New Medicare Benefit Could Have Unexpected Treatment Consequences

Without significant changes in the U.S. health care system, baby boomers who experience depression in the coming years will likely face increased barriers in access to, and quality of, mental health care, new research has concluded.

Today the vast majority of elderly patients with depression receive care in primary-care settings under Medicare. They have limited access to comprehensive psychiatric care because of Medicare's discriminatory 50 percent copayment for mental health services. Now, with the debut of the new Medicare Part D drug benefit only months away, some researchers believe that many of these patients will greatly expand the number of people already treated for depression with medications only, without the benefit of appropriate comprehensive care, including psychotherapy.

“Undoubtedly, what you are going to see with Part D is even more undermanaged, drug-only treatment,” predicted Stephen Crystal, Ph.D., a research professor at the Rutgers University School of Social Work and chair of the Division on Aging at Rutgers Institute for Health, Health Care Policy, and Aging Research.

“What we see now is 20 to 25 percent of the elderly depressed population who lack prescription drug coverage, and another 20 percent who have minimal coverage. With Part D, you'll have increased use of antidepressants, without a doubt. And because availability drives diagnosis—rather than the other way around—you'll see even more patients being diagnosed with depression simply because the drug treatment is available.”

Moreover, Crystal told Psychiatric News, he expects the quality of care to be substandard.

“There's no way psychiatry [as a field] can keep up with providing services to all those people who will be diagnosed, especially in nonurban areas,” Crystal predicted. The result could be an impending disaster.

Crystal based his observations on research he and colleagues at Rutgers recently completed on the use of psychotherapy for depression in elderly patients covered by Medicare. Their report appeared in the April American Journal of Psychiatry. The study was funded by grants from the National Institute of Mental Health, the National Institute on Aging, and the Agency for Healthcare Research and Quality.

Crystal and his colleagues noted that several types of psychotherapy have been shown to be effective in treating the elderly for depression. While pharmacotherapy is considered a mainstay of treatment, many experts have raised concerns recently regarding the effectiveness of antidepressants in elderly patients, particularly since drug-drug interactions and adverse effects can be significant in this population.

Although Agency for Health Care Policy and Research guidelines recommend treatment for four to nine months in older patients with depression to reduce the likelihood of recurrence, the extent that psychotherapy is used in such treatment is unknown. Crystal examined national patterns in psychotherapy treatment in elderly patients with depression by analyzing Medicare claims and survey data from the 1992 through 1999 Medicare Current Beneficiary Survey cost and utilization files.

A lot of the treatment for depression, Crystal said, “is very superficial, not very well managed. The great bulk of it is done in the primary care sector in 10- or 20-minute encounters where there's usually a whole series of issues that must be dealt with.”

As a result, he continued, depression gets short shrift. Primary care providers seldom use structured instruments to screen for the disorder or evaluate response to treatment, he added.

What Crystal and his colleagues found did not surprise them, he said.“ There's a minority—only about a quarter of elderly patients diagnosed with depression—who are getting any psychotherapy, and most of that therapy is very brief,” he noted. “The thing that jumped out though, in addition to the low treatment rate, were socioeconomic disparities.”

Patients who were under age 80, had higher education levels, and lived in urban areas were significantly more likely to receive psychotherapy.“ The whole issue about rural mental health care is huge; the services simply are not there.”

To understand the trends, Crystal said, “you really have to look at what has happened to psychiatry in the past 10 to 15 years.” With managed care in general, the emphasis has been increasingly shifted toward medication-only therapy.

With respect to the elderly population, Crystal added, “I have to think it has even more to do with the limitations on supply [of geriatric psychiatrists] and to the very substantial financial limitations. How many patients can afford a 50-percent copayment [required by Medicare]?”

Another significant barrier facing elderly patients with depression, Crystal said, is that Medicare may only reimburse psychiatric consultations for patients in primary care settings at 50 percent.

“This is something that Medicare is going to have to look at,” Crystal continued. “There are never going to be enough psychiatrists and certainly not going to be enough geriatric psychiatrists to care for all these patients.”

Nonetheless, as the brunt of the mental health care has fallen to primary care physicians, efforts have aimed at building effective models of primary care–based depression treatment, Crystal acknowledged.

One such model is NIMH's Project IMPACT, which uses depression care managers—typically nurse practitioners or social workers—within primary care practices (Psychiatric News, April 4). However, these models remain problematic, he said.

“I don't agree with the trend that depression has become a primary care disease that doesn't really need specialist treatment,” Crystal said. “I'm not sure our psychopharmacology is analogous” to other treatments once the domain of specialists, such as treating ulcer disease or reflux and uncomplicated cardiovascular disorders. “The advances [in psychopharmacology] aren't so definitive that it makes the `trickle-down' analogy as clinically rational as it might be for some other specialties.”

Crystal noted that many elderly depression patients do not respond well to antidepressant pharmacotherapy, especially those with recurrent depression. Yet the discriminatory 50 percent copayment makes psychotherapy a costly option.

“The statutory discrimination inherent in Medicare has no evidence base—it is simply a cost-containment vehicle,” Crystal said. With new drug coverage under Medicare Part D, this will only be exaggerated, he added.

Cost-effectiveness, rather than simply cost, should weigh heavily in Medicare coverage decisions, Crystal concluded. As it does for children, adolescents, and nonelderly adults, research suggests that combining medication with psychotherapy improves depression treatment outcomes in the elderly.

“We need to look at cost-effectiveness, head to head, with some other highly expensive services that we provide for elderly patients,” Crystal offered, “and it may be that some other specialty treatments should have a 50 percent copayment before you require it of psychotherapy.”

An abstract of “Use of Psychotherapy for Depression in Older Adults” is posted online at<http://ajp.psychiatryonline.org/cgi/content/abstract/162/4/711>.▪