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
 Privately-insured
populations have
an even lower
treatment rate:
5.5%.2
1
SAMHSA 2004, 2 NCQA 2002
1 SAMHSA 2004, 2 NCQA 2002
Prescribing patterns by provider type
Mark, Tami et. al. Psychiatric Services September 2009 vol. 60 no. 9 1167
Chronic Health Conditions Underlie
the Bulk of Health Care Costs in 2007
1% of population
represents over
20% of spending



% of HC Spending
10% of population
represents over
64% of spending

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
Top
1%
Top
5%
(≥$39,688) (≥$13,387)
Top
10%
Top
15%
Top
20%
Top
50%
Bottom
50%
(≥$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.
Disease Prevalence and Impact on Work
Impairment
Work Impairment Because of Illness
Reason
Prevalence
Population (%)
Days Impaired per 1000 Employees
Kessler RC, et al. J Occup Environ Med. 2001;43:218-225.
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
Total costs up to 36% of payroll!**
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; 39:224231; IBI Full Cost Data, 2006
** The Total Financial Impact of Employee Absences, Mercer Study sponsored by
Kronos®, Oct. 2008
Primary Care Behavioral Program: Enhance
collaboration and increase capacity
Usual Care
Collaborative Care
PRIMARY CARE
CