How a score became a payment: the measures

Significant findings

Two federal quality measures turn the questionnaire into money.

Quality ID 134, "Screening for Depression and Follow-Up Plan", is a process measure: the "Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter." The specification names the PHQ-9, the PHQ-2 and others as acceptable tools, and defines the plan: "Documented follow-up for a positive depression screening must include one or more of the following: Referral to a provider for additional evaluation and assessment...; Pharmacological interventions; Other interventions or follow-up for the diagnosis or treatment of depression." It carries its own caution: a clinician should "Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation."

Quality ID 370, "Depression Remission at Twelve Months" (CBE 0710), is an outcome measure, marked "High Priority": "The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event date." The index event is a diagnosis plus "an initial Patient Health Questionnaire - 9 item version (PHQ-9)... greater than nine". Remission is "a PHQ-9 or PHQ-9M score of less than five." The specification is copyrighted "MN Community Measurement, 2024", the Minnesota non-profit that developed it. Its own clinical text calls the PHQ-9 "an effective monitoring and management tool" and notes that "A five-point drop in PHQ-9 score is considered the minimal clinically significant difference."

Health plans answer to a parallel set from NCQA's HEDIS: screening and follow-up; "Utilization of the PHQ-9 to Monitor Depression Symptoms", the share of members with a depression diagnosis "who had an outpatient encounter with a PHQ-9 score present in their record"; and remission or response within 4 to 8 months, remission again below 5. Medicare's own coverage rule dates to 2011: annual screening "up to 15 minutes", once per 12 months, with staff-assisted supports.

Worth asking

None of these measures is dishonest, and the outcome one asks for something worth wanting: fewer symptoms a year on. But notice which behaviours are rewarded. A screen with a plan documented inside 48 hours; a PHQ-9 present in the record; a score under five. The form has become the unit of account. What happens to your care when the number is the thing being counted?