Comparison of Estimated Incentives for Preventing Postpartum Depression in Value-Based Payment Models Using the Net Present Value of Care vs Total Cost of Care.

Importance: Strong financial incentives are critical to promoting widespread implementation of interventions that prevent postpartum depression. Value-based payment (VBP) approaches could be adapted to capture longer-term value and offer stronger incentives for postpartum depression prevention by sharing the expected future health care savings estimated by reduced postpartum depression incidence with clinicians. Objective: To evaluate whether sharing 5-year expected savings estimated by reduced postpartum depression incidence offers stronger incentives for prevention than traditional VBP under a variety of circumstances. Design, Setting, and Participants: This decision analytic model used a simulated cohort of 1000 Medicaid-enrolled pregnant individuals. Health care costs for individuals receiving postpartum depression preventive intervention or not, over 1 or 5 years post partum, in a variety of scenarios, including varying rates of Medicaid churn (ie, transitions to a new Medicaid managed care plan, commercial insurance plan, or loss of coverage) were estimated for the period 2020 to 2025. The model was developed between March 5 and July 30, 2021. Exposure: Sharing 100% of 1-year actual health care cost saving vs 50% of 5-year estimated health care cost savings associated with reduced postpartum depression incidence. Main Outcomes and Measures: The main outcome was the amount of clinician incentive shared in a VBP model from providing preventive interventions. The likelihood of the health care payer realizing a positive return on investment if it shared 50% of 5-year expected savings with a clinician up front was also measured. Results: The simulated cohort was designed to be reflective of the demographics characteristics of pregnant individuals receiving Medicaid; however, no specific demographic features were simulated. Providing preventive interventions for postpartum depression resulted in an estimated 5-year savings of $734.12 (95% credible interval [CrI], $217.21-$1235.67) per person. Without health insurance churn, sharing 50% of 5-year expected savings could offer more than double the financial incentives for clinicians to prevent postpartum depression compared with traditional VBP ($367.06 [95% CrI, $108.61-$617.83] vs $177.74 [95% CrI, $52.66-$296.60], respectively), with a high likelihood of positive return for the health care payer (91%). As health insurance churn increased, clinician incentives from sharing estimated savings decreased (73% reduction with 50% annual churn). Conclusions and Relevance: In this decision analytic model of VBP approaches to incentivizing postpartum depression prevention, VBP based on 5-year expected savings offered stronger incentives when churn was low. Policy should support health care payers and clinicians to share estimated savings and overcome health insurance churn issues to promote wide-scale implementation of interventions to prevent perinatal mental health conditions.