Introduction
This document details the methodology for the Depression measure and should be reviewed along with the Depression Measure Codes List file, which contains the medical codes used in constructing the measure.
Measure Description
Episode-based cost measures represent the cost to Medicare for the items and services provided to a patient during an episode of care (“episode”). In all supplemental documentation, the term “cost” generally means the standardized1 Medicare allowed amount,2 and claims data from Medicare Parts A, B, and D3 are used to construct this episode-based cost measure.
The Depression episode-based cost measure evaluates a clinician’s or clinician group’s riskadjusted and specialty-adjusted cost to Medicare for patients receiving medical care to manage and treat depression. This chronic condition measure includes the costs of services that are clinically related to the attributed clinician’s role in managing care during a Depression episode.
Measure Rationale
An estimated 13% of all Medicare patients age 65 or older experience depression,4 and prevalence of diagnosed major depressive disorder among older adults ranges from 5-10% in primary care settings and up to 10-42% in inpatient and long-term care settings,5 with highest overall prevalence of major depressive disorder being among the oldest age group of patients 90 years or older.6 Beyond considering the impacts and costs of treatment for depression itself, findings from the literature report that patients with depression are more likely to utilize health care services and resources for other types of medical illness beyond just mental health disorders compared to patients without depression,7 and the average total health care costs for patients with depression aged 60 or older are greater compared to those without depression.8
Research has also indicated that the integration of primary care and mental health care could reduce spending and lead to improvements in the management, treatment, and quality of care for patients with mental health disorders and chronic conditions, 9 and specifically that ongoing depression disease management for patients with major depression can increase clinical improvement and be less costly overtime.10 In addition to improving care integration, research indicates another opportunity for improvement in effective case management to improve medication and treatment adherence. A 2020 paper indicated that that over half of patients with major depressive disorder do not adhere to prescribed medications (i.e., antidepressants), both in the primary care and psychiatric settings.11 which may be due both to patient-related factors (i.e., due to concerns about side-effects, cultural issues, costs12,13), as well as factors that clinicians can influence, such as inadequate patient education, lack of shared decision-making, and lack of follow-up.14 Given the prevalence of major depressive disorder in the Medicare population, and the high costs associated with the management of the disease and its complications, the Depression cost measure represents an opportunity for improvement on overall cost performance. The Depression episode-based cost measure was selected for development because of its high impact in terms of patient population, clinician coverage, and Medicare spending, and the opportunity build a complex, yet feasible, chronic condition measure that would address a condition not captured by other cost measures. Following initial feedback gathered during the Wave 4 public comment period,15 the subsequent measure-specific clinician expert workgroup provided extensive, detailed input on this measure.
Measure Numerator
The measure numerator is the weighted average ratio of the winsorized16 scaled standardized observed cost to the scaled expected17 cost for all Depression episodes attributed to a clinician, where each ratio is weighted by each episode’s number of days assigned to a clinician. This sum is then multiplied by the national average winsorized scaled observed episode cost to generate a dollar figure.
Measure Denominator
The measure denominator is the total number of days from Depression episodes assigned to the clinician across all patients.
Data Sources
The Depression measure uses the following data sources:
- Medicare Part A, B, and D claims data from the Common Working File (CWF)
- Enrollment Database (EDB)
- Long Term Care Minimum Data Set (LTC MDS)18
Care Settings
The Depression measure focuses on the care provided by clinicians practicing in non-inpatient hospital settings for patients with depression. The most frequent settings in which a Depression episode is triggered include: office, nursing facility, skilled nursing facility (SNF), and outpatient hospital.
Cohort
The cohort for this cost measure consists of patients who are Medicare beneficiaries enrolled in Medicare fee-for-service that receive care for depression.
The cohort for this cost measure is also further refined by the definition of the episode group and measure-specific exclusions (refer to Section 4).
