Integrating Behavioral Health and General Health: One Insurer s Perspective

1. Integrating Behavioral Health and General Health: One Insurer’s Perspective Rhonda J. Robinson Beale, M.D. Chairman, Board of Directors, ABHW Chief Medical Officer, OptumHealth Behavioral Solutions

2. Overview Background on ABHW MBHO Scope of Responsibility to Purchasers What Purchaser’s Believe and Want What is Behavioral Medical Integration (BMI) Evidence to Support BMI Clinical System Transformations Role for National Association of Psychiatric Health Systems (NAPHS) members

3. ABHW - Background ABHW is a large trade organization that has engaged members who collectively cover more than 142 million people and has relationships with well over >85% of behavioral health providers across the country. ABHW covers in its membership managed behavioral health organizations (MBHOs), EAP organizations and Wellness Companies.

4. ABHW - Membership Aetna and Schaller Anderson Alliance Behavioral Care Centpatico College Health IPA Magellan Mental Health Network (MHN) United Behavioral Health (new name -OptumHealth Behavioral Health Solutions) Value Options

5. Scope of Work ABHWs members are contracted by purchasers of behavioral health care ( employers, Taft Hartley entities, health plans, states and federal government to be accountable for: Providing access to high quality behavioral health care; Creating a check and balance system that embraces the need to effectively allocate fixed resources; and, Being responsible for ensuring quality of care, access to appropriate providers and accountability for good outcomes. Accountability is measured by MBHOs through performance measurements and standards that ensure consumers receive evidence based treatment tailored to the needs of the individual. NCQA* URAC* eValue8* RFIs

6. What Do Purchasers Want? Healthy and productive workforce Without illnesses or conditions that interfere with their productivity Without significant psychosocial burdens With healthy life style habits “Best bang for the buck” Demonstration that treatment works Demonstration of clinical improvement

7. Cost Burden of Behavioral Health Conditions

8. Work Impairment Due to Illness

9. Depression - Time Loss and Impairment

10. Value Proposition Definition Quantitative and qualitative demonstrations of the value behavioral health treatment brings to the purchaser and members. Value is based on clinical effectiveness wedded to the best return on investment due to the array of clinical programs and services offered.

11. Value Proposition Definitions Quantitative and qualitative demonstrations – use of standard or credible performance metrics that are reported quantitatively and have relevance to the clinical effect and value of the behavioral health intervention Clinical effectiveness – a demonstration of: Closure of significant clinical gaps in care that are strong proxies for adherence to best practices and better clinical outcomes Quantitative improvements in clinical outcomes and/or functionality above the “normal care” benchmark Return on investment – demonstration of: Cost neutrality with significant improvement in clinical outcomes/functionality and/or closure of clinical gaps Quantitative cost savings directly or indirectly to the purchasers of services. Cost savings could be due to cost avoidance - cost lowered due to avoidance of anticipated services that were not needed. Cost savings - lowered overall unit cost for services to reach outcome

12. Value Based Behavioral Health Benefits – Clinical Approach Clinical Approach – “right care at the right time for the right person(s)” Focused on the clinical needs to assure return to stability and functioning Requires the right infrastructures and capabilities in combination together

13. The Behavioral Health Management Maze

14. Prevalence of Mental Disorders Lifetime Prevalence Anxiety Disorders 28.8% Impulse Disorders 24.8% Mood Disorders 20.8% Depression excluding Bipolar 16.6 Substance Use Disorder 14.6% Other 11.0% !2 month Prevalence Anxiety Disorder 18.1% Mood Disorder 9.5% Impulse Disorder 8.9% Substance Use Disorder 3.8% Any Disorder 26.2% Lifetime Prevalence Anxiety Disorders 28.8% Impulse Disorders 24.8% Mood Disorders 20.8% Depression excluding Bipolar 16.6 Substance Use Disorder 14.6% Other 11.0% !2 month Prevalence Anxiety Disorder 18.1% Mood Disorder 9.5% Impulse Disorder 8.9% Substance Use Disorder 3.8% Any Disorder 26.2%

15. Proportional Treatment Contact within 12 Months of Disorder Onset Major Depression 37.4% sought treatment Median 8 years delay Dysthymia 41.6 % sought treatment Median 7 years delay Generalized Anxiety 33.3 % sought treatment Median 9 years delay Panic Disorder 33.6 % sought treatment Median 10 years delay

17. Undetected Diagnosis

18. Effective Medical – Behavioral Interventions Key studies are indicating treatment effectiveness with “enhanced care models Rost study 2005 – Depression with any medical diagnosis with a demonstrated ROI within two years UBH study 2005 – High risk medically ill patients within medical case management who screened positive for behavioral health co-morbidity demonstrated a 7% decrease in medical cost for the intervention population with in one year UBH study 2006 – Medicare population screened positive for depression with intervention suggest a substantial decrease in medical cost, ( average $3,000 decrease) with in one year. UBH/Kessler study 2007 to be released – Early indications of positive effects on reducing workplace absenteeism via intervention with employees identified from a HRA with behavioral co-morbidities and psychosocial issues interfering with work Simon 2006 - suggest that successful behavioral treatment (achieving remission) has a positive effect on reducing medical cost

19. “Enhance Care Models” - Virtual

20. LifeSolutions Core Components Telephonic outreach to program participants Participant self-management education Comprehensive symptom assessment through PHQ-9 and other clinically validated assessment tools Coordination of care with PCPs, behavioral health clinicians and facilities Coordination of care with medical referral partners and vendors (ie: Disease Management, Medical Case Management, Disability vendors, EAP, etc.) Support and education to family members Coordination with community based service agencies and resources Primary Care Physician line for consultation with UBH Psychiatrists Web-based information about behavioral conditions including self-help tools on depression, anxiety, substance abuse and stress Monthly Member mailings Provider Education mailings Outcomes evaluation Customer-specific reporting

