Steven Levine, MD

 Before we conclude, I’d like to get some final thoughts from each of you, if you have any. Let’s start with you, Dr Nordberg.

 From my perspective, treatment-resistant depression and other complex mental health challenges are systems challenges as much as they are clinical challenges. We haven’t moved the needle in treatment effectiveness in about 50 years, and in no small respect that may be because we haven’t changed our systems that provide care. I’m a big fan of looking at developing systems where we’re doing a lot more precision referral work, and to Martin’s earlier point, identifying different providers, clinics, and centers of strength, and referring to strengths. The only way to do that is to collect the data.

There are challenges around collecting the data. It creates vulnerability and a lot of visibility where there hasn’t been historically. One of the things that we’re working on at Reliant Medical Group is trying to be more precise about how and who we refer. A lot of that involves understanding the patient that we’re being presented with, and also understanding how that person matches up with what we believe is the most likely treatment to be effective for them based on data.

I’m pretty confident that if we can do that work in naturalistic settings, we’ll get past the archaic requirement of failing 2 bonafide medication interventions and get more rapidly to something that’s going to allow a care delivery organization to say, “This is a patient with treatment-resistant depression,” and a payer to say “No problem,” and then allows that care delivery organization to connect that patient with a reimbursed intervention that has a likely shot of helping them. That’s a lot of work to be done, but it starts with measurement and having the confidence to integrate that measurement into your clinical routine.

 Well said. To your original point, we haven’t moved the needle much in these past 50 years. You’re calling for improved systems, better measurement, and moving toward precision care. Hopefully that will be supported by the validation of some biomarkers that can lead to more precise and predictive treatments. Would you also agree that part of this as well is that we haven’t had very many new tools in the past 50 years, and potentially having some effective new tools in the toolbox may also help move that needle?

 It may. We also know that there’s a lot of variability between different providers and that there are different kinds of treatments that appeal more to different kinds of patients. The biomarker research is sexy and exciting because of that possibility of carving nature at its joints and being precise. It’s also a long way off. RDoC [Research Domain Criteria] didn’t deliver the promise of precision opportunities for understanding and deep learning about what drives mental health on a physiological level.

We still have a lot of opportunities with the systems and treatments that are already out there. This system still has a lot of room for optimization. It starts with having the courage to collect more data and letting those data start to tell us what kind of a patient this is and the best place for the patient to go based on what we’ve already learned about similar patients. That’s where my focus is, less so on developing novel interventions. It’s important to figure out where the patients that we’ve been discussing fit in that overall model, but we’re not going to be able to figure that out if we’re not collecting the right data.

 For those of us who deal with the fun stuff, the insurance and billing portion of things, like I’ve been saying this whole time, it’s important to make sure that you understand your payers and their guidelines and policies. You have to play that middleman role between the insurance carriers, providers, and patients. We need to make sure that we’re educating our providers so that they know if there are any changes to these policies so that they can find the right fit for patients.

It’s also important to educate the patients in regard to what qualifies them as having treatment-resistant depression and what’s available out there. Be an advocate for the patient with the payer and keep them involved in the process so that they’re not at home wondering, “What’s going on with my prior authorization? When is my treatment going to start?” Let them know everything along the way and be there for them.

 The theme that I’d leave with is the idea of “better together.” If you think about it, there are 3 participants in the goal here. Front and foremost is the patient because they want to get better. They’re suffering. There’s the provider who’s trying their best to figure out the appropriate care. There’s also the payer who wants to make sure that the patient gets access to the benefit that they deserve and that they’re able to go on and live a healthier and happier life. You have to see that triad.

There’s a likelihood that you can blame the insurer or blame someone else, but at the end of the day, it’s about figuring out how to work better together, that triad, because we have a common interest in improving the life of that patient. That’s the part that I like to focus on. What are we doing this for? Who matters the most? The other stuff can be worked out.

 Thank you. Last but not least, Dr Ares-Romero.

 I love that. I love how you ended with that. Because as somebody who treats treatment-resistant depression regularly, I’m very passionate about having my patients improve their lives. Their quality of life is what’s important, and that they get passion and fulfillment from their lives. It’s beautiful to hear that, that we can work together. That’s key, getting the payer together with a provider. It’s not about you or me. It’s about the patient and how can we come together to work together. I love that.

