Challenges in Integrating Specialty Behavioral Health in

Primary Care

Hyong Un, M.D.

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

1 SAMHSA 2004, 2 NCQA 2002

Privately-insured populations have an even lower treatment rate: 5.5%.2

1 SAMHSA 2004, 2 NCQA 2002

Prescribing patterns by provider type

Mark, Tami et. al. Psychiatric Services September 2009 vol. 60 no. 9 1167

1% of population represents over 20% of spending

10% of population represents over 64% of spending

Chronic Health Conditions Underliethe Bulk of Health Care Costs in 2007

Top1%

Top5%

Top10%

Top15%

Top20%

Top50%

Bottom50%

% of Population Ranked by HC Spend

% o

f H

C S

pen

din

g

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

(≥$39,688) (≥$13,387) (≥$7,509) (≥$5,191) (≥$3,733) (≥$724) (<$724)

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.

Disease Prevalence and Impact on Work Impairment

Population (%) Days Impaired per 1000 Employees

Work Impairment Because of Illness

Kessler RC, et al. J Occup Environ Med. 2001;43:218-225.

Rea

son

Prevalence

Direct costs: only the tip of the iceberg

Direct (medical) costs:1/3 of total costs; $6,020 PEPY*

Indirect (productivity) costs:2/3 of total costs; $12,000 PEPY*

Doctor visits Hospitalization Pharmacy Diagnostic testing Behavioral health Workers’ comp Salary continuation Wellness/prevention

+

Total costs up to 36% of payroll!**

* 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

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

PRIMARY CARECLINICIAN

MENTAL HEALTHSPECIALIST

PATIENT PATIENT

Usual Care Collaborative Care

Primary Care Behavioral Program: Enhance collaboration and increase capacity

Patient

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

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

Employee Assistance Program

Continuum of Behavioral Health Services

Specialized Behavioral Health Service

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

Aetna Behavioral Health Strategy: Integrated Clinical Programs

PCP Depression Program: Clinical Outcome

PHQ 9 Scores CountInitial PHQ9

Second PHQ9

Change (%)

Minimal Symptoms (5-9)

41 7 61

(14%)

Major Depression, mild / Dysthymia (10-14)

59 12 75

(42%)

Major depression, moderate (15-19)

51 17 710

(59%)

Major depression, severe >19

31 23 815

(65%)

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%)

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%

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