– POLICY –

by Joy Burkhard, MBA
Founder and Director 2020 Mom

It's an exciting development that the USPSTF no longer excludes pregnant women from its depression screening recommendations, and now notes the specific importance of screening pregnant and postpartum women due to negative consequences of untreated depression on fetus/infant development.

Patients are Already Provided Coverage
Insurers currently provide coverage to patients for depression screening in the full adult population. However, most primary care doctors and OBGYNs continue (and will continue) NOT to screen because of lack of referral and case management support, which is a critical need for them in feeling comfortable when uncovering positive screens.

Provider Payment Still Depends on the Contract
Some are wondering whether this position means that insurers must pay providers for screening. It's an interesting question. The recommendation and ACA don't dictate how an insurer contracts or pays a provider. There are several types of insurance payment mechanisms. The two most well-known payment structures are Fee-for-service (a provider bills for every service s/he provides) and capitation (providers receive a flat payment per month for any/all services provided). Under a fee-for-service type arrangement, an insurer would reimburse for a depression screen. Under a capitation payment, providers are expected to provide all necessary services under their negotiated monthly payment, including depression screening. The USPSTF recommendation doesn't change these structures. Because of the focus on staying healthy, the Centers for Medicare/Medicaid Services (CMS) and others are promoting capitation type arrangements with primary care doctors, including pediatricians who may screen mothers for depression. Separate, and often in place for maternity, an OBGYN agrees to be paid a "global maternity rate" by the insurer for prenatal and postpartum services (through the postpartum visit). Under these types of arrangements, insurers generally expect providers to render all medically necessary screenings and services, which generally would include maternal depression screening and other types of screenings. Insurers are not obligated to pay providers for depression screening outside of this flat rate.
Note, however, that some payers/insurers have addressed this. For example in Colorado, the state Medicaid program is reimbursing pediatricians and OBGYNs for conducting screening. Our sources tell us that there are challenges, including limitation on the number of times screening can occur (causing challenges as the pediatrician may not know if the OBGYN already screened) and low reimbursement levels, leaving many to not bother billing even if they do screen. Further, there is no measurement currently in place, so there is no evidence that payment is making a difference. Furthermore, several years ago, Aetna, interested in improving depression screening and treatment rates, began reimbursing primary care providers for depression screening. They found it didn't increase depression screening rates (though those who were already screening were thrilled) pointing to the notion that clear referral and treatment pathways must be in place first, and additional payment really is secondary.

What should Insurers Do?
Insurers are in a unique position to provide this complex case management service (they do so now for many other conditions) but until there is also a way to locate psychiatrists as well as therapists who have training/experience in treating maternal mental health insurers will have difficulty making a dent. Beyond the general difficulty in knowing who is qualified to treat these moms, there are also general psychiatry shortages, and most reproductive psychiatrists don't contract with insurers because they don't have to.
This is why the federal bill, HR 3235, Bringing Postpartum Depression out of the Shadows Act is critically important. If passed states could apply for federal grants to implement innovative access solutions, like the Massachusetts telepsychiatry program, MCPAP for moms, which successfully addresses and integrates training of providers, referral pipelines for qualified therapy, and prescription consultation for OBGYNs and other MDs when necessary.

Screening Rates Must be Measured
There is no measurement in place to capture how often OBGYNs (or others) are screening for depression. "We don't manage what we don't measure" the adage goes. It's critical that accreditation bodies and/or states require measurement of screening rates. Insurers are in the best position to monitor these rates, through a program like the National Committee for Quality Assurance's (NCQA's) Healthcare Effectiveness Data and Information Set (HEDIS) measures, which involve monitoring medical records and/or claim submission data. Cigna was the first insurer to adopt a HEDIS-like measure developed by external bodies, in 2013 but this measurement process needs to be implemented widely. When health plans understand what gaps in care exist they invest resources to improve screening and health outcomes and work collaboratively with providers to support their needs.

Conclusion
Inclusion of pregnant and postpartum women in the USPSTF position is a critical step in validating the importance of this screen, but much more work is needed to ensure providers are actually able to screen. 2020 Mom is supporting this work through in several ways. Want to know more? Drop us a line:
info@2020mom.org