Minnesota pilot project trying a new tack on depression

For the first time, doctors in Minnesota soon will have a financial stake in helping patients feel less depressed. ¶ Starting next year, a group of Minnesota's largest employers will pay bonuses to doctors and clinics based on how well their depressed patients score on a standardized questionnaire.

The project, announced Wednesday, is part of a growing trend in medicine called "pay for performance." Until now, it's been used to reward doctors if their patients lower their blood pressure or cholesterol rates, for example, to help control diabetes and heart disease.

But this is the first time the concept is being tried in mental health, said Carolyn Pare, executive director of the Bloomington-based Buyers Health Care Action Group (BHCAG), which is sponsoring the project. If it works, she said, it could turn into a national model.

Pare says the goal is simple: to pay doctors extra if patients report significant drops in symptoms of depression within six to 12 months of starting treatment. "If they're providing high-quality care to their patients, then they get a bonus," she said. "How can you argue with that?"

But critics worry that the idea could backfire on patients. "Anytime we tie pay for performance to people getting better in terms of a mental illness, I always worry that there's going to be an incentive not to treat the hard-to-treat," said Sue Abderholden, executive director of the National Alliance on Mental Illness in Minnesota. "Some people are harder to treat than others. So what happens with those folks?"

But advocates say that a program such as this can motivate doctors to change for the better. "Today, physicians and hospitals are rewarded simply on the volume of services they provide, not necessarily the results," said Francois de Brantes, head of Bridges to Excellence, a national pay-for-performance group working with the Minnesota project. "We're looking to shift that focus."

The goal is to encourage doctors to give better follow-up care to depressed patients, and track their symptoms more closely.

Pare's group -- which includes such employers as 3M Co., the Carlson Companies, Honeywell, Target Corp. and the state of Minnesota -- has spent about $750,000 on pay-for-performance bonuses for diabetes and heart disease programs. But this is the first time the group has tried to use its clout to influence the treatment of depression, which costs billions a year in lost productivity.

The key in this project is a nine-point depression questionnaire. As part of the project, patients will be asked about their symptoms -- such as trouble sleeping or concentrating or feeling sad -- every six months, and given a numerical score (0 to 27, with 10 or above signifying moderate or severe depression).

Pare called the test "a very simple tool" to "gauge the effectiveness of treatment."

Under the pilot project, bonuses will go to doctors or clinics whose patients drop to a score of five or below, Pare said. The first bonus checks will go out in summer 2009, though amounts have yet to be determined. In the diabetes program, bonuses have ranged from $25 to $100 per patient who met the target score.

Some are skeptical

"I'm not sure that psychiatrists would be comfortable [with] that being their marker for depression," said Dr. Jeffrey Sawyer, a psychiatrist in St. Louis Park. With truly complex patients, he said, "It sort of flies in the face of reality" to tie their progress to a score.

The state's leading medical society also is skeptical. "We still don't know if the pay-for-performance plans in the long term are helping improve quality or not," said Dr. Robert Meiches, executive director of the Minnesota Medical Association. "If I'm [given incentives] to care for those who have good outcomes, how will that change things?"

The supporters say they expect some resistance, especially from doctors who feel that they're being penalized for circumstances beyond their control.

"Some of the providers are going to think that this isn't fair," Pare said. But right now, she said, too many depressed patients fall through the cracks after they leave the doctor's office. So professionals need a better way to track and help them.

"You have to start somewhere," she said. In her view, it's "absolutely" fair to hold the doctors accountable. "Because isn't that the ultimate goal of my [going] to the doctor? I want to get better, right?"