Despite the hurdles and challenges and everything we’ve talked about, it’s an exciting time in psychiatry. This is a time when we have new modalities, new things, all the data collection, all the systems, and the artificial intelligence that we have now that we haven’t explored. There are so many wonderful things coming that I’m excited. I’m excited for our patients. I’m excited for everything that we’re doing.

 Thank you all again. To our viewing audience, we hope you found this 

® panel discussion to be useful and informative.

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An expert panel shares insight on the future treatment landscape for treatment-resistant depression. 

Optimizing the Management of TRD

 How might a payer flag a patient who’s receiving a medication like intranasal esketamine [Spravato] that requires high touch to support access and reduce delay to therapy? What are some strategies that can be employed there?

 One thing that we have a lot of is data. We also have data that fits across episode and provider, or place of service. We have mechanisms by which we can track a member course. It’s claims-based, but it gives us that transactional, longitudinal view that many providers don’t have. Second, we have a system where we can put flags in place, develop an algorithm that would identify if you’ve had this amount of drugs in this setting and so on, and it would actually bubble up that patient for identification for one of our case management programs. These things exist right now in terms of determining the high-severity or high-need members and how we target them for outreach from our case management services.

To reiterate regarding what Sam was saying about the value of measurement-based care, we have that encounter-based or claims view. We’re driven as an organization to get some of that granular measurement at the clinical level because it also helps us understand which providers are skilled at treating which conditions, and what severity of conditions. If you’re running a practice that focuses on treatment-resistant depression, if we had their profile, we’d know that you’re getting these really sick patients and you’re able to move them along. It may take you a little longer and use more service, but it helps us understand why vs an inefficient provider who holds on to patients forever.

I want to underscore that the part that makes the system work more efficiently is data. It’s the granular data that can help us understand what providers are struggling with. I’m still in active practice and treating a lot of treatment-resistant depression is very time-consuming. These aren’t easy patients. They’re much more complex than an uncomplicated first episode of depression. We want to be able to support that and understand what alternative payment models we could develop where they would understand and support how these patients get taken care of.

 Can you say a little about those potential alternative payment models and how that maybe leads to more of an alignment between the support required among patients, providers, and payers?

 The piece around alternative payment models is that if we understand the population and have some measures, there’s a way for us to pay for an episode of care rather than them worrying, “Am I going to get a black mark because I’m taking longer?” It probably helps from a practice management point of view to know that if I get this patient, my job is to get them from point A to point B, and I’m going be given the resource. I don’t have to keep going back and asking for it.

It’s a win-win all around. For the provider, it’s an easier experience. For the patient, they don’t have to worry about some of the barriers we talked about. From our point of view, we’re meeting the Quadruple Aim of the right care, right place, right time, and right costs. That’s the real value behind seeing if there’s a way that we could develop a methodology to bundle and take care of an episode, particularly with this population that can be very challenging to treat.

Dr Martin Rosenzweig discusses the importance of data collection to improve patient care in treatment-resistant depression, as well as alternative payment models.

Payer Strategies to Reduce Delay to TRD Therapy

 Let’s go back to Dr Rosenzweig for another payer-focused question. Thinking about drugs or services like intranasal esketamine [Spravato], or perhaps other nonoral alternative therapies, and in the case where there might be a combination of a drug and some service delivery component, how do you ensure the policymaking for a drug and its evaluation and management and the service component attached are integrated?

 It’s a complicated issue because, as Patricia hinted to earlier, particularly in a commercial population, you have to understand that there are sometimes carve-outs of services. You may have 1 payer doing the medical but someone else doing the pharmacy benefit management. That may change year-over-year, so that’s part of what Carrie was getting at. They may have the same medical insurance but the pharmacy coverage differs. There are systemic issues that complicate that seamless integration.

One of the things we try to do when there’s something new on the market is we have processes where we look at that. What codes are we going to use? How do we put those as addendum in the provider contracts to make sure they’re covered? Some of it is getting feedback from the end user. I mentioned the difficulty we had with the introduction of esketamine. It’s not about pointing fingers. Sometimes these things roll out and it’s not well-thought-out regarding the operational implications. I’d encourage to have a conversation with the insurer and identify what the issues are. We listen. From our point of view, having lots of calls and complications is expensive for us as well. It’s horrible from a service point of view for providers, but it chews up our resources as well having to address this resource and figure out how to fix it. It’s a partnership to address this.

 I like that sentiment, and it’s a good segue to a question to Dr Nordberg. In your opinion, how do behavioral health organizations and payers work together to support patient care?

