Background: Despite increasing consensus about the value of depression disease management programs, the field has not identified which stakeholders should absorb the relatively small additional costs associated with these programs.

Aims of Study: This paper investigates whether two stakeholder groups (health plans and employer purchasers) in two delivery systems (rural and urban) economically benefit from improved depression treatment by testing whether depression care management results in: (1) a greater reduction of utilization costs in insured rural patients than their urban counterparts (health plan stakeholders), and (2) a greater reduction in work costs in employed urban patients than their rural counterparts (employer purchaser stakeholders). Methods: We examined the main and differential effects of intervention on utilization and work costs over 24 months in a preplanned secondary analysis of 479 depressed patients from rural and urban primary care practices who participated in a randomized controlled trial of depression disease management.

Results: Reductions in work costs were observable in both the rural and urban cohort, while reductions in utilization costs were observable in the urban cohort.

Discussion with Limitations: While our small sample size limits definitive conclusions, the economic incentives to assure improved depression treatment may differ across stakeholders in rural and urban delivery systems.

Implications for Health Policy: Employers may have more consistent economic incentives than health plans to assure improve depression treatment across rural and urban delivery systems.