Improving Access to Alternative Therapies for Treatment Resistant Depression - Episode 12

Integrated Policymaking and Measuring Patient Outcomes in TRD

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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.

Steven Levine, MD: 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?

Martin Rosenzweig, MD: 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.

Steven Levine, MD: 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?

Samuel Nordberg, PhD: 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.

Steven Levine, MD: 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.

Samuel Nordberg, PhD: Yes. Well summarized.

Transcript Edited for Clarity