Challenges in Integrating Specialty Behavioral Health in Primary Care Hyong Un, M.D.

1. Challenges in Integrating Specialty Behavioral Health in Primary CareHyong Un, M.D.

2. Low behavioral health treatment rates • Population-based treatment rates are low; although 20-28% of adults have a diagnosable mental illness in any given year, only 13.2% receive treatment.1 • Privately-insured populations have an even lower treatment rate: 5.5%.2 1 SAMHSA 2004, 2 NCQA 2002 1 SAMHSA 2004, 2 NCQA 2002

3. Prescribing patterns by provider type Mark, Tami et. al. Psychiatric Services September 2009 vol. 60 no. 9 1167

4. Chronic Health Conditions Underliethe Bulk of Health Care Costs in 2007 • Diabetes • Heart Failure • Coronary Artery Disease • Depression • Chronic Pain • Cancer • Asthma and COPD • Dementia • Falls • Obesity • Co-morbidities Chronic Conditions Are Costlier to Treat and Control 1% of population represents over 20% of spending 10% of population represents over 64% of spending % of HC Spending Top1% Top5% Top10% Top15% Top20% Top50% Bottom50% (≥$39,688) (≥$13,387) (≥$7,509) (≥$5,191) (≥$3,733) (≥$724) (<$724) % of Population Ranked by HC Spend Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2004.

5. Disease Prevalence and Impact on Work Impairment Prevalence Work Impairment Because of Illness Reason Population (%) Days Impaired per 1000 Employees Kessler RC, et al. J Occup Environ Med. 2001;43:218-225.

6. Direct costs: only the tip of the iceberg • Doctor visits • Hospitalization • Pharmacy • Diagnostic testing • Behavioral health • Workers’ comp • Salary continuation • Wellness/prevention Direct (medical) costs:1/3 of total costs; $6,020 PEPY* + • Absenteeism—lost work time due to illness/injury • Presenteeism—impaired performance • Turnover • Flagging product quality • Overtime • Temporary staffing, training • Replacement training • Employee and customer dissatisfaction • Administrative costs Indirect (productivity) costs:2/3 of total costs; $12,000 PEPY* * Loeppke, et. al., JOEM, July 2007; 45:349-359 and Brady, et. al., JOEM, July 2007; 39:224-231; IBI Full Cost Data, 2006 ** The Total Financial Impact of Employee Absences, Mercer Study sponsored by Kronos®, Oct. 2008 Total costs up to 36% of payroll!**

7. Primary Care Behavioral Program: Enhance collaboration and increase capacity Usual Care Collaborative Care PRIMARY CARE CLINICIAN PATIENT Patient PATIENT MENTAL HEALTH SPECIALIST

8. Challenges and responses: Primary Care Contracted provider network – predominant delivery system Multiple payers with lack of consistent model Low penetration – most offices at most 20% Aetna membership Lack of standard reimbursement methodology Lack of infrastructure – issue of contracted network Solo practices with minimum infrastructure Registry, care management, data management infrastructure / EMR Group / organized practices – EMR, academically based practices Need for facilitated and multiple approaches Office type and organization Geographic density Lack of adoption and persistency Relationship with health plan care management Reframing of health plan care management services

9. Challenges and responses: Behavioral health Behavioral health provider network Conceptual framework and training model medical versus psychological / social science Cultural and delivery model issues with integration Training behavioral health and primary care providers Privacy Incentives (carrot vs. stick vs. frozen carrot) Health plan integration Similar to provider Integration and cultural issues Integration of BH and Medical health data set and care management system Health Financing Transactional versus longitudinal / outcome based Silos between behavioral health and medical reimbursement Lack of standard reimbursement codes to support screening, case management, and integration BH funding and delivery model Carve in versus care out Data sharing - privacy Funding integration

10. Aetna Behavioral Health Strategy: Integrated Clinical Programs Specialized Behavioral Health Service Continuum of Behavioral Health Services Employee Assistance Program • Counseling • Worksite Consultation • Work/Life Support • Legal/Financial Support • Crisis Debriefing • SBIRT • Network • Utilization Management • Integration with PCPs • Depression • Pediatrics • SBIRT • Integrated BH • Intensive Case Management • Med/Psych Case Management • Eating Disorder Case Management • Autism Advocacy Program • Disease Management • Depression • Alcohol Use Disorder • Anxiety Disorder • Bipolar disorder Primary Prevention Tertiary Prevention

11. PCP Depression Program: Clinical Outcome • PHQ 9 results on 182 enrollees • 45% of enrollees have moderate to severe depression (PHQ9>14) • Average admission PHQ 9 is 14 • Average second PHQ 9 is 7 • 50% drop in PHQ 9 score indicates treatment response • 48% of enrollees with major depression achieve full remission as defined by PHQ9 less than 5 (Literature rate - 30%)

12. PCP Depression Program: Financial Outcomes (6 month data) • Medical cost impact – Reduction on completion • Emergency room – 39% • Inpatient – 30% • Outpatient – 47% • Psychiatric visit – 3% reduction • Psychotherapy visits – 290% increase • Net total cost savings - 39%

13. Primary Care Based Behavioral Health: Aetna’s Next Steps Pediatric – Child Psychiatry Initiative Reimburses for screening, telephonic consultations, and office visits Pilot Sites: NJ, PA, ME, OH, TX Screening and Brief Intervention for problem drinking Facilitated adoption of SBI CPT codes Integration with Alcohol Disease Management program Utilization of integrated psychosocial and medication assisted treatment Behavioral health provider integration in primary care setting 2009 pilot Partial solution to low adoption and utilization rates Scaling challenges - closed staff versus network model Claims administration and medical cost challenges Requires modification of office based behavioral health practice