Project Summary
Depression and anxiety disorders are common in patients in the primary care setting and have clear evidence-
based guidelines for screening, diagnosis, and treatment. However, rates of screening, detection, and
treatment among Medicare beneficiaries remain low. Without proper treatment, these patients may experience
persistent depression and anxiety symptoms, difficulty co-managing other chronic conditions, worsening
functional status, and avoidable and expensive acute medical events. In 2017, Medicare launched the Quality
Payment Program (QPP) to incentivize delivery of high quality, low cost, evidence-based care in the outpatient
setting. The program covers a variety of alternative payment models (APMs) such as patient-centered medical
homes (PCMHs) and accountable care organizations (ACOs). Across all payment models, clinicians are paid
for their performance based on the quality and cost of care they deliver to patients. However, the effects of the
QPP on treatment of depression and anxiety disorders by primary care providers (PCPs) are unknown. There
is a critical need for research on the effect of the QPP on access to care and delivery of evidence-based
treatment for depression and anxiety disorders in the primary care setting, as well as the subsequent outcomes
for patients. Our scientific premise is that the QPP, which is a program targeted at the general patient
population, is likely to produce mixed incentives and unintended consequences for primary care delivery to
patients with depression and anxiety disorders. On one hand, the QPP incentivizes PCPs in higher-risk bearing
APMs such as ACOs and PCMHs to adopt innovative and collaborative care models that may increase rates of
evidence-based treatment. However, on the other hand, the QPP does not risk adjust for the most prevalent
types of depression and anxiety disorders when judging clinician performance, which creates a financial
disincentive to PCPs for caring for patients with these conditions, potentially threatening their access to care.
The objectives of this R01 application are to conduct a longitudinal study using real-world data to evaluate the
effect of the QPP on: 1) access to PCPs across payment models for patients with depression and anxiety
disorders; and 2) delivery of evidence-based treatment for these conditions and subsequent patient outcomes.
This study will pursue two specific aims. For aim #1, we will conduct a retrospective cohort study using
longitudinal data from the Medicare Current Beneficiary Survey, Centers for Medicare and Medicaid Services
Virtual Research Data Center, and Physician Compare for 2017-2020 to investigate two hypotheses: 1)
beneficiaries with depression and anxiety disorders will have less access to PCPs in higher risk-bearing APMs;
2) PCPs who disproportionately treat beneficiaries with these conditions will receive lower QPP performance
scores and payments. For aim #2, we will use the same data to investigate the hypotheses that beneficiaries
with these conditions with access to PCPs in APMs, such as ACOs and PCMHs, will: 1) receive higher rates of
evidence-based treatment; 2) have better health and cost outcomes.
