By Joy Burkhard, MBA
Have you ever wished that someone would monitor how often screening for maternal depression is happening and to report that rate?
It’s been a dream of mine to have such a measurement in place so we can gauge how quickly change is occurring, determine states where rates are highest/lowest, and push for more aggressive action until screening rates are in the acceptable 90% range nationally.
Now, development of such a measure, referred to as a Healthcare Effectiveness Data and Information Set (“HEDIS”) measure, is underway thanks to The California Health Care Foundation and the ZOMA Foundation.
In addition to a measure of screening, there is also a measure being developed to address whether the screening provider followed-up. Here are the proposed measures - which include assessment for screening/follow-up during both pregnancy and the postpartum period.
Prenatal Depression Screening and Follow-Up
1. Depression screening: The percentage of deliveries in which women were screened for clinical depression using a standardized tool during pregnancy.
2. Follow-up on positive screen: The percentage of deliveries in which pregnant women received follow-up care within 30 days of screening positive for depression.
Postpartum Depression Screening and Follow-Up
1. Depression screening: The percentage of deliveries in which women were screened for clinical depression using a standardized tool within 12 weeks (84 days) post-delivery.
2. Follow-up on positive screen: The percentage of deliveries in which postpartum women received follow-up care within 30 days of screening positive for depression.
These critical new measures are set to be implemented next year.
The proposed measures were tested throughout 2018, and now the public comment period is closing today at midnight ET.
Below is 2020 Mom’s response including our responses to questions the HEDIS team specifically asked for feedback on.
For those who didn’t get to submit comments, even if just gratitude for the measures, you can do so today, and perhaps our comments will inspire you.
Click here to read the 45 pg detailed brief on the new measures.
Dear HEDIS Measure Development Team,
We applaud the expert committee, funders and NCQA leadership team for tackling this important measure.
We are deeply grateful.
2020 Mom was founded in 2011 to close gaps in maternal mental health disorder detection and treatment in the U.S. We understand the complex health care and mental health care delivery systems, understand the levers for change are and who the key decision makers are. We educate, collaborate, and legislate if needed.
We are a network of over 10,000 stakeholders including health systems, providers and patients.
Thank you for the opportunity to provide comment on the two new measures. Here is our general feedback:
-Thank you for anchoring measurement and follow up to the role of the obstetric provider. This is consistent with the recommendations of the most recent state report on maternal mental health, issued in California, specifically acknowledging the obstetrician as a woman’s primary provider during the perinatal period.
-We believe use of both medical record review and claims data (“Hybrid” measurement) is critical given obstetricians are paid a global capitation fee. We recognize that new measures are only being developed using electronic medical records (EMRs) and not standard records. We know provider EMR adoption is increasing. We also wish to acknowledge that those providers who are using EMRs are potentially also more likely to screen/implement new recommendations faster than their slower to adapt colleagues. It will be important to note this potential for skewed results.
-Though we understand that depression screening has been universally addressed by bodies like the American College of Obstetrics and Gynecology and then the U.S. Preventive Services Task Force the following is critically important to consider:
Research also now shows perinatal anxiety is critically important to identify and treat as it can exist as a comorbid condition or a stand-alone disorder and is often a precursor to depression.
Eighty percent of patients who suffer from the less common but very serious perinatal psychosis (which carries substantial increased risk of suicide and infanticide) often have an underlying Bipolar Disorder. Bipolar disorder, if treated with standard antidepressants alone, can trigger a mania, which may lead to psychosis. To ensure safety of mothers and babies those who are diagnosed with depression, especially those who may be prescribed an antidepressant, must also be screened to rule out bipolar disorder (the MDQ is a research-validated questionnaire).
The HEDIS workgroup asked for specific feedback on the following two topics (1) Medicaid coverage for those who qualify due to pregnancy alone and (2) telehealth vs face to face delivery of screening and follow up.
Women who qualify for Medicaid due to pregnancy alone lose coverage at 60 days post-delivery, yet ACOG recommends postpartum care through 12 weeks (84 days) after delivery. For the Prenatal and Postpartum Care and Postpartum Depression Screening and Follow-Up measures, the HEDIS team proposes to specify continuous enrollment beyond the 60 days in order to align with the guidance that providers are receiving. The disadvantage of this approach is that women who lose Medicaid coverage at 60 days will not be captured in the measure’s eligible population. However, per the HEDIS team, fewer women may lose Medicaid coverage in states that have implemented Medicaid expansion programs (which currently includes 32 states and the District of Columbia, with an additional four states expected to implement Medicaid expansion in 2019). Additionally, there have been some proposals including in California and Federally to extend “pregnancy Medicaid” coverage through 12 months postpartum. Given the likely possibilities of such change in the coming years, this proposal seems reasonable for the postpartum measure. All insured women should be screened during pregnancy.
Regarding telehealth delivery of screening, we believe such method is acceptable, however, we wish to ensure that the patient has developed a trusting relationship with such provider or delivery personnel (as should also be the case for face to face delivery) so that she is more likely to answer the screening questions openly.
Should you have interest in speaking further please don’t hesitate to reach out.
Again thank you for prioritizing women and families by developing these proposed measures. It’s critically important to us all.
Joy Burkhard, MBA
Founder and Executive Director
If you wish to share any or all of this feedback too, or your own feedback, you can do so by following the submission instructions here:
Go to my.ncqa.org
Under My Services, click to select Public Comment.
Click Add Comment.
Click to select HEDIS 2020 Public Comment from the drop-down menu.
It’s undoubtedly an exciting time in maternal mental health!