At least 40 percent of people who suffer from major depression receive some mental health care from primary care physicians (PCPs). Many managed care organizations (MCOs) encourage PCPs to treat depression. However, some wonder how knowledgeable PCPs are about depression and how capable they are of treating it. The Depression Patient Outcomes Research Team (PORT) is a 5-year project to evaluate the cost effectiveness of alternative practice strategies and specific treatments for depression in prepaid group medical practices. The PORT is led by Kenneth B. Wells, M.D., M.P.H., of the RAND Corporation, and is supported by the Agency for Health Care Policy and Research (HS08349).
Two studies using data from the Depression PORT are summarized here. The first shows that policies within an MCO may encourage or discourage primary care treatment of depression. The second study finds that age per se does not affect a person's preferences regarding treatment risks and outcomes.
Meredith, L.S., Rubenstein, L.V., Rost, K., and others (1999, January). "Treating depression in staff-model versus network-model managed care organizations." Journal of General Internal Medicine 14, pp. 39-48.
In staff/group-model MCOs, all providers work within a relatively large, uniform clinical practice structure. These MCOs typically include both primary care and specialty care providers within the same organization, and they are all paid by a single source. In contrast, network-model MCO providers manage their clinical practices independent of plan dictates. Primary care providers and specialty care providers often work in different small practices linked only by the payment plan, and they may serve multiple payers.
These organizational differences affect primary care treatment of depression, finds this study. For instance, compared with network-model providers, staff/group-model providers believed more strongly that treating depression was burdensome to their practice and that time was a barrier to optimal depression treatment. More network-model providers reported limited access to mental health specialists as a barrier to referral. Not surprisingly, staff/group-model providers were more apt than network-model providers to treat patients with major depression through referral (51 percent vs. 38 percent) or to assess but not personally treat depression (17 percent vs. 7 percent). Network-model providers were more likely to treat depression themselves by prescribing antidepressant medications (57 percent vs. 36 percent) as first-line treatment. Providers in both types of MCOs were equally knowledgeable about treatment of depression.
These findings were based on a survey of 410 providers from 80 outpatient clinics in 11 MCOs. The clinics participated in four studies (including the Depression PORT) designed to improve the quality of care for depression provided in primary care.
Sherbourne, C.D., Keeler, E., Unutzer, J., and others (1999, June). "Relationship between age and patients' current health state preferences." The Gerontologist 39(3), pp. 271-278.
Today, people in the United States are living longer, but they often have chronic conditions that affect their quality of life. Increasingly, older individuals are interested not only in adding years to their life, but also in adding "life to their years," that is, improving the quality of their lives. This study shows that although older primary care patients assessed their current health as worse than younger patients, they were no more willing than younger adults to give up years of life in exchange for perfect health—a sign of the high value to them of their remaining years, even if in less than perfect health.
Older individuals, like younger people, varied in their circumstances and their preferences for different health outcomes. Thus, health care providers should assess individual preferences regarding treatment risks and outcomes, without regard to age, conclude the researchers. They analyzed data from 17,707 adult outpatients visiting 46 primary care managed care practices. They assessed patient preferences for their current health by methods of time trade-off (years of life an individual is willing to give up for perfect health until death, relative to 10 years in his or her current health state) and standard gamble (maximum risk of death an individual is willing to face for treatment that results in either complete cure or death).
The mean number of reported chronic conditions increased significantly from the youngest to oldest patients, the level of physical functioning decreased with age, yet mental health status was lowest in younger patients (aged 18 to 44 years). The majority of patients (70 percent) were not willing to give up any months of life or take any chance of death. Among all patients, the average months of life they were willing to give up for perfect health was 7.6 months (out of a maximum of 10 years). They were willing to take a 5.1 percent chance of death for a given procedure in exchange for perfect health. After accounting for health differences, age was not a factor in these preferences. For instance, for the standard gamble, the chance of death the patient was willing to risk for perfect health did not vary much across age groups (5 to 6 percent).