Several studies have demonstrated that models of collaborative care for depression, in which depression treatment is coordinated between a primary care provider, a treating mental health specialist, and a care manager, result in better-quality depression care and better depression and functional outcomes (1,2,3,4,5). Although these are promising models, particularly in group health settings, coordinating care and creating incentives for providers to participate in these models is complicated in systems in which mental health care is subcontracted or carved out to one or more managed behavioral health organizations (MBHOs). In particular, carve-out arrangements may create disincentives for primary care providers if the providers do not receive compensation for diagnosing or treating depression when a patient's medical plan defers the claim to the MBHO or if the providers are not given easy access to a mental health specialist or care manager to help coordinate complex cases.
This structure poses a significant barrier to improving treatment of depression in primary care settings and contributes to a lack of dialog and collaboration between the primary care sector and the behavioral health care sector (6). Given that 70 percent of mental health care is managed in carve-out systems (7), adapting collaborative care models for practices that serve patients in MBHOs is a priority.
This column describes a collaborative care model for depression that has been in operation since 2003 and discusses the effectiveness of incentives used to encourage participation by primary care providers.
The main aim of the collaborative care program described here is to address the structural and financial barriers dictated by a carve-out arrangement through an innovative economic and clinical partnership, consisting of a primary care practice, located at the University of California, San Francisco (UCSF); a health insurer, Blue Shield of California (BSC); and a managed behavioral health organization, United Behavioral Health (UBH). This partnership resulted in a service expansion of the existing UBH care coordination infrastructure so that primary care providers at UCSF have access to a depression care manager located at UBH. The care manager provides ongoing monitoring of patients who initiate depression treatment prescribed by the primary care provider and telephone access to a psychiatrist for consultation on complex cases.
In addition, primary care providers who participate in a "credentialing" seminar on chronic care depression management are eligible to bill UBH for depression services and to increase their follow-up visits with elegible depressed patients to 30 minutes. Each primary care provider receives "credit" and time off from patient responsibilities in exchange for participating in the seminar. Credentialed primary care providers are enrolled in the UBH system in a special category, eligible to bill for medication management services rendered in the primary care setting and to receive reimbursement under CPT code 90862.
The partners felt that these financial, time, and resource incentives would stimulate providers' participation in collaborative care for their depressed patients who were covered by BSC and UBH. As part of the credentialing and ongoing educational process, primary care physicians also have one-on-one depression education sessions with the project director, loosely based on an academic detailing model that emphasizes person-to-person education by a credible expert to enhance changes in knowledge and behavior (8).
Before implementation of the collaborative care depression program, BSC capitated UCSF primary care practices for the medical treatment of its insured members and subcontracted to UBH the management of its behavioral health benefits. After implementation of the program, UCSF primary care physicians were eligible to become credentialed members of the UBH clinician network. As a result, a mechanism was created by which the BSC capitation for behavioral health is directed back to the primary care setting specifically for management of depression, thus removing a disincentive to the provision of this care.
As described previously (9), 37 UCSF primary care providers (81 percent) have been credentialed. In informal focus groups held during the credentialing training, providers indicated that access to the psychiatry consult hot-line and the availability of a depression care manager were important incentives in their participation. Although three-quarters of the credentialed providers have referred patients to the collaborative care program, initial referral numbers were quite low. In addition, only a small number of credentialed providers who made referrals used the "behavioral health" appointment that would permit them the extra time with a depressed UBH or BSC patient and the additional financial incentive to treat depression.
Feedback from credentialed providers revealed that restricting the program to patients with UBH or BSC coverage was overly burdensome and that information on patients' coverage was sometimes unavailable or inaccurate. Under this original model, the services of the collaborative care program were available only for a relatively small percentage of the primary care providers' patients (approximately 15 percent). Primary care providers were unable to accurately identify a patient's mental health coverage, and this barrier overshadowed the benefits of financial reimbursement, increased time, and access to clinical resources for eligible patients.
To better understand the impact of financial, time, and resource incentives on the behavior of primary care physicians, the partners in the collaborative care program expanded eligibility to all depressed patients with managed behavioral health care insurance who were seen in the UCSF primary care practice. All patients with depression may be referred to the depression care manager for education about depression and treatment, about ongoing support and self-management, and about how best to gain access to services through the plan that covers their mental health care. Only patients whose behavioral health care is covered by UBH are eligible for referrals to specific behavioral health care providers within the UBH system. Primary care providers may also use the psychiatry hot-line to consult on any patient in their practice, regardless of insurance status. However, the time and financial incentive is available only to primary care providers when they treat UBH or BSC patients.
Although the program's credentialed providers are still underutilizing the additional time and financial incentives, they have increased the number of UBH and BSC patients referred to the program, as well as the total number of referrals, and they are satisfied with the increased coordination of care between their practice and the mental health system. Interestingly, many primary care providers who did not participate in or were not eligible for the credentialing program have referred many patients to the program, further highlighting the importance of ready access to clinical resources as a significant incentive for participation.
The collaborative care program for depression has raised interesting economic and practice issues with regard to improving depression management for patients covered by MBHOs. One important finding is that allowing primary care providers to refer only certain patients to the program significantly diminishes their overall willingness to refer patients. Even though a large percentage of the primary care providers are credentialed by the program—and they made a substantial number of referrals once the restrictions on referrals were lifted—their underutilization of time incentives suggests that they are motivated by the clinical aspects of the collaborative care program, such as care management and access to a UBH psychiatrist for consultation, but are deterred by the extra effort required to identify patients who are eligible for extended visits (UBH and BSC patients). In addition, the financial incentive was apparently not a powerful enough inducement for the providers or the practice to complete the necessary billing forms to receive financial credit from UBH for depression care. As evidenced by the partners' decision to allow referral of all depressed patients into the program regardless of coverage, reducing the number of steps providers have to engage in increases the value of resource incentives for providers.
Sustaining a collaborative care program that is provided by one MBHO is a challenge. Because providers increased their referrals to the program after the eligibility restriction was lifted, the UBH care manager has had to commit additional time to helping depressed and distressed patients who do not have UBH coverage. Furthermore, the financial costs and the potential risks incurred by this arrangement are likely to meet resistance from MBHO management. Thus our solution to offer the clinical services to "all comers" is unlikely to be a sustainable feature of the program, unless a system whereby all MBHOs participate in a centralized case management program can be created. However, results from the collaborative care program for depression at UCSF indicate that although time, financial, and clinical resource incentives may initially interest providers and practices in participating in such a program, the ongoing availability of additional clinical resources for all patients in the practice seems to be the most critical incentive. Future program development and research should focus on methods for facilitating collaborative care programs among MBHOs and primary care practices.
This work was supported by grant 048170 from the Robert Wood Johnson Foundation.
Dr. M. Feldman, Dr. Areán, and Dr. Lee are affiliated with the department of medicine and psychiatry at the University of California, San Francisco, 400 Parnassus Avenue, San Francisco, California 94143-0320 (e-mail, email@example.com). Dr. Ong is affiliated with the department of medicine at the University of California, Los Angeles. Dr. S. Feldman is chair emeritus of United Behavioral Health. Steven S. Sharfstein, M.D., Haiden A. Huskamp, Ph.D., and Alison Evans Cuellar, Ph.D., are editors of this column.