Chris Langston, right, with his Chris Langston, right, with his "Faraway" grandmother Nancy Imber, circa late 1970s. Joining them are his mother Adair and younger sister Anne.

When I was a child, I had two grandmothers. A nearby grandmother (Gammy) and a faraway grandmother, known forever after just as “Faraway.” I know she found it rather odd to be looked right in the face and addressed as “Faraway,” but as it was all I ever knew, it seemed just right to me.

In her last years, after the death of her second husband and the usual pile-up of chronic conditions, my Faraway grandmother came to live with her daughter, my mother. But the active and interested woman we had known was gone. She had lost most interest and pleasure in activities that had previously occupied her and seemed unwilling to try new things.

Despite its slightly atypical (anhedonic = loss of interest and pleasure) presentation, her depression was noted by her primary care provider (PCP) and she was started on a low-dose antidepressant, unfortunately with little effect. Her doctor suggested that she see a mental health specialist, but she refused—despite, or perhaps because of, her career as a psychologist—and the physician did not pursue changes to drug or dose.

Faraway remained stuck and we will never know how her life might have been different with a more effective approach to treatment.

Sadly, her case is the norm, not the exception. As I learned many years later when working at the John A. Hartford Foundation on one of my first projects, the problem of depression is not so much that it is unrecognized nor that it is untreated. As one of our polls showed, even older adults are more than willing to share their psychological problems with their health care providers. And considering the fact that anti-depressants are among the most prescribed drugs in America (most ordered by PCPs), the initiation of treatment, at least by prescription, is not the problem, either.

The problem is that treatment is often delivered by an unprepared primary care practice with patients who are not adequately supported for their role in their own care.

We have medications that work (and therapies, for that matter), but they are not used effectively in practices that don’t have the resources or systems to deliver effective chronic care for depression. Treatment by referral to providers outside of primary care is often unwelcome to patients and unsuccessful.

To be successful, there must be a structure around the treatment process within primary care that follows up and communicates with patients, measures treatment response, modifies treatments, and gets expert consultation.

These structures are the ingredients of the “Collaborative Care” model that we were able to successfully test almost two decades ago in the IMPACT trial—still the largest randomized clinical trial in depression treatment ever conducted—and which, in the years since, has amassed a mountain of evidence demonstrating its efficacy. The evidence is so overwhelming that if Collaborative Care were a drug, it would have long ago been added to every formulary in America.

However, we have never had the one thing that would make this model of care available to the people who need it most, such as my grandmother. We have never had a way of getting appropriate payment for the components of the model through Medicare. Until last week, it seemed that there would never be a payment for all the critical elements of the model in fee-for-service Medicare, which still covers the vast majority of older Americans.

Then, everything changed.

Click on image to view the full proposed rule change. Click on image to view the full proposed rule change.

The Centers for Medicare and Medicaid Services (CMS) proposed a major rule change to the Physician Fee Schedule (PFS) that, among other things, opens the door to creating a funding mechanism for collaborative care:

Because this particular kind of collaborative care model has been tested and documented in medical literature, we are particularly interested in seeking comment on how coding under the PFS might facilitate appropriate valuation of the services furnished under such a collaborative care model. (page 92)

This is not a decision by CMS to cover collaborative care. It is a request for feedback on how to cover collaborative care while avoiding paying for duplicative services. For example, it asks what structural capacities (e.g., registries) might need to be present for providers to legitimately bill, and it asks for comment on complex issues such as patient co-pays for non-face-to-face services about which the patient may not be aware.

Nonetheless, this is hugely exciting.

Just like the Annual Wellness Visit, the Care Transitions Benefit, and the Chronic Care Management benefit that have been added in recent years, in this request regarding collaborative care, CMS is trying to modernize fee-for-service Medicare to ensure that it can support the evidence-based services that older adults need to stay healthy and independent as long as possible.

The request by CMS is recognition of what we at the John A. Hartford Foundation have known since we first invested in the collaborative care model in 1999: It dramatically improves mental health care for older Americans. The results of the original IMPACT trial were perhaps better than we could have hoped: Consistently, across the eight participating health systems, patients randomized to IMPACT care showed roughly twice the benefits of usual care, such that approximately 50 percent of intervention patients showed substantial recovery as compared to approximately 25 percent of usual care (not “no-care”) controls.

Sub-analyses and follow-up studies have replicated these results in people with serious co-morbidities, younger adult populations, racially and ethnically diverse populations, and an even wider variety of health systems. Today, the entire body of research on collaborative care includes more than 70 randomized controlled trials of its effects and benefits—including strong evidence that the additional costs of collaborative care are off-set within a year or two by reduced total health care spending.

Ironically, the U.S. Preventative Services Taskforce recognizes collaborative care as the evidence-based standard of care in its recommendation against depression screening in primary care unless there is an organized system (i.e., collaborative care) prepared to serve patients so identified.

Ever since the results of the initial IMPACT trial, we at the John A. Hartford Foundation have supported the adoption of the collaborative care model through the work of the AIMS (Advancing Integrated Mental-Health Solutions) Center at the University of Washington. AIMS, led by long-time John A. Hartford Foundation grantee Jurgen Unutzer, has supported successful adoptions in more than a thousand practices and trained many, many thousands of health professionals around the United States.

At the Foundation, we continue to push the spread of the model in every way we can—such as our poll on mental health care among older adults and our current demonstration of the benefits of the model in Federally Qualified Health Centers in the rural Northwest and Alaska. In this demonstration initiative we are using a Social Innovation Fund (SIF) grant we won from the Corporation for National and Community Service for spreading evidence-based practices to put the model in place.

The SIF project enables us to show in eight rural practices the model’s usual outstanding clinical results, despite the challenges faced by providers and patients in these settings, and also to attract attention to the work from leaders at the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA) and Office of the Assistant Secretary for Planning and Evaluation (ASPE), as well as CMS.

Please read the section of the draft rule regarding collaborative care—it isn’t really very long. If you are familiar with the model or the issues, add your comments at www.regulations.gov (or hand delivery works, too :) ). Comments are due by Sept. 8, 2015, and if we are lucky, we might see a change in payment in 2016 or 2017 or some other important movement to make this model as widely available as it should be.