 One of the things that care delivery organizations can do more of and do better is integrate the routine collection of patient-related data into your clinical process. There are a couple of reasons for doing it. One is that there’s pretty good evidence that it improves the quality of care you’re able to offer if you’re feeding that back to your providers and basing treatment decisions off of that. Second, in scenarios where you may not have been able to predict it, it gives you the data to pull up and make a compelling argument with a payer around why something should be expedited or bundled or why there should be some changes. Without data, it’s difficult to have that conversation in a compelling way with a payer.

Historically, there has been a lot of reluctance or resistance to collecting data in the clinical routine, but I look at it as a way of advocating very strongly on behalf of the care delivery organization with payers, who respect data. If you’ve got those data as part of your clinical routine, you’ll be armed with it when you need to have that conversation and support your clinical judgment and requests.

 It sounds like you’re calling that out as an opportunity for improvement, that if organizations commit to measuring outcomes and measuring the care that they’re delivering and sharing those outcomes with payers, there’s now a basis for conversation, collaboration, and agreement on what constitutes a good outcome and an appropriate use of services.

Drs Martin Rosenzweig and Samuel Nordberg share perspectives for integrated policymaking in behavioral health, as well as payer and provider collaboration for treatment-resistant depression.

Integrated Policymaking and Measuring Patient Outcomes in TRD

 Dr Rosenzweig, you mentioned this earlier. Sometimes, and often with intranasal esketamine [Spravato], some payers may require prior authorizations prior to approving administration of that therapy. Carrie, can you talk a bit about how payers’ differing prior authorization requirements can impact patient access?

 Absolutely. One of the biggest hurdles that we’ve seen recently is that there tends to sometimes be “new year, new insurance.” You’ll have patients who are starting therapy in 2021 and changing payers at the beginning of 2022. If we’re able to catch those, if the patients let us know ahead of time that they’re changing insurance, we can start that prior authorization process before the insurance changes. However, if patients don’t let us know, then we’re sometimes stuck having to find alternative forms of therapy while we’re undergoing that prior authorization process because you’re basically starting the whole thing over with a new payer.

The qualifications can also be different payer to payer in regard to failed therapies. You may have a patient who qualified under X carrier that they had in 2021 and unfortunately no longer qualify for Y carrier in 2022. Being able to start that process and discuss with peer-to-peer review, “This patient has been undergoing this treatment. We’ve been doing measures. Here’s what we’re finding,” can hopefully get over that, but it can be a lengthy process that can delay continued treatment for the patient and be aggravating for the patient and provider.

 That’s important. You were talking about the various scenarios of coding earlier, depending on your contract, the payer, the use of G-codes, comprehensive codes vs S- or J-codes vs CBT [cognitive behavioral therapy] coding for evaluation, management services, prolonged services, and observation and so forth, and all the complexity therein. Certainly, under some payer policies, those prolonged service codes are used to support the administration of intranasal esketamine. But sometimes there may be a limit on the number of those codes you can use or the length of time that those codes will cover. Sometimes the time of service may exceed the cap on that. Can you talk a bit about that?

 Yes. We have been utilizing a newer code that was first used in 2021, which is 99417, to bill that additional observation time. That code is what’s called an add-on code. It’s added on to the evaluation and management services that are done. That code is in increments of every additional 15 minutes. CMS [Centers for Medicare & Medicaid Services] does have an edit that will limit that code to 4, which is 60 minutes.

Of course, every patient is different, and not every patient only needs 2 hours or a little more than that. Some patients are there because they’re having nausea or other issues for a longer period of time. We’re seeing that there are payers who are following those CMS guidelines in regard to putting a cap at 4 units. Some of them are paying 4 units and denying the additional. I have seen payers who deny every single unit that you bill if you bill more than 4 units, so you’re having to then go back and submit appeals or a corrected billing, which delays the reimbursement process even longer.

 As you mentioned, each patient is different. Some people need additional support beyond the time that those 4 units of that code cover. How do you ensure that additional patient support from the provider is reimbursed in that scenario?

 You can submit an appeal to the insurance company letting them know that the patient was having issues and required additional use of the provider’s time. Documentation is key in those cases. You have to be very clear in your documentation about why you were spending additional time with that patient. “If it’s not documented, it didn’t happen,” is what we follow here as billers. You need to make sure that additional time is documented so that you can file an appeal with the insurance carrier.

Carrie Jardine leads a discussion on varying prior authorization policies for alternative therapies for treatment-resistant depression along with implications to patients.

Steven Levine, MD

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