By Gary Oftedahl, MD

Comparative cost-of-illness studies continue to show that depression is among the most costly of all health problems for employers. According to the Journal of the American Medical Association (JAMA), depression costs U.S. employers $44 billion a year. A recent Minnesota Department of Health and Minnesota Department of Human Services report said although the cost per employee with depression in Minnesota varies, some studies show a cost range to employers from $3,000 to $4,000 per year.

In today’s tough economy, the number of people suffering from depression has sky­rocketed. This requires that employers pay more attention to treating depression in
the workplace.

The seriousness of depression

Depression is simply a terrible disease. A 2007 study by the World Health Organization (WHO) of more than 245,000 people showed depression decreased the quality of their health more than other chronic diseases such as diabetes, arthritis, and asthma.

The negative impact of depression on employees has been further verified in a study, “The Cost of Lost Productive Work Time Among U.S. Workers With Depression,” published by the Journal of the American Medical Association (JAMA) in 2003. It found that diabetes, low back pain, migraines, allergic rhinitis, gastroesophageal influx, and depression dominate health-related lost labor costs. Depression is among the most costly because it is highly prevalent and often linked with other health conditions. Furthermore, although workers with depression are usually present at work, their performance can be substantially reduced.

The development of collaborative care

One of the challenges with helping patients with depression to recover is that primary care physicians treat about 75 percent of these patients. Care usually consists of prescribing antidepressants, supportive counseling, and/or referral to behavioral health specialists.

However, after antidepressants are prescribed there is often little monitoring, and many patients stop taking antidepressants too soon. Just 10 percent of those treated show substantial improvement within 12 months of diagnosis. This is in part because more than 80 percent of patients with depression have an additional health condition or disease, and primary care physicians are usually better trained to address physical versus mental health problems.

With primary care deficient in helping patients recover from depression, new models of care have been explored. “Collaborative care” models, which take a team approach to treatment, indicate that by integrating care managers and mental health professionals into primary care, outcomes of patients with depression improve.

Among the research in collaborative care, the most comprehensive work has been done by Wayne Katon, MD, and Jürgen Unützer, MD, both of the University of Washington. Under the latter’s collaborative care model, participants had fewer suicidal thoughts, higher recovery rates and improved function, and more depression-free days compared to typical primary care treatment. In addition, Unützer’s research has shown potential overall health care savings of $3,300 per individual over a four-year period compared to individuals in usual primary care treatment.
Much of this savings was attributed to patients not requiring more intensive medical care or hospitalization due to unmanaged depression. Also, since so many people with depression are plagued by another disease or illness, eliminating depression gave patients the energy and motivation to tackle other health issues.

The DIAMOND program

The Institute for Clinical Systems Improvement (ICSI), a non-profit organization dedicated to improving the quality and lowering the cost of health care, recently set out to establish a sustainable collaborative care model for managing depression in the primary care clinic. It brought together providers, behavioral health specialists, employers, health plans, and patients to develop a program called DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction).

DIAMOND is unique in that it changes how care for the patient with depression is delivered and paid for in primary care. Certified DIAMOND clinics hire care managers to help patients with education, self-management support, stepped therapy, primary care-mental health care coordination, and relapse prevention. The care manager uses telephone calls, e-mails and/or face-to-face meetings with the patient. These contacts occur more frequently than is feasible for office visits with the primary care physician. The care manager typically contacts the patient on a weekly basis. As the patient improves, contact is scaled back.

The consulting psychiatrist, in collaboration with the care manager, reviews the clinic’s DIAMOND patient caseload weekly and recommends changes in treatment for patients who are not improving. The primary care physician makes all final treatment decisions and initiates changes to patient treatment plans.

Psychologists, social workers, and other mental health providers continue to play a key role. Patients may be referred for therapy and other services as part of their treatment plan. In this way, DIAMOND helps ensure that patients requiring behavioral health expertise are more apt to get to specialists, while those who can be helped in primary care receive the evidence-based level of care known to get results.

A new reimbursement model

DIAMOND’s reimbursement model is unique. Dann Chapman, director of employee benefits at the University of Minnesota, says, “Employers have recognized the return on investment of collaborative care models for treating depression, but these models have been research-based and lacked long-term funding. There is a unique health plan payment model behind DIAMOND that promises to make it a sustainable program.”

Under the new payment model, nine Minnesota health plans agreed to make a monthly payment to participating DIAMOND clinics for a bundle of services that includes the roles of care manager and consulting psychiatrist. Only clinics trained and certified to deliver the DIAMOND program are reimbursed, and all clinics use a single, established billing code. Each medical group and health plan has negotiated a care management fee.

DIAMOND results

The DIAMOND program has now been implemented in 59 clinics in Minnesota, with additional facilities being introduced through 2010 for an expected total of about 85 clinics.
Of the patients contacted six months after enrollment in DIAMOND, 43 percent have recovered from their depression. An additional 20 percent of these patients have seen at least a 50 percent reduction in the severity of their depression. These results are 5-10 times better than recovery and improvement noted under usual primary care as noted in August 2009 by MN Community Measurement. They are matching or exceeding the outcomes re­ported in the collaborative care research studies proven to lower health care costs and provide financial benefits by getting employees with depression back to productive work faster.

The future of DIAMOND

The DIAMOND collaborative model is being implemented in a sequenced fashion in an effort to identify the benefits that might be gained from this innovative approach to both care delivery and payment reform. Further discussions regarding the extension of the program to additional clinics have begun. Employers should inquire of the health plans with whom they contract to identify opportunities for involvement in this unique program.

The number of employers providing coverage for the DIAMOND program is expected to grow as the program spreads across the state through additional primary care clinics. Based on its novel care delivery and payment models, DIAMOND is being hailed as the possible model for managing depression in primary care clinics not only in Minnesota, but nationwide.
“Depression affects people from all walks of life. I believe the personalized approach of the DIAMOND program provides a sense of hope and direction to people with depression,” says Tim Crimmins, MD, vice president and director of health, safety, and environment for General Mills. “This program has demonstrated dramatic response and remission rates. Its widespread adoption is an important step forward for employers everywhere.”

For more information on the DIAMOND program, go to www.icsi.org.

Gary Oftedahl, MD, is chief knowledge officer at the Institute for Clinical Systems Improvement, a nonprofit quality improvement organization based in Bloomington.

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