Community Dialogue December 9, 2011 Call to Action: Using Incentives to Improve Optimal Depression Care

BHCAG: Who We Are Multi-stakeholder membership coalition ● Majority of members private and public purchasers ● Buy-side focused agenda ● Use collective voice of purchasers to improve ‒ Consumer engagement and access ‒ Provider accountability and outcomes ‒ Reduce health care costs Vision: Health care consumers get the care they need at the right time, in the right place, at the right price Mission: Redirect the health care system to focus on a collective goal of optimal health and total value 2

Minnesota Bridges to Excellence (MNBTE) Implemented in 2006 – National initiative – Redesigned by BHCAG to leverage MN infrastructure ICSI guidelines MNCM measures and public reporting Goals: – Improve the quality of care for patients – Raise the level of purchaser and consumer awareness about the variation in quality – Spark provider competition based on quality outcomes BHCAG manages and administers program – Added administration of State of MN Quality Incentive Program in

MNBTE Participating Purchasers 3M Best Buy Carlson Companies Honeywell Medtronic South West/West Central Service Cooperative 4 ●State of Minnesota Department of Human Services (managed care population) ●State of Minnesota Employee Group Insurance Plan ●Target ●University of Minnesota ●U.S. Bank ● Wells Fargo ●Private and public purchasers ●Provide health care to over 900,000 covered lives ●Finance incentive rewards for their members treated at higher performing clinics

Measures Eligible for MNBTE P4P Rewards Optimal Diabetes Care (since program inception) Optimal Vascular Care (2008, when changed from CAD) Optimal Depression Care (2009) – Six Months 5

Overview 2011 DDS: Statewide Rates *2007,2008,2009, 2010 Daily aspirin use (ages 41-75) on aspirin therapy **2011 Daily aspirin use if co- morbidity of IVD Caution should be made when making comparisons to 2011 because the aspirin component changed, and can’t be recast like A1c and Blood Pressure. 6

Overview of 2011 DDS: Depression Remission at Six Months Statewide Rates Percent of Patients in Remission 7

Public Reporting on Depression Care Measures Prior to 2011, clinics voluntarily reported to MNCM on depression care measures (around 150 clinics) State of MN mandated reporting on depression measures in 2011 (now around 560) Lots of room for improvement – Statewide Average similar to where Optimal Diabetes was when MNBTE implemented 8

2012 MNBTE Program Continue to pay rewards for Optimal Diabetes and Optimal Vascular Care Depression is key ambulatory focus – MNBTE purchasers had more patients with depression (24,132) in 2011 than diabetes (11,005) or vascular care (2,907) Excludes DHS patient counts since they don’t participate in depression care – Indirect relationship between severity of depression and productivity; 1-point increase in PHQ-9 score = 1.65% productivity loss 1 – Depression is frequently co-morbid with other chronic conditions Growing literature on impact of depression on optimal management of other chronic conditions Add two more measures eligible for rewards as additional motivation for improvement 1 Severity of Depression and Magnitude of Productive Loss, Annals of Family Medicine, July/August

2012 MNBTE Performance Design: Depression Achievement Two measures eligible for achievement rewards; clinic qualifies for only one – Continue rewards for Remission 6 Months Definition: Patients with major depression or dysthymia whose initial PHQ-9 score is >9 and the patients’ subsequent score within 6 months is <5. – Add rewards for Response 6 Months Definition: Patients with major depression or dysthymia whose initital PHQ-9 score is >9 and the patients’ subsequent score reflects a 50% of greater reduction within 6 months 10

2012 MNBTE Performance Design: Depression Improvement Add reward for Use of the PHQ-9 and characterize it as an “improvement” reward – Most likely for 2012 and 2013 only – Patients can’t get to remission or response if never given PHQ-9 Current clinic level use rates range from 0% to 100%; statewide average 61% – Increase the number of patients with depression who are given PHQ-9 to determine their “severity” of depression Clinics with a use rate of < 30% eligible (around 200 clinics) Clinics’ 2012 report year “use rate” must increase by 10 percentage points over 2011 report year “use rate” Clinics that qualify receive reward 11

Depression Toolkit Project Result of observing performance for 560+ clinics reporting in 2011 – Range of 0% - 30% for 6 months But only 30 clinics above 10% Jointly managed by BHCAG and MNCM – AF4Q Quality Improvement Project – Funded by RWJF grant Audience is non-DIAMOND primary care; may also be helpful to behavioral health providers Workgroup of providers and consumers established to identify tools to assist in the identification and treatment of depression in primary care – Leverage DIAMOND tools to the extent possible 12

Depression Toolkit Project 13 Goals : ●Engage providers and patients in the identification of the tools/aids that are within the project budget ●Improve care providers give (determined by improvement in the depression measure performance results) ●Aid adult patients in self management Deliverables : ●Develop toolkit with providers to be used by providers ●Develop patient oriented, self management tools with input from consumers and patients ●Promote and disseminate toolkit in late 2012