medicaid” has been a common argument made by officials opposing the law. But Florida public policy experts say that Scott’s arguments about the Medicaid expansion have been “vastly inflated [and] lacking in merit.”
The Supreme Court justices have already voted in secret about their position on the law, but a decision will not be announced until late June.

Medicaid and Early Births –

Medicaid wants fewer early births
By: Joanne Kenen
April 2, 2012 10:19 PM EDT

Everyone who looks at the high cost of health care worries about the expense at the end of life.

But what about at the beginning?

Turns out there’s one deceptively simple change in obstetric care that can save millions of dollars and lead to healthier babies and healthier moms: stopping women and their obstetricians from inducing births before 39 weeks without a pressing medical reason.

That could be a tough sell though because early induction has become part of the culture.

About one in 10 births in the United States is intentionally early, and some estimates are higher. It’s a matter of choice and convenience, and sometimes efficiency, for both women and their doctors. A baby born at 38 weeks — a common time for early induction — isn’t premature. It sounds safe.

But mounting evidence shows that planned early births put babies at risk: more infants staying in neonatal intensive care units, more complications, more permanent damage and a higher death rate. Respiratory and digestive problems occur, and scientists are learning how early delivery can disrupt brain development.

There’s “an explosion of brain development in the last few weeks of gestation,” Billie Short, division chief of the Neonatal Intensive Care Unit at Children’s National Medical Center in Washington, said in a presentation about the costs and consequences of elective early births.

So private insurers, health quality groups, the March of Dimes, some large hospital organizations and now Medicaid — which pays for more than 40 percent of births in the U.S. — have teamed up to spread the word to women who are expecting. Their message: If nature intended for babies to be born at 38 weeks, pregnancy wouldn’t last 40 weeks.

“This is something that has got to change,” said Cindy Mann, Medicaid director at the Centers for Medicare & Medicaid Services — which along with its state partners could save hundreds of millions of dollars a year if such births were less common.

A baby born at 37 or 38 weeks isn’t premature, these groups tell women and doctors. But maybe they aren’t quite “full term,” either. The phrase being introduced is “early term.”

The message isn’t always getting through.

“We live in a culture of convenience and a culture of planning,” said Sue Gullo, managing director of the Institute of Healthcare Improvement, “Our whole culture is about making things neat and tidy,” she added.

A woman might want to avoid a particular birth date or choose to deliver when she knows it’s convenient for grandma to watch the older kids. She might try to maximize her maternity leave or improve the odds of having a specific obstetrician in a group practice when she delivers. Or she may just get tired of being hugely pregnant.

Obstetricians might like pre-planned births as a way of keeping more of their nights and weekends free. It might help make their practice more efficient if they can plan to be in the hospital delivering five babies on Tuesday, for instance, and be able to tend to their patients in the office on Wednesday.

Mann told POLITICO the trend must be reversed — not just on economic grounds but to protect newborns’ health. Early induction doesn’t mean quick or uncomplicated delivery; women who are induced early are also at increased risk for cesarean section. Some hospitals and medical practices have brought their early induction rates down sharply.

The Seton Family of Hospitals in Austin, Texas, has been a pacesetter by basically stopping the practice cold. It has seen a corresponding drop in birth traumas. In Ohio, a statewide collaboration on perinatal health in hospitals prevented an estimated 8,236 early deliveries and about 250 NICU admissions from September 2008 through March 2010 based on numbers researchers anticipated for births without intervention.

But elsewhere, the rate hasn’t budged, and in some hospitals, it’s a whopping 40 percent, according to the Leapfrog Group, a data-driven health care quality organization. Some outlier medical centers are even higher.

“There are pockets of success,” Mann said. “We know that the reduction can be accomplished. But it needs a lift.”

Getting doctors and women to bring the early induction rate down by half could save Medicaid $483 million a year — and several billion over a decade — and that figure doesn’t even include care that a child may need weeks, months or years after birth. Such efforts would be a lot less painful — and a lot better for the newborns and their families — than some of the other cost cutters that hard-pressed state Medicaid directors are contemplating.

A few states have imposed or are considering financial penalties for elective early births, but federal Medicaid officials aren’t considering such policies, Mann said.

Early deliveries aren’t unique to Medicaid. They happen across the country, in all socioeconomic groups, said Barbara Rudolph, senior science director for Leapfrog, which works with businesses and big health plans to address cost and quality.

And it’s one reason so many hospitals have NICUs. Early births keep them full — and profitable.

Gullo says it’s sort of a catch-22. Hospitals have NICUs, in part, because so many early-term babies end up needing them. And they go ahead and deliver the early babies because as long as they have NICUs, they can treat the infants if there’s a problem.

But some hospitals, like Seton, have changed that pattern quickly. Hospitals that have laid down the law, telling doctors they can’t deliver babies early without a compelling medical reason — a sort of zero tolerance — have seen the deepest and fastest drop in induction rates, Rudolph said.

Health and Human Services has targeted hospitals as a good starting point to leverage change. HHS Secretary Kathleen Sebelius earlier this year announced the Strong Start initiative to improve prenatal care, reduce preterm births and address the elective inductions.

The initiative is part of the Partnership for Patients quality improvement drive under the Center for Medicare and Medicaid Innovation, which was created under the health care reform law. About 3,200 hospitals are participating in the voluntary quality program.

“Women need to understand what they are asking for,” Gullo said.

“ If we help them understand the new evidence, people will make intelligent decisions,” Gullo said.