Aetna to Pay for Depression Screening By Primary Care Physicians

Aetna has begun depression screening in primary care settings for health plan enrollees who have certain high-risk, chronic medical conditions.

The insurer will reimburse primary care physicians to use the nine-item Patient Health Questionnaire, or PHQ-9, to screen patients who have diabetes, coronary artery disease, or other chronic medical conditions that are known to accompany depression frequently, according to Hyong Un, M.D., national medical director for behavioral health at Aetna.

The PHQ-9, developed at Columbia University and the Regenstrief Institute at Indiana University, screens for the presence of depression and provides an assessment of severity (Psychiatric News, June 3, 2005).

Aetna's screening program is being piloted in the District of Columbia and six states: New Jersey, Pennsylvania, Maryland, Virginia, Texas, and Oklahoma. If successful, it will be extended nationwide.

The move by Aetna to screen high-risk patients in primary care settings is a first among large health insurers. It is regarded as a sign of widening recognition of employers of the toll that depression takes in the workplace and by health plans of the comorbidity of depression with general medical conditions.

“Since family physicians and other primary care doctors write an estimated two-thirds of prescriptions for antidepressants in the United States and are often the gatekeepers for referral to psychiatrists and mental health professionals, this Aetna program, which will be carefully evaluated, is an important breakthrough in providing financial support for depression treatment,” wrote APA President Steven Sharfstein, M.D., in his president's column in the January 6 Psychiatric News.

“With nearly half of lost productivity in the United States attributed to major depression, with an estimated cost of $44 billion annually, this Aetna program will be carefully reviewed by other major payers, HMOs, and employer groups, as well as professional organizations such as APA,” Sharfstein wrote.

Un told Psychiatric News that the depression-screening plan is part of Aetna's effort to integrate general medical and mental health care, an effort that includes the termination of “carveout” care for enrollees who have mental health benefits with Aetna. As of January 1, coverage of mental health under Magellan Behavioral Healthcare—the carveout company contracted with Aetna—will cease, and enrollees will have their claims paid for by Aetna.

“We want to integrate behavioral health care with the rest of medical care,” Un said. “If you want to do that, you can't talk about two different data systems and two different care processes. You have to look at it holistically.”

Un emphasized that, contrary to some reports, Aetna was not undertaking general population screening of all of its enrollees. “What we are trying to do is assess members at risk,” he said. “That means people with medical comorbidity—diabetes, coronary artery disease, or back pain, for instance. We know the prevalence of depression is higher in that population.”

Aetna's initiative encompasses three components: training of primary care physicians and office staff to use the PHQ-9, a care-management system to support patients and primary care physicians in managing depression, and access to mental health specialists.

“This program is focused on collaboration with specialists,” he told Psychiatric News. “It is not meant to divert patients away from psychiatrists. We are committed to working with APA to make sure psychiatrists are involved in this process. Based on our data, most of our patients are getting treated by primary care physicians, but we want to get those patients who need to see a psychiatrist an appropriate referral.”

The Aetna initiative also expands the use of the PHQ-9 as a quantitative measure for assessing depression. In New York City, primary care doctors began using the instrument last year to screen for depression in primary care settings (Psychiatric News, May 20, 2005).

“The Aetna initiative can potentially provide greater access to treatment for depression at the primary care site,” said Darrell Regier, M.D., M.P.H., executive director of the American Psychiatric Institute for Education and Research and director of APA's Division of Research. “We are very interested in how this is going to work for Aetna, and we are looking at how the PHQ-9 could be used eventually as a quality indictor in other quality improvement efforts.”

Regier said a large number of studies have shown that “if primary care physicians will use the PHQ-9 to quantify severity and treatment response, and if they will have a care manager to follow up with the patient after the patient has started treatment, there will be a major improvement in quality of care and outcome for these patients.”

He added, however, that while the instrument has proven highly successful in test conditions, physicians tend to neglect use of the instrument, when the study is over. For that reason, APA has been collaborating with the American Academy of Family Physicians and the American College of Physicians to examine the barriers and obstacles to adoption of the instrument.

“The main problems are logistical, involving staff support and tracking of patients,” he said. “To make efficient use of this instrument, you may need support staff who can monitor patients. If you don't have the support staff, then you need a mechanism for tracking patients to make sure they have periodic assessments of treatment effectiveness—to guide treatment changes as needed.”

More information about the screening initiative is posted on Aetna's Web site at<www.aetna.com/news/2005/pr_20051102.htm>.▪