Can the Medicare Quality Payment Program Incentivize Evidence-Based Treatment of Depression and Anxiety Disorders by Primary Care Providers?

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Project Summary Depression and anxiety disorders are common in patients in the primary care setting and have clear evidence- based guidelines for screening, diagnosis, and treatment. However, rates of screening, detection, and treatment among Medicare beneficiaries remain low. Without proper treatment, these patients may experience persistent depression and anxiety symptoms, difficulty co-managing other chronic conditions, worsening functional status, and avoidable and expensive acute medical events. In 2017, Medicare launched the Quality Payment Program (QPP) to incentivize delivery of high quality, low cost, evidence-based care in the outpatient setting. The program covers a variety of alternative payment models (APMs) such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). Across all payment models, clinicians are paid for their performance based on the quality and cost of care they deliver to patients. However, the effects of the QPP on treatment of depression and anxiety disorders by primary care providers (PCPs) are unknown. There is a critical need for research on the effect of the QPP on access to care and delivery of evidence-based treatment for depression and anxiety disorders in the primary care setting, as well as the subsequent outcomes for patients. Our scientific premise is that the QPP, which is a program targeted at the general patient population, is likely to produce mixed incentives and unintended consequences for primary care delivery to patients with depression and anxiety disorders. On one hand, the QPP incentivizes PCPs in higher-risk bearing APMs such as ACOs and PCMHs to adopt innovative and collaborative care models that may increase rates of evidence-based treatment. However, on the other hand, the QPP does not risk adjust for the most prevalent types of depression and anxiety disorders when judging clinician performance, which creates a financial disincentive to PCPs for caring for patients with these conditions, potentially threatening their access to care. The objectives of this R01 application are to conduct a longitudinal study using real-world data to evaluate the effect of the QPP on: 1) access to PCPs across payment models for patients with depression and anxiety disorders; and 2) delivery of evidence-based treatment for these conditions and subsequent patient outcomes. This study will pursue two specific aims. For aim #1, we will conduct a retrospective cohort study using longitudinal data from the Medicare Current Beneficiary Survey, Centers for Medicare and Medicaid Services Virtual Research Data Center, and Physician Compare for 2017-2020 to investigate two hypotheses: 1) beneficiaries with depression and anxiety disorders will have less access to PCPs in higher risk-bearing APMs; 2) PCPs who disproportionately treat beneficiaries with these conditions will receive lower QPP performance scores and payments. For aim #2, we will use the same data to investigate the hypotheses that beneficiaries with these conditions with access to PCPs in APMs, such as ACOs and PCMHs, will: 1) receive higher rates of evidence-based treatment; 2) have better health and cost outcomes.