Columbia Doctors: Mental Health

Background

New York Quality Care (NYQC), the Medicare Shared Savings Program (MSSP) Accountable Care Organization (ACO) affiliated with the outpatient faculty practices of NewYork-Presbyterian (i.e., ColumbiaDoctors, Weill Cornell Medicine, NewYork-Presbyterian Medical Group) has piloted a collaborative care model (CoCM) that integrates the management of depression into the primary care setting (Exhibit 1). The CoCM pilot is part of a broader effort by NYQC to improve its depression screening rates, which lag the national average generally, and other academic medical centers in the New York region more specifically, according to annual reporting provided by the Center for Medicare and Medicaid Services (CMS).

The CoCM is currently centrally-funded by the CoCM, but as it scales, will need to become a financially self-sustaining program. Thus, the primary objective of this project was to determine the expected financial impact of the CoCM as an independent program, and identify strategies to improve its financial self-sustainability as it scales.

Project approach

In order to address the questions laid out by ColumbiaDoctors and NYQC, we conducted this project over two phases:

1. Phase 1: Identify the ‘base case’ configuration and impact

During this phase, we developed a quantitative methodology, shown in Exhibit 2, to estimate the financial impact of the CoCM, and conducted both (a) secondary research and (b) interviews with stakeholders from across NYQC to collect the inputs necessary to forecast the CoCM’s estimated annual financial impact through 2026

2. Phase 2: Produce and prioritize options for financial improvement

In the second phase of the project, we reviewed the model methodology to identify levers for improving the net impact of the CoCM, quantified the impact of each of these levers through a model sensitivity analysis, and worked with stakeholders at NYQC to prioritize each of these improvement opportunities in terms of feasibility. Then, we leveraged interview feedback with NYQC stakeholders to identify tactics to drive improvement in these prioritized areas.

Key findings

Although the CoCM is expected to operate at a loss through the end of the forecast period, this loss is relatively modest, and is expected to diminish as the model reaches scale (i.e., more patients are screened for depression and ‘screen into’ the CoCM). The estimated financial loss may even be offset by the potential shared savings incentives generated through the MSSP, although these benefits will be difficult to directly attribute to the CoCM.

The primary levers through which to improve financial sustainability include improving the depression screening rate, improving patient acceptance of CoCM care, capturing additional opportunities for coding, and dynamically adjusting CoCM staffing to meet patient demand. The most feasible levers to affect are improving the depression screening rate, and improving patient acceptance of CoCM care, which can be activated primarily via patient and provider education.

Closing Thoughts

The benefits of better screening and management of behavioral health conditions has been well-documented, and models for affecting outcomes such as the CoCM have been in existence for many years. However, financing these models continues to be a challenge, and improving these models’ financial sustainability and ultimate efficacy require both changing physician behavior and addressing broader societal stigma around mental health care. We look forward to seeing ColumbiaDoctors and NYQC continue to evolve this model to better serve patients.

Exhibits

Exhibit 1: Schematic of the Collaborative Care Model

Exhibit 2: Model Methodology