A Budget Impact Analysis of Telemedicine-based Collaborative Care for Depression

Background: Patients with depression use more health services than patients without depression. However, when depression symptoms respond to treatment, use of health services declines. Most depression quality improvement studies increase total cost in the short run, which if unevenly distributed across stakeholders, could compromise buy-in and sustainability. The objective of this budget impact analysis was to examine patterns of utilization and cost associated with telemedicine-based collaborative care, an intervention that targets patients treated in small rural primary care clinics. Methods: Patients with depression were recruited from VA Community-based Outpatient Clinics, and 395 patients were enrolled and randomized to telemedicine-based collaborative care or usual care. Dependent variables representing utilization and cost were collected from administrative data. Independent variables representing clinical casemix were collected from self-report at baseline. Results: There were no significant group differences in the total number or cost of primary care encounters. However, as intended, patients in the intervention group had significantly greater depression-related primary care encounters (marginal effect = 0.34, P = 0.004) and cost (marginal effect = $61.4, P = 0.013) to adjust antidepressant therapy for nonresponders. There were no significant group differences in total mental health encounters or cost. However, as intended, the intervention group had significantly higher depression-related mental health costs (marginal effect = $107.55, P = 0.03) due to referrals of treatment-resistant patients. Unexpectedly, patients in the intervention group had significantly greater specialty physical health encounters (marginal effect = 0.42, P = 0.001) and cost (marginal effect = $490.6, P = 0.003), but not depression-related encounters or cost. Overall, intervention patients had a significantly greater total outpatient cost compared with usual care (marginal effect = $599.28, P = 0.012). Conclusions: Results suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers. Thus, there is no disincentive for mental health providers to offer telemedicine-based collaborative care or for primary care providers to refer patients to telemedicine-based collaborative care.