1. Using Population-Based Data to Estimate Treatment Gaps in Depression and the Impact of Physician Incentives
Joseph H Puyat, MA (Psychology), MSc, PhD
Centre for Health Evaluation & Outcome Sciences
Providence Health Care
29 November 2016

3. Outline 1) Background 2) Gaps and variations in depression care
3) Impact of physician on depression care
4) Conclusions
For more info:

4. What is Depression? Mood Disorder > 5 symptoms from the following
Sleep changes
Interest (loss of)
Guilt (feelings of)
Energy (lack of)
Cognition (substantial changes in)
Appetite (loss of)
Psychomotor (irritability or depressed mood)
Suicidality

5. How Prevalent is Depression?
CCHS 2012, Canada

6. How Prevalent is Depression?
NSDUH 2014, US

7. How is Depression Treated?

8. Treatment Gap
How Many Have Untreated Depression?
16%
84%
54%

9. Depression costs the economy CAD$32.3B/year
So What?
Global Burden of Disease Study
Depression is the leading cause of disability worldwide (1990, 2000, 2010, 2020)
Depression costs the economy CAD$32.3B/year

10. Data Canadian Community Health Survey
Medical Services Payment (MSP) Data
Mental Health Services Data File
Hospital Discharge Database
PharmaNet Database

11. Treatment Gap
Statistics Canada, CCHS 2012

12. Gap in Minimally Adequate Treatment
Overall Results
108,101
Diagnosed with MD in BC
13%
48%
53%
47%
MACP
MAAT
MAT
Inadequately Treated
Puyat JH, Can J Psychiatry, 2016

13. Real Gap in Minimally Adequate Treatment
Overall Results
Real Gap in Minimally Adequate Treatment
63%
37%
Treated by health care professionals
Untreated
MAT 33%
67%
Puyat JH, Can J Psychiatry, 2016

14. Sex and MAT
Disparities by Gender
Puyat JH, Can J Psychiatry, 2016

15. Age and MAT
Disparities by Age
Puyat JH, Can J Psychiatry, 2016

16. Disparities by Residence
Location and MAT
Disparities by Residence
Puyat JH, Can J Psychiatry, 2016

17. BC Mental Health Initiatives (2008) Mental Health Incentives
BC Mental Health Initiatives (2008)
Mental Health Incentives
MH Planning Fee ($100/yr)
Increased billable counselling sessions from 4 to 8 per year ($53.31 – $79.97)
Up to 5 tel/ follow-up fees/18 months ($15)
Up to conferencing fees ($40/15min)
CDM fee if patient has CPC ($120/year)
Training modules (diagnosing and managing mental disorders)
$2,900 compensation
By 11/2012, 42% enrolled, 67 of whom completed the program.
What the rest of Canada can learn from BC
“Provinces have been attempting ambitious and far-reaching reforms with new impetus over the last decade. Ontario, Quebec and Alberta have largely embraced  structural reform, changing how services are delivered, creating community health clinics or family health teams with other allied health professionals like nurse practitioners, and putting doctors on salary or other payments models rather than traditional fee-for-service payments…
British Columbia, has chosen a different route, opting to focus on operational reforms rather than structural reforms, through an active dialogue with physicians, patients, and other stakeholders to better align physician reimbursement with the provision of care to patients with complex health conditions and by supporting family doctors (also called General Practitioners or GPs) to feel better equipped both clinically and practically to do their job.”

18. Interrupted Time Series Analysis

19. Impact: Psychological Therapy
Percent
2005
2006
2007
2008
2009
2010
2011
2012
2013 53 55 57 59 61
Yr 5 = 3.3
Mean = 2.2
Puyat JH, Med Care, 2016

20. Impact: Antidepressant Therapy
Percent
2005
2006
2007
2008
2009
2010
2011
2012
2013 54 56 58 60 62
Mean = -2.8
Yr 5 = -4.5
Puyat JH, Med Care, 2016

21. Impact: Minimally Adequate Psychological Therapy
Yr 5 = 1.8
Percent
2005
2006
2007
2008
2009
2010
2011
2012
2013 8 10 12 14 16
Mean = 1.0
Puyat JH, Med Care, 2016

22. Impact: Minimally Adequate Antidepressant Therapy
Percent
2005
2006
2007
2008
2009
2010
2011
2012
2013 54 56 58 60 62
Mean = -1.7
Yr 5= -2.2
Puyat JH, Med Care, 2016

23. Impact: GP Continuity of Care (Mental Health)
Average
2005
2006
2007
2008
2009
2010
2011
2012
2013 77 79 81 83 85
Yr 5 = 4.4
Mean = 2.4

24. Summary
Reliable data are available and can be used to estimate gaps in treatment and examine the impact of policies
Gaps and disparities in depression care and treatment adequacy continue to persist
Physician incentives can influence depression care patterns, but the overall impact is modest

25. Implications Improve mental health services to everyone in general
Examine how younger adults and men access mental health care
Accelerate efforts to promote team-based approaches to mental health service delivery and not rely mainly on operational reforms
Expand public coverage for psychological therapies

26. Thank You!
References
Puyat JH, Kazanjian A, Wong H, Goldner EM. Is the Road to Mental Health Paved With Good Incentives? Estimating the Population Impact of Physician Incentives on Mental Health Care Using Linked Administrative Data. Medical Care Sep 14;
Puyat JH, Kazanjian A, Goldner EM, Wong H. How Often Do Individuals with Major Depression Receive Minimally Adequate Treatment? A Population-Based, Data Linkage Study. Canadian Journal of Psychiatry Jul 1;61(7):394–404.