Must-Read: Richard Mayhew: Depression and paying for pills or exercise: “Last night in the Super Tuesday open thread…

…Iowa Old Lady  told us about her evening plans:

I go to the gym because it’s supposed to fight my depression, but lately I’ve come to believe that I’m depressed because I have to go and ‘feel better’ part is that I’m so happy it’s over.

This morning I just got out of a meeting with an accountable care organization that is brainstorming on ways to get some of their behavioral health and co-morbidity health and cost risks under better control.  The big suggestion from some of the Primary Care Providers (PCP’s) and master level clinicians was getting some of these individuals into personal training classes to do something fun… increased social connectives and increased physical activity… better health, lower pharmacy costs and fewer infrequent but high cost acute events. Their revenue model is a modified capitation model with gain sharing, they can pay for dance classes, weight lifting classes, gym memberships and yoga instructors without having to justify the expense on a claim. There is a long history of research that shows moderate exercise is at least as good as common Selective Serotonin Re-uptake Inhibitors (SSRI’s) in managing depression….

A gym membership with personal trainers and potentially day by day incentives for people to go to the gym may make a lot of medical sense and even more financial sense. However under a fee for service model, reducing pharmacy costs because people were able to step down their SSRI dose or eliminate it entirely was probably a net money loser for the PCP…. The incentives change on risk capitation models as the personal trainer still can not bill the insurer directly, but her salary is paid by the provider office. A personal trainer at $50 to $75  an hour in total costs  is far cheaper than a PCP at $180 to $250 per hour…. Things like this is why I am fundamentally optimistic about health care reform in the United States. This is not genius-level work. It is basic work and rejiggering of incentives to avoid being stupid. We have several iterations of being less stupid before we actually have to get too smart.