Maryland HMOs Score Poorly in Depression Treatment

By EMILY HAILE, Capital News Service

WASHINGTON - Doctors in Maryland's Health Maintenance Organizations exercise little oversight after initially prescribing anti-depressants, according to an annual report released earlier this month.

After being diagnosed and treated for depression, patients should see a doctor at least three times within three months, according to medical specialty groups.

But the 10th annual HMO report card, released by the Maryland Health Care Commission, found that doctors administered proper follow-up care to patients on anti-depressants just 20 percent of the time on average.

The report card was based on clinical records and a survey of members in each of seven HMO plans, including most point-of-service plans. The companies rated were Aetna Health Inc.; CareFirst BlueChoice Inc.; CIGNA HealthCare Mid-Atlantic Inc.; Coventry Health Care of Delaware Inc.; Kaiser Foundation Health Plan of the Mid-Atlantic States Inc.; MD-Individual Practice Association Inc.; and Optimum Choice Inc.

The guide is meant to help consumers choose an insurance plan tailored to their health needs. It can be found online at .

Overall, Kaiser Permanente, the only non-profit HMO in the state, ranked highest in 2006, scoring above-average for more than half of the quality measures for customer satisfaction and care.

But to mental health professionals, the results were disappointing.

"The mental health field has been hit harder by managed care than any other specialty," said Dr. Marta Hopkinson, director of mental health services at the University Health Center at University of Maryland, College Park.

By limiting the number of visits, imposing requirements on treatment plans and cutting reimbursement rates, many practitioners are refusing to contract with HMOs, said Hopkinson.

But it's the patients who suffer most.

Experts say depression is most effectively treated with a combination of medication and psychotherapy.

Follow-up is important because anti-depressants are not one-size-fits-all drugs, said Dr. Paul Clavelle, president of the Maryland Psychological Association.

Many people need to have their dose adjusted to mitigate side-effects or effectively curb symptoms.

It's important that physicians monitor symptoms and educate their patients, especially because they may decide not to come back or will stop taking the medication if they start feeling better.

On average, just 44 percent of HMO members took anti-depressants for at least six months, the recommended amount of time.

Some physicians suggested that the number would be higher if patients were seeing a doctor while taking medication.

About 75 percent of depression is treated by primary care physicians, not mental health professionals. But general practitioners tend to underdose and use anti-depressants for too short a time, said Dr. Steve Daviss, past president of the Maryland Psychiatric Society.

Also, primary care doctors are so busy, it's hard for them to follow up specifically with each patient, said Dr. William G. Prescott, president of the Maryland Psychiatric Society and a former primary care physician.

Most people start with their primary care doctor when experiencing depression, which is normal, but there's also a large group of psychiatrists that won't participate in HMO plans, said Prescott.

Psychiatrists can feel scrutinized when having to justify their actions to the insurance companies.

"There's a feeling of intrusiveness in the doctor-patient relationship," he said.

This leaves patients paying out of pocket or dealing with insurance companies on their own. For psychiatric patients who are already depressed, this can be particularly burdensome, said Prescott.

HMOs focus on absolute numbers, said Daviss. But unlike blood pressure or glucose levels, depression can't be measured.

Managed care may have decreased costs, said Daviss "but it never really did manage the care."

Some HMOs received high marks in other measures of the report card.

Kaiser Permanente also received the designation "star performer" five times for above-average performance in 40 percent of the measures for the past three years. No other plan received this distinction.

After Kaiser Permanente, Blue Choice came in second with above-average scores 32 percent of the time, followed by CIGNA with 24.5 percent. Coventry scored above-average 18.9 percent of the time, IPA 15 percent. Aetna scored well 9.4 percent of the time, while OCI, the second most popular plan, had above-average scores just 7.5 percent of the time.

In overall effectiveness of care, Kaiser was again ahead of the pack, scoring above-average two-thirds of the time.

BlueChoice won for access to care, with high marks more than 75 percent of the time. Coventry was close behind at 67 percent. While no clear leader emerged in behavioral health care, Blue Choice and Kaiser tied for first, performing above-average 43 percent of the time.

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