Addiction, Mental Health Screenings Play Important Role in Preventative Care
> 7/12/2007 10:50:08 AM

Yesterday, the Centers for Medicare and Medicaid Services (CMS) issued a release detailing the progress of the Medicare Physician Group Practice Demonstration, a large-scale exercise begun over two years ago to examine ways to reward doctors groups for reducing costs to the health care services. The program will run over three years, and will expand its focus each year. This release detailed some of the successes of the first year in which doctors focused on preventative maintenance of diabetes as a strategy for reducing overall costs.

The program marks an important shift in the way Medicare and Medicaid pay providers for care. Instead of focusing on volume of service, the 10 groups participating in the experiment are payed bonuses for saving Medicare and Medicaid money. They do this by helping patients to manage chronic conditions so as to avoid more costly procedures and treatments. In this pilot program, groups were payed bonuses for performing better than other groups in local markets. Only two of the 10 groups qualified for bonuses in the first year, but overall, all groups grew their spending at rates slower than their local markets. While CMS has shown forward thinking in moving toward a preventative care model, the conspicuous lack of mental health screening--for relatively common conditions such as depression, anxiety disorders or substance abuse--is a major blemish on an otherwise strong plan.

Outlining the logic behind this new program, CMS Acting Administrator Leslie V. Norwalk said:

"Twenty-three percent of beneficiaries have five or more of the chronic conditions that account for 68 percent of Medicare spending. They see an average of 11 physicians and fill 50 prescriptions a year. Creating payment incentives that can lead to better patient outcomes and lower total costs is the right thing to do."

Discussing the plan's initial successes, the New York Times explained how the focus on diabetes in year one was paying dividends:

Although Medicare and the doctors’ groups are still analyzing the information for the first year, many of the programs put in place seem to have resulted in fewer hospitalizations. Among its efforts, for example, Marshfield started a program in which eye exams for diabetes patients could be performed at a local doctors’ office rather than requiring a trip to a specialist. The clinic, which is based in Wisconsin, says it has reduced hospitalizations for its diabetes patients by about 13 percent in mid-2007 compared with 2004.

Other successful measures include simple follow-up. The University of Michigan group is having a nurse or nursing assistant call patients who have been discharged from the hospital or emergency room within 24 hours, making sure they understand the drugs they need to take or that, for example, a visiting nurse came as scheduled.

During the program's 2nd year, heart health will be added to the doctors group's itinerary for preventative care, and then in the 3rd year further preventative steps will be included. While it appear as though doctors participating in the program see the benefits, both to the patient as well as to the overall system, there is still some worry about how individual doctors will be incentivized to provide care, as we learned in the New York Times's write up:

And questions remain about how to motivate individual physicians because the experiment rewards organizations, not the individual doctor who must actually ensure that the patient gets a flu shot or goes to the right specialist.

“The real driving force of change needs to occur in a physician office,” said Dr. Karl Ulrich, the president and chief executive of the Marshfield Clinic.

These are issues that need to be addressed by CMS with input and discussion coming from the providers groups. Working together a plan can be worked out that will ensure that doctors continue to be reimbursed for their work, while at the same time incentivizing proper, preventative measures.

One major area where this program continues to lag, however, is in incentivizing early screenings for damaging mental health disorders such a major depression and substance abuse. Reseachers from Brandeis University have demonstrated that behavioral health screenings are not currently happening at appropriate levels in primary care situations. This leads to undertreatment and more damaging and costly outcomes down the road. Technology has provided the tools for quick and efficient screening, and combined with electronic medical records, something already in place at the 10 groups participating in this study, these screenings can and will save money and lives.

While CMS should be commended on their effort to find new and improved ways to manage health care costs, they can go further, faster by simply adding behavioral health screenings into their already comprehensive plan for preventative care. The best preventative medicine is that which looks at the entire individual, and mental health has an enormous role to play in the everyone's overall health.

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