Research Project
10366446
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 and treatment among Medicare beneficiaries remain low. Without proper treatment, these patients may experience persistent depression and anxiety symptoms, difficulty co-managing other 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. Primary care providers (PCPs) are required to participate in the QPP via one of two tracks: 1) the Merit-Based Incentive Payment System (MIPS), the default track; or 2) alternative payment models (APMs) such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). In the both the APMs and MIPS, PCPs are paid for their performance based on the quality and cost of care they deliver to patients. However, the effects of these QPP models on treatment of depression and anxiety disorders by PCPs are unknown. There is a critical need for research on the effects of the APMs and MIPS on access to care and delivery of evidence- based treatment for depression and anxiety disorders in the primary care setting, as well as subsequent outcomes for patients. Our scientific premise is that the QPP, which is a program targeted at the general patient population, has conflicting incentives for primary care delivery to patients with depression and anxiety disorders. On one hand, the QPP incentivizes PCPs in ACOs and PCMHs to adopt innovative 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, which creates a financial disincentive to PCPs in ACOs and PCMHs for caring for patients with these conditions, potentially threatening their access to care. This negative consequence may be further magnified among patients who are poor, belong to racial and/or ethnic minority groups, or live in rural areas. The objective of this R01 application is to conduct a longitudinal study linking rich national datasets of Medicare claims, patient surveys, and PCP data from 2017-2022 to evaluate: 1) patient and PCP risk selection into the APMs vs. MIPS (Aim #1); 2) whether financial incentives to PCPs in the QPP contribute to this risk selection and how they may be remedied (Aim #2); and 3) the effect of patient care from PCPs in the APMs vs. MIPS on delivery of evidence-based treatment for depression and anxiety disorders and subsequent patient outcomes (Aim #3). We hypothesize that although patients with depression and anxiety disorders will receive higher rates of evidence-based treatment and have better outcomes when treated by PCPs participating in the APMs vs. MIPS, these patients will nonetheless be less likely to be cared for by PCPs in the APMs vs. MIPS than patients without these conditions due to negative financial consequences to their PCPs caused by inadequate risk adjustment in the QPP for these conditions.
