Utilizing HEDIS Measures to Treat Major Depressive Disorder

Atlanta—With numerous generic drugs available, the costs of treating depression are often seen as low compared with chronic, more expensive diseases. However, according to a presentation at the AMCP meeting, depression is a common condition that is comorbid in other diseases, leading to a high economic burden and a difficulty in diagnosing the disease in many patients. The speakers examined ways to gain a better understanding of and measurements related to depression during a satellite symposium titled Improving Outcomes in Major Depressive Disorder: Advancing Health Plan Performance and Community Health Using NCQA HEDIS® Measures. Suzy Harrington, DNP, RN, MCHES, director of customer resources of the National Committee for Quality Assurance (NCQA) in Washington, DC, began the session with information regarding the NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS). She said HEDIS is the health insurance industry’s standard measurement tool for comparing plans’ performances and focuses on quality improvements. “Anyone who doesn’t want to measure doesn’t want to be held accountable,” Ms. Harrington said. The HEDIS 2012 includes 76 measures across 5 domains of care, including effectiveness, access/availability, experience, utilization, and cost. Two of the measures are related to depression. Antidepressant medication management (AMM) evaluates the compliance with medication regimens in the acute phase and continuation phase treatment, while follow-up after hospitalization for mental illness (FUH) evaluates follow-up within 7 and 30 days of discharge. In 2010, the AMM during the acute phase for commercial payers was 64.7% compared with 65.0% for Medicare participants and 50.7% for Medicaid patients. The AMM in the continuation phase for commercial payers was 48.3% compared with 51.9% for Medicare participants and 34.4% for Medicaid patients. Meanwhile, the FUH 7 days postdischarge was 59.7% for commercial payers, 37.4% for Medicare patients, and 44.6% for Medicaid participants. The FUH 30 days postdischarge was 77.4% for commercial payers, 55.4% for Medicare patients, and 63.8% for Medicaid participants. Ms. Harrington said the AMM and FUH measures could use improvement. If patients had better adherence to their medication and received proper follow-up treatment, they would have lower rates of relapse and recurrence, which would lead to cost savings. Clinical Burden of MDD Charles B. Nemeroff, MD, PhD, Leonard M. Miller Professor at the University of Miami Miller School of Medicine, Florida, said 5% to 10% of adults meet the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) criteria for major depressive disorder (MDD), which is the leading cause of disability in the United States. According to the DSM-IV, a person with MDD has a persistent depressed mood with feelings of sadness or emptiness or a loss of interest or pleasure in daily activities, with symptoms lasting ≥2 weeks. According to Dr. Nemeroff, there will be an estimated 40,000 suicides in the United States this year, including 1100 among college-aged people. He said nearly all of the suicides are due to partial treatment or nontreatment of depression. “Depression is a very serious problem,” Dr. Nemeroff said. Several chronic medical conditions are associated with depression, which Dr. Nemeroff said leads to higher healthcare costs, contraindicated health behaviors, significant functional impairment, lost work productivity, occupational disability, and increased utilization of healthcare resources. When treating depression, there are 5 outcomes: response (clinically significant reduction in baseline symptom severity), remission (absence of symptoms), recovery (sustained remission after major depression), relapse (return of major depression before recovery), and recurrence (new episode of depression following recovery of previous episode). Dr. Nemeroff said the goal of treatment is remission, with a study indicating that patients achieving remission have a 4 times greater chance of not having a relapse. Another study found that patients with remission miss significantly fewer number of work days compared with patients who have persistent or improved depression (P<.001). The Centers for Disease Control and Prevention released a recent report indicating 11% of people in the United States are on antidepressants. According to Dr. Nemeroff, no antidepressant medication has been proven to be better than another treatment approved by the US Food and Drug Administration. He said that physicians should consider previous response, family history, safety and adverse event profiles, ease of use, and costs when prescribing an antidepressant. After choosing the antidepressant, Dr. Nemeroff said physicians must monitor patients to determine their susceptibility to adverse effects, treatment failure, resistance, and suicide tendencies. If any changes occur, the clinician can modify or add on therapies. “We need to be as aggressive treating depression as we are treating cancer,” Dr. Nemeroff said. Improving Outcomes in MDD Jeffrey Dunn, PharmD, MBA, formulary and contract manager, SelectHealth, Inc, Murray, Utah, said 87% of people with MDD have moderate to very severe functional impairment and that the disease is commonly chronic and relapsing. He added there are several links to depression, and depression is frequently found as a comorbid condition in patients with conditions such as cardiac disease, cerebrovascular disease, Alzheimer disease, Parkinson disease, epilepsy, diabetes, cancer, HIV/AIDS, chronic pain, and obesity. “[Depression] is extremely complicated,” Dr. Dunn said. It is also costly. In 2000, the economic burden associated with depression was an estimated $83.1 billion compared with an estimated $43.7 billion in 1990. Of the 18.1 million people suffering from depression in 2000, only 7.9 million were treated. In 1990, an estimated 17.5 million people had depression and 4.9 million were treated. Treatment can help offset the costs, according to Dr. Dunn. He cited a study that found the cost per quality-adjusted life-year associated with an improvement in depression ranged from $2519 to $49,500. Dr. Dunn said improving medication adherence is crucial to containing costs and helping patients. He suggested several ways for health plans to get better adherence results. In pay-for-performance models, incentives are offered to patients, such as reduced copays, or to providers, such as direct payments. Another option is strengthening the relationships between patients and providers by empowering patients, utilizing motivational interviewing, and introducing other strategies that stress communication and coordination. Medication therapy management (MTM) is also an effective way to improve adherence, according to Dr. Dunn. In MTM, participants target drug therapy problems, establish interventions, and develop a patient-centered framework for educating and evaluating depression. Dr. Dunn said they must establish baseline compliance levels and compare them to compliance levels over time to measure medication compliance. He added that health plans should monitor drug costs and total medical costs to determine the return on investment. “We’re only as good as our data,” Dr. Dunn said. “If we’re guessing, it’s much more difficult than if we have the data.” Dr. Dunn said antidepressants should be covered through value-based benefit designs, in which health plans reduce or eliminate patient copays with the goal of improving adherence. In turn, they hope to lower costs through reduced relapses and follow-up treatment. He said patients with depression have an increased use of healthcare resources, increased comorbidities, and high rates of complicating comorbidities. “Even though generics are widely available, depression is still very important,” Dr. Dunn said. “It affects other disease states.”