Our study demonstrates that Medicare beneficiaries with depressive symptoms report worse experiences with care across the full range of patient experience covered by the CAHPS Medicare 4.0 Survey, extending previous findings that patients with depressive symptoms tend to provide poorer ratings of patient–provider communication. Our research shows that patients with depressive symptoms also report experiencing greater problems in accessing needed care and getting that care in a timely way. They also provide less favorable overall ratings of their health plans, the primary and specialty care providers they see, and the care that they have recently received. Based on our analyses, we conclude that at least part of the depression effect is due to beneficiaries with depressive symptoms actually having worse interactions with the health care system. These findings suggest deficits in access to care and interactions with health care providers as plausible mechanisms for some of the known correlates of depression, including worse adherence and worse outcomes for chronic conditions (Wells et al. 1996
In most cases, the differences we observed between depressed and nondepressed beneficiaries were in the range of 2–4 points on a 0–100 scale. In evaluating these differences, it is important to consider that approximately 60–70 percent of ratings on the original 0–10 scales used for the global ratings are in the 9 or 10 categories. Thus, a 3-point deficit on a 0–100 scale is approximately equivalent to the difference between a health plan's having 20 percent versus 50 percent of its members rating it a 10 versus 9 on a 0–10 scale. Likewise, a 3-point deficit on the composite measures is roughly equivalent to a plan's having 40 percent versus 50 percent of its members report “always” versus “usually” on a 4-level scale.
In considering the magnitude of the depression effect found here, it may also be useful to compare it to another source of variation in patient experience that is recognized as important: geography. Quality of patient care varies geographically in both outpatient (Zaslavsky, Zaborski, and Cleary 2004
) and inpatient settings (Jha et al. 2008
; Lehrman et al. 2010
). To put the depression effect in the context of this geographic variation, we used hierarchical models to compare the coefficients for depression from our multivariate Model 2 to the standard deviations of the state-level distributions of scores on our measures. Under normal approximations, we found that the differences between care experiences of depressed and nondepressed beneficiaries on most measures are as large as the difference between getting care in a state at the 90th percentile versus one at the 50th percentile. Differences of these magnitudes have been associated significantly with disenrollment from a Medicare health plan (Lied et al. 2003
). Thus, we conclude that the differences observed in this study between depressed and nondepressed beneficiaries are likely to represent important differences in care experiences.
Patients' confidence in their ability to recognize their need for care appears to play a significant role in the relationship between depression and experiences of care. A growing literature suggests that patients who actively participate in their own care have improved health outcomes and patient experience (Lorig et al. 1999
; Rohrer 1999
; Hibbard et al. 2004
). For patients to assume responsibility for their own health care, they need knowledge, skills, and confidence that they can do so. Our study suggests that patients with depressive symptoms lack confidence needed to actively participate in their own care. As a result, patients with depressive symptoms may act in ways that result in lower quality care and poorer health outcomes, for example, by being less discerning regarding their need to seek appointments, asking fewer questions of their doctors, and adhering less well to their medication regimens. This finding is consistent not only with the chronic care model, which emphasizes patient activation as integral to the health care process and a factor influencing outcomes of care, but also a substantial literature that demonstrates the importance of self-efficacy in chronic disease self-management (Marks, Allegrante, and Lorig 2005
Our study is limited in that we tested our hypotheses among a sample of FFS beneficiaries not enrolled in prescription drug plans (PDP). We do not know whether the associations we identified are also present among FFS beneficiaries with PDP. Approximately half of the 75–80 percent of Medicare beneficiaries with FFS coverage are enrolled in a Medicare-sponsored PDP. There are no published data on whether or how Medicare beneficiaries with or without PDP coverage differ, though one might reasonably expect both health and socioeconomic differences between the two groups. Those not enrolled in a PDP may be in poorer health because they lack drug coverage (though some have coverage from sources other than Medicare), but on the other hand, they may be in better health and have less need for prescription drugs. One might also expect that beneficiaries without PDP coverage are of lower socioeconomic status than covered beneficiaries, although this difference is likely offset somewhat by low-income supplements for those with income levels at <150 percent of the federal poverty level.
Although our DIF analyses increase our confidence in interpreting the associations between depression and composite measures of care experiences, the global ratings of care items do not permit DIF analyses. Given the lack of evidence for differential use of the composite scales by depressed and nondepressed beneficiaries, it seems unlikely that measurement bias fully explains the observed associations between depression and the global ratings. Nevertheless, future studies should investigate the possibility that the CAHPS global ratings function differently for individuals with and without depressive symptoms.
Despite its limitations, our study has important implications for interventions at the plan or beneficiary level to improve the experience of depressed beneficiaries. For example, a simple 3-item screener consisting of the PHQ-2 and the confidence item could be administered periodically upon enrollment, in waiting rooms, or other health care settings to all plan members to identify a subset of beneficiaries who may be at risk for worse health care experiences, less engagement in their own health care, less adherence, poorer outcomes, and of course, depression. It may especially important to identify such individuals who also have significant chronic disease comorbidities.
Depressed seniors might benefit from a variety of interventions that seek to address the specific obstacles to optimal health care experiences imposed by depression and identified in this research. For example, to address the issue of inadequate confidence in the domain of health care, such seniors may benefit from seminars designed to increase their knowledge, health literacy, and sense of self-efficacy regarding health care. In addition, providers and office staff could be trained to communicate with such seniors in a manner that elicits their input and reinforces their health care self-efficacy. More instrumentally, health information technology resources, such as electronic appointment reminders (e.g., via cell phone), could be targeted to such beneficiaries. Future research should implement and evaluate such initiatives, which have the promise of improving health care experiences and outcomes for a large, growing, and vulnerable segment of patients.