--------------------
1 Claim payments are standardized to account for differences in Medicare payments for the same service(s) across Medicare providers. Payment standardized costs remove the effect of differences in Medicare payment among health care providers that are the result of differences in regional health care provider expenses measured by hospital wage indexes and geographic price cost indexes or other payment adjustments such as those for teaching hospitals. For more information, please refer to the “CMS Part A and Part B Price (Payment) Standardization - Basics" and “CMS Part A and Part B Price (Payment) Standardization - Detailed Methods” documents posted on the CMS Price (Payment) Standardization Overview page (https://www.resdac.org/articles/cms-price-payment-standardizationoverview).
Claim payments from Part D are payment standardized to allow resource use comparisons for providers who prescribe the same drug, even if the drug products are covered under varying Part D plans, produced by different manufacturers, or dispensed by separate pharmacies. For more information, please refer to the “CMS Part D Price (Payment) Standardization” document posted on the CMS Price (Payment) Standardization Overview page. (https://www.resdac.org/articles/cms-price-payment-standardizationoverview).
2 Cost is defined by allowed amounts on Medicare claims data, which include both Medicare trust fund payments and any applicable beneficiary deductible and coinsurance amounts.
3 Part D branded drug costs are also adjusted to account for post-point of sale drug rebates; more information can be found in the Methodology for Incorporation of Rebates in Part D Standardized Amounts on the QPP Cost Measure Information "About Cost Measures" page (https://www.cms.gov/medicare/quality-payment-program/cost-measures/about).
4 Ewald E, Loganathan S, Hache J, Lochner K. Access to Care Among Medicare Beneficiaries With and Without Depression. Medicare Current Beneficiary Survey. 2017. https://www.cms.gov/ResearchStatistics-Data-and-Systems/Research/MCBS/Downloads/ATC_Depression_2017.pdf
5 McQuaid, JR, Lin EH, Barber JP, et al. 2019. Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts. American Psychological Association, Guideline Development Panel for the Treatment of Depressive Disorders.
6 Bashyal R, Du H, Wang L, Yuce H, Baser O. PMH17 – Mortality and Prevalence of Major Depressive Disorder in the US Medicare Population from 2008-2013. Value in Health. 2016; 19(3): A184.
7 Zivin K, Wharton T, Rostant O. The Economic, Public Health, and Caregiver Burden of Late-Life Depression. Psychiatric Clinics of North America. 2013; 36(4): 631-649.
8 Katon WJ, Lin E, Russo J, et al. Increased Medical Costs of a Population-Based Sample of Depressed Elderly Patients. JAMA Psychiatry. 2003; 60(9):897-903.
9 Bao Y, Casalino LP, Pincus HA. Behavioral Health and Health Care Reform Models: Patient-Centered Medical Home, Health Home, and Accountable Care Organization. Journal of Behavioral Health Services and Research. 2013; 40(1):121-132.
10 Rost K, Pyne J, Dickinson LM, LoSasso A. Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis. Annals of Family Medicine. 2005; 3(1): 7-14.
11 Dell’Osso B, Albert U, Carra G, et al. How to Improve Adherence to Antidepressant Treatments in Patients with Major Depression: A Psychoeducational Consensus Checklist. Annals of General Psychiatry. 2020; 19(61).
12 Piette JD, Heisler M, Wagner TH. Cost-Related Medication Underuse Among Chronically Ill Adults: The Treatments People Forgo, How Often, And Who Is At Risk. American Journal of Public Health. 2004;941782-1787.
13 Bambauer KZ, Safran DG, Ross-Degnan D, et al. Depression and Cost-Related Medication Nonadherence in Medicare Beneficiaries. JAMA Psychiatry. 2007; 64(5):602-608.
14 Dell’Osso B, Albert U, Carra G, et al. How to Improve Adherence to Antidepressant Treatments in Patients with Major Depression: A Psychoeducational Consensus Checklist. Annals of General Psychiatry. 2020; 19(61).
15 “Wave 4 Public Comment Summary,” QPP Cost Measure Information, Prior cost measure development and input, (https://www.cms.gov/medicare/quality-payment-program/cost-measures/prior)
16 For information on how costs are winsorized, please refer to Section 4.7.
17 Expected costs refer to costs predicted by the risk adjustment model. For more information on expected costs and risk adjustment, please refer to Section 4.7.
18 For information on how LTC MDS data are used in risk adjustment, please refer to Section 4.7.