Funding Models for Depression Care Management in Primary Care Settings

A key component of the chronic illness carecapitated and have a relatively flexible capacity to
model for treatment of depression is careallocate resources, can provide and fund care
management: a collaborative process ofmanagement services internally.
assessment, planning, facilitation, and advocacy for4. Flexible Infrastructure Support for
options and services to meet an individual's healthChronic Care Management
needs through communication and availableThis funding model includes an allocation of money
resources to promote quality and cost-effectiveby health plans to practices designed to support
outcomes. Several well-controlled studies havespecific quality improvement efforts, such as
demonstrated the clinical efficacy and costinfrastructure developments (e.g., information
effectiveness of care management for behavioralsystem upgrades), provider training, or care
disorders in general and for depression in primarymanager salaries that will improve clinical
care settings specifically. In these studies, careoutcomes and patient satisfaction. The additional
managers provided combinations of the followingmoney is available to a practice either to meet
services:specific, predetermined expenses or, more
- Patient and family education aboutdepressionflexibly, for purposes of its own choosing. In the
and its treatmentlatter case, practices may choose to reward
- Development of treatment andphysicians for meeting or exceeding pre-selected
selfmanagementplansclinical performance expectations, reinvest the
- Coordination of care with primary andbehavioralmoney to enhance quality infrastructure (e.g.,
health specialty providerssupport care managers), or do both.
- Assessment and monitoring of5. Health Plan-Based Care Management
patients'preferences, needs, barriers, and progressManaged care and/or managed behavioral
- Encouragement of treatment adherencehealthcare organizations employ care managers in
bypatients and medication guidelinecompliance bya variety of roles to perform multiple tasks, with
physiciansa focus on utilization review and treatment
- Brief, structured forms of psychotherapyplanning with treating clinicians via telephone. These
- Specialty referrals and hospitalizations asneededtypical managed behavioral healthcare
A significant challenge to providing depression caremanagement services usually involve minimal or
management is finding sustainable fundingno contacts with patients or primary care
mechanisms for these services. The Robertproviders. As health plan employees, care
Wood Johnson Foundation's $12 million nationalmanagers' salaries and expenses are typically
program, "Depression in Primary Care: Linkingabsorbed in the administrative costs charged to
Clinical and Systems Strategies," funds threethe health plan's customers (i.e., purchasers). In
related grant components - incentivessome cases, health plan-based care management
(demonstration projects), value research, andtargets specific diseases (e.g., asthma, diabetes,
targeted leadership awards - to stimulatedepression) or populations (e.g., the frail elderly).
innovation in primary depression care. TheseDemand for enhanced, collaborative care by
components help to identify and implementpurchasers and consumers will be instrumental in
economic and organizational strategies that, alongmanaged behavioral healthcare organizations'
with evidence-based clinical best practices, willcommitment to invest in care management
sustain chronic illness care improvements in theservices to support primary care providers.
primary care treatment of depression. Several6. Third-Party Based Care Management
extant models for funding depression careUnder Contract to Health Plans
management services have been piloted throughHealth plans may subcontract with disease
the program's demonstration projects and similarmanagement organizations, managed behavioral
programs as described below.healthcare organizations, and/or community
1. Practice-Based Care Management on amental health organizations to provide off-site
Fee-for-Service Basiscare management services for specific patient
In the fee-for-service model, care managers arepopulations (e.g., chronically ill elderly patients) and
employees of the primary care practice andor diagnostic classes (e.g., patients with
located within its clinical site(s). Revenue flowsdepression). These arrangements are typically
from the insurer (e.g., a health plan orcapitated wherein the subcontractor receives per
governmental payer) to the primary care practicepatient per month revenue that is generally based
upon the insurer's receipt of properly coded billingon historical estimates of both the service costs
statements and in accordance with the payer'sand patients served. As with the other funding
benefits structure and coverage policies. Few, ifmechanisms, consumer expectations and
any, explicit care management billing codes arepurchaser demands will exert clinical and economic
recognized by third-party payers, especiallypressure on health plans to extend support to
private insurers, thus making fee-for-service billingthird parties to provide care management
dependent on "medically necessary" servicesservices.
rendered "incident to" physicians' care. To be a7. Hybrid Models
viable source of funding, however, anyCombinations of the funding mechanisms listed
fee-for-service care management billing fromabove results in various hybrid-funding models for
primary care would have to address currentcare managers and their services. For example,
constraints on billing for patient telephone contactscommunity mental health center counselors can
and inability of the sites to bill for multiple primarybe placed in primary care practices and funded
care provider encounters in the same day.partly through fee-for-service billing and partly
2. Practice-Based Care Managementthrough health plan contracts.
Under Contract to Health PlansChallenges and Opportunities
Health plans can contract with primary careBecause care management services fall outside
practices to provide care management servicesthe conventional margins of the healthcare
to certain plan members with specified diseases,delivery system and are delivered by healthcare
including depression. In these arrangements, careprofessionals whose training cuts across traditional
managers are typically located at the practiceboundaries, third-party payers require cogent
site(s) and may be employees of the practice,demonstrations of their value in order to justify
the health plan, or another entity (e.g., asubsidizing them. However, a decade of
community mental health organization or a diseasewell-controlled health services research
management company). Such arrangements candemonstrating the benefits of depression care
include providing full or partial salarymanagement (i.e. better integration of primary and
reimbursement to practice sites for depressionbehavioral healthcare for depressed patients,
care managers. Revenue for the care managers'improved clinical outcomes) and the strong
services is generally based on historical estimatesendorsement of major health policy institutions
of both the service costs and the number of(such as the President's New Freedom
members served, and takes the form of monthlyCommission, the Institute of Medicine, and the
or yearly retrospective payments.Centers for Medicare and  Medicaid Services) can
3. Global Capitationdrive ongoing efforts to find sustainable
Group model HMOs, which are generally fullymechanisms for funding these services.