NCQA: Early Intervention, Quality Follow-Up Care to Combat High Cost of Mental Health Care

A new study conducted by the National Committee for Quality Assurance hopes to aid in the development of measures intended to improve the quality of depression care. 

In 2014, an estimated 2.8 million US adolescents 12 to 17 years of age suffered at least one major depressive episode within the past year, according to the National Institute of Mental Health (NIMH), a figure representing a whopping 11.4% of that population. Despite the prevalence of adolescent depression, however, a new study is raising some serious concerns about the quality of care this group is receiving. 

Conducted by the National Committee for Quality Assurance (NCQA) and published in JAMA Pediatrics, the study found that care for adolescents with newly identified depression was generally low in the 3-month follow-up period. For example, 19% of did not have any follow-up care, 36% did not receive any treatment, and 68% had no documentation that symptoms were monitored or reassessed using a valid questionnaire. 

In addition, 40% of the adolescents who were prescribed antidepressant medication did not have any documented follow-up contact with a provider in the 3 months following the initial prescription, which is particularly alarming considering Black Box Warnings that highlight the suicide risk for youths taking this form of medication as well as the recommendations for close monitoring during this period of time.

“The concern here is that these practices are diverging from best practices and care standards that we would hope adolescents are receiving,” said lead author Briannon O’Connor. “Also, there’s quite a bit of awareness that adolescent depression, if left untreated, isn’t something that just goes away. It often gets worse and can lead to more problems.”

Adolescents who fail to achieve symptom remission, she noted, are more likely to relapse and develop recurrent depression, develop additional mental health concerns, and experience difficulties with school, work, relationships, and functioning in day-to-day life. 

“Therefore, best practices, clinical guidelines, and scientific evidence converge on the understanding that it is critical to identify and treat adolescent depression early so young people develop skills they will need to manage their symptoms and know when to seek help and additional support,” she added.

O’Connor pointed out that the overall medical costs for adolescent depression are higher than those for most other mental health conditions, so early intervention and quality follow-up care could also be viewed as tools in the battle against the hefty price tag associated with the illness. 

Root of the Problem

Despite the worrisome results of the study, O’Connor acknowledged the encouraging findings as well. “A positive finding is that treatment is initiated for the majority of adolescents,” she said, noting that nearly two-thirds of those with newly identified depression symptoms did receive some sort of treatment. “And most included psychotherapy, which is often considered one of the best components of treatment for adolescent depression.”

She also pointed out some of the uncertainties that need to be taken into account. “An important point about this study is that we can only see what is in the electronic health record, so we can speculate about why some of the follow-up care didn’t occur but we can’t test it in this study because we didn’t see it,” she said. “There are a lot of variables we’re not aware of that could contribute to this lack of follow-up.”

Perhaps the adolescent didn’t want to return for treatment, maybe the family chose not to pursue treatment, or maybe a long wait to see a specialist pushed the follow-up visit beyond the 3-month period analyzed in the study, O’Connor put forth as examples. There is also a small percentage of adolescents whose symptoms alleviate without any follow-up care, eliminating the need to seek further treatment. 

Dig even deeper, though, and there could be other issues contributing to the current level of care, such as the stigma that continues to surround mental health, a lack of resources needed to ensure appropriate follow-up, or even the cost structure and how care is paid for. 

Cost of care is less of a concern now because of recent legislation regarding mental health parity that requires health insurance plans to provide the same benefits for mental care services as for medical services, explained Sarah Hudson Scholle, the study’s principal investigator and vice president, Research and Analysis, NCQA. But sometimes the real issue boils down to availability within a plan network. Services may be offered, but they may not be readily available if long wait times delay appointments and treatment. 

Payment arrangements can play into this as well. Coordination between the primary care provider and the behavioral health provider includes follow-up with patients, and those are the kinds of services that aren’t paid by traditional fee-for-service arrangements, she pointed out. Private doctors’ offices, for example, aren’t compensated for the time spent interacting with the behavioral health provider and coordinating related care. 

Some alternative arrangements are beginning to emerge, however. “We see this in patient-centered medical homes,” Scholle said. “Some health plans and other kinds of payers are actually providing primary care practices with essentially a care management fee to recognize their role in coordinating care and following up with patients to make sure they’re getting the care they need.”

The Affordable Care Act (ACA) has supported a number of delivery system reforms, particularly with advanced primary care for patients in a medical home, she added, so there are a number of initiatives across the country to encourage practices to organize the infrastructure needed to manage their patient population and monitor the quality of care. It’s also embedded in the Medicare Access and CHIP Reauthorization ACT of 2015 (MACRA), which reinforces the shift of Medicare spending into value-based payment models. 

Fixing a Broken System

Scholle contends that there are tangible steps that can be taken to make improvements across the nation. One is to encourage better communication among providers, adolescents, and their families about depression. This affects a number of adolescents, she said, and this should be discussed because effective treatments do exist. 

“The second piece is building on good access to mental health treatment,” she said. This includes medication, talk therapy, and additional forms of treatment so that adolescents and their families can work with their care team to identify the most appropriate treatment.

“Part of that access is to make available for adolescents services beyond medication,” she emphasized. For many adolescents and their families medication may not be the right fit. Oftentimes talk therapy is preferred, but that may not be as readily available.

Coordination and follow-up is essential as well. “When you’re depressed you feel worthless,” Scholle explained. “You often don’t feel like doing anything, so having someone on the care team who is working and reminding you that you can get better is an important step.” Sometimes it’s just having the systems in place to track people and ensure they’re coming back, she added. Organizations really need to implement a systematic approach to successfully handle this aspect.

Bigger Picture 

During the search for organizations to include in the study, Scholle and O’Connor sought out practices that consistently utilize standardized tools to assess depression symptoms and also capture that information in an electronic format. Ultimately, they examined routine care within 3 large health care systems that included 2 sizable HMOs in the western United States and a network of community health centers in the Northeast region. 

One aspect that is important to understand about the study’s results, Scholle explained, is that the organizations examined are well-positioned leaders that have essentially taken a leap ahead of many other providers by demonstrating a commitment to use tools and adopt the approach of making behavioral health services available. Because sites that participated in the study are highly regarded institutions, the results potentially overstate the quality of care found in other settings. 

It just goes to show how difficult it is to treat adolescent depression even when resources are available. And while this particular study honed in on the treatment of adolescents in particular, the authors believe it also sheds light on the challenges of treating depression at large, regardless of age. The stigma surrounding mental health care is pervasive, O’Connor said. As such, there’s a real opportunity for primary care doctors and other physicians to discuss depression and maybe even provide treatment and support for mental health concerns. 

Allowing providers in various roles to have access to best practices, guidelines, training, and support for how to identify mental health concerns like depression using validated tools is important, but so is knowing how to appropriately coordinate care—an issue that certainly extends beyond adolescent depression alone.

“We have taken the results of this study, and NCQA has developed measures that we’ll be using to try to encourage health plans to work with providers on improving the quality of depression care for adolescents and adults,” Scholle said. “That was the [inspiration] for this work was to develop quality measures, and we’re happy to say that we’re going to be using those to encourage health plans to pay attention to this problem and to work with primary care and behavioral health providers—and the adolescents and families who are their members—to try to really improve outcomes.” ■