21. LifeSolutions Interventions

22. “Enhance Care Models” – Office Based

23. Chronic Mental Illness Populations Are Different SPMI populations do not readily seek medical care Die 20 -25 years earlier that the general population Depend on medications that have effects on medical functioning but generally are not monitored

24. “Enhance Care Models” – SPMI

25. Measuring Treatment Effectiveness ALERT

26. The Wellness Assessment (WA) works like a “lab test” that: Measures level of psychological distress (NOTE: it is not a diagnostic tool) Can detect presence of global distress and stratify clinical severity Flags potential at-risk issues that allow UBH Care Advocates and clinicians to evaluate and modify treatment plans Is used to monitor therapeutic progress throughout the course of treatmentThe Wellness Assessment (WA) works like a “lab test” that: Measures level of psychological distress (NOTE: it is not a diagnostic tool) Can detect presence of global distress and stratify clinical severity Flags potential at-risk issues that allow UBH Care Advocates and clinicians to evaluate and modify treatment plans Is used to monitor therapeutic progress throughout the course of treatment

27. UBH Proprietary Case Selection Algorithms A set of algorithms based on the patients’ report of their clinical status at onset of treatment Measures treatment in progress at visits 3-5 and, for high-risk members, between visits 8-10

28. Questionnaire Only SCENARIO: Chemical Dependency Risk Bill has been feeling down since his recent divorce and thought he’d benefit from seeing a UBH counselor. At the first session, he completed the Wellness Assessment and talked about his problems with the counselor. But afterward, he decided not to see the clinician again. Upon receiving the Wellness Assessment from the clinician, the UBH ALERT algorithms flag a potential alcohol abuse risk, as Bill stated on the questionnaire that he has been drinking a bit heavily. UBH contacts counselor, and is told that Bill did not schedule another appointment. UBH contacted Bill directly and referred him back to his UBH clinician so he could get the treatment he needs. UBH also helped Bill find community support groups and other local resources to help him deal with his alcohol use as well as the emotional anguish from his divorce. SCENARIO: Chemical Dependency Risk Bill has been feeling down since his recent divorce and thought he’d benefit from seeing a UBH counselor. At the first session, he completed the Wellness Assessment and talked about his problems with the counselor. But afterward, he decided not to see the clinician again. Upon receiving the Wellness Assessment from the clinician, the UBH ALERT algorithms flag a potential alcohol abuse risk, as Bill stated on the questionnaire that he has been drinking a bit heavily. UBH contacts counselor, and is told that Bill did not schedule another appointment. UBH contacted Bill directly and referred him back to his UBH clinician so he could get the treatment he needs. UBH also helped Bill find community support groups and other local resources to help him deal with his alcohol use as well as the emotional anguish from his divorce.

29. Questionnaire + Claims Data SCENARIO: Report of Depressive Symptoms with No Medication Evaluation Visits Jack felt like his life has fallen into rut, and a co-worker suggested he call UBH for help. Jack visited a UBH counselor and talked about his problems that seem to be bogging down his life. After an assessment of Jack’s Wellness Assessment and the counselor claims, the UBH ALERT algorithms indicated that Jack’s questionnaire showed possible depression symptoms, yet the claims did not indicate that the appropriate treatment was being used to address them. (NOTE: This algorithm triggers an intervention only after 7 visits for depression without evidence of a medication evaluation.) UBH immediately notified the counselor of the situation, asking her to review the treatment plan and to look into whether Jack would benefit from depression treatment and medication. After an adjustment to his treatment, Jack is now dealing with his problems and is slowly learning how to move forward with his life. SCENARIO: Report of Depressive Symptoms with No Medication Evaluation Visits Jack felt like his life has fallen into rut, and a co-worker suggested he call UBH for help. Jack visited a UBH counselor and talked about his problems that seem to be bogging down his life. After an assessment of Jack’s Wellness Assessment and the counselor claims, the UBH ALERT algorithms indicated that Jack’s questionnaire showed possible depression symptoms, yet the claims did not indicate that the appropriate treatment was being used to address them. (NOTE: This algorithm triggers an intervention only after 7 visits for depression without evidence of a medication evaluation.) UBH immediately notified the counselor of the situation, asking her to review the treatment plan and to look into whether Jack would benefit from depression treatment and medication. After an adjustment to his treatment, Jack is now dealing with his problems and is slowly learning how to move forward with his life.

30. ALERT® 2007 Results

31. ALERT Messages Improve Clinician Performance

32. Next Generation of Approach to Behavioral Health Condidtions Brain Resource

33. OptumHealth and Brain Resource

34. What does Brain Resource do? Brain Resource measures of brain health provide the most coherent picture of the brain to support confident health management decisions Through an integrative and standardized approach to testing the brain we are able to reliably link specific brain markers to optimal intervention paths (whether it be medication, training or lifestyle interventions) critical to keeping people well and keeping costs low Developers of personalized and effective brain health solutions use Brain Resource reports to bring increased speed and certainty to their decisions Investment in science has been highest priority- access to an international network of studies and scientists through BRAINnet

35. Brain Resource International Database (BRID)

39. Importance of Markers

40. Connecting Markers to Ecologically Valid Solutions

42. Rules Based Report Generated

43. Role for NAPHS Members Work collaboratively with medical sector Modify patient approach to support engagement Consider different models of care