Not screening for anxiety? Costs and solutions

In recent years, there has been an increased emphasis on advancing screening recommendations for anxiety among health care providers and organizations, particularly in women’s health practices. The U.S. Preventive Services Task Force (USPSTF) recommends screening for anxiety in adults aged 18 to 64, including pregnant and postpartum persons. In addition, the Women’s Preventive Services Initiative (WPSI), which was launched in 2016 and again in 2021 by the American College of Obstetricians and Gynecologists (ACOG) as part of a five-year cooperative agreement with the Health Resources and Services Administration (HRSA), provides recommendations to update guidelines for women’s preventive health care services, such as the Women’s Preventive Services Guidelines originally established by the National Academy of Medicine (formerly known as the Institute of Medicine). Current WPSI recommendations for anxiety screening in adolescent and adult women are based on the high prevalence of anxiety disorders in these populations, the lack of detection in clinical practice, and the associated medical and quality of life costs with untreated anxiety.

An estimated 19.1% of the American population experience an anxiety disorder each year, according to the Anxiety & Depression Association of America (ADAA). Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders, affecting 6.8 million adults (3.1% of the national population) and twice as many women as men. The difference in the prevalence of anxiety between women and men is particularly marked around times of hormonal transitions, such as puberty, premenstrual, pregnancy or postpartum, and perimenopause, and its accompanying psychosocial stressors, according to researchers. Indeed, the prevalence of any anxiety disorder during pregnancy is 18.2%. Furthermore, comparable to nonpregnant women, 13% of currently pregnant and postpartum women report having experienced an anxiety disorder within the past year.

The annual cost of anxiety disorders is estimated to be $94.7 billion, or $3,453 per patient, with nonpsychiatric direct medical costs constituting the largest component at 54%. Anxiety disorders have been linked to higher rates of health care utilization in various outpatient settings (primary care, internal medicine, neurology, cardiology, gynecology, gastroenterology, rheumatology, psychiatry, and psychology), as well as twice as many visits to emergency and urgent care centers as the general population.

For most patients, anxiety treatment begins with a visit to their primary care physician. In primary care, however, anxiety symptoms may be mistaken for and/or associated with somatic symptoms, which further poses a risk for unnecessary testing and treatment and resulting health care costs. It is estimated that up to 50% of primary care patients present with somatic complaints, with the highest rates among women. Patients with anxiety who report somatic symptoms present a unique treatment challenge, emphasizing the need for effective screening for anxiety in primary care.

The Generalized Anxiety Disorder subscale (GAD-7) is a highly validated and widely used screening tool designed to identify and measure generalized anxiety symptoms among primary care patients. There are various CPT® codes available to facilitate screening for anxiety, with 96127 being the most often utilized and reimbursed code by payers and the majority of state Medicaid fee schedules. The average reimbursement for screening is $4.74. Also applicable to the Medicare population is HCPCS code G0444. It is generally recommended to include the code for all screening even though reimbursement frequency varies by payer. There is an additional code, 96161, which is used to screen parents in infant visits, which reimburses higher than 96127 for many payers. Despite this, many providers do not screen, as they may feel unable to care for these patient needs and/or do not have access to evidence-based behavioral health treatment. However, there are now options to support primary care practices to screen and care for their patients with anxiety.

Collaborative care is an evidence-based model designed to identify and treat patients with depression and anxiety in health care settings. In 2017, specific CPT® codes (99492,3,4) were added by the Centers for Medicare & Medicaid Services (CMS) and have since been adopted by commercial plans and onto Medicaid fee schedules in almost half of the states. With over 90 randomized control trials supporting its efficacy, collaborative care can be an effective care model that provides the necessary support for providers and treatment for patients to improve patient and practice outcomes.

Concert Health anxiety data

Concert Health, a behavioral health medical group that provides collaborative care to partnering providers and organizations, shares data to support the adoption of anxiety screening in primary care practices and demonstrate that patients can experience significant symptom reduction in the first few months of care. Practices could expand and optimize screening initiatives while providing or partnering to offer evidence based treatment.

Conclusion

Anxiety symptoms and disorders are continuing to increase in prevalence across all populations, and the USPSTF is considering expanding anxiety screening recommendations to seniors. The ability to both screen and identify patients in their trusted health care setting and subsequently provide treatment could significantly impact prevalence rates but also reduce utilization and health care costs for patients, providers, and health care organizations.

Virna Little, PSyD, LCSW-r is an internationally recognized executive and advisor for her work integrating primary care and behavioral health, developing sustainable integrated delivery systems and suicide prevention. She is the chief clinical officer and cofounder of Concert Health, a national organization providing behavioral health services to primary care providers. Her extensive clinical experience and leadership roles have distinguished Concert as a leading medical group. Outside of Concert, Dr. Little is a member of the national and international Zero Suicide initiatives and the National Council for Mental Wellbeing, and she has spoken on national suicide prevention strategies at the White House.

Alissa Mallow, DSW, LCSW-r, is the director of education and research for Concert Health and is part-time faculty at Adelphi University School of Social Work.

Lindsay Standeven, MD, is an assistant professor of psychiatry and behavioral services at Johns Hopkins School of Medicine where she acts as the clinical and education director of the Johns Hopkins Reproductive Mental Health Center.

Roni Berger, PhD, LCSW, is a professor at the Adelphi University School of Social Work. Her fields of expertise are cross cultural aspects of trauma and posttraumatic growth, immigrants, families, specifically stepfamilies, evidence-based practice and group work.

Jian Joyner is a specialization year intern at Concert Health, working under the supervision of Virna Little, PsyD, LCSW-r, SAP, CCM, while enrolled in Temple University’s online master of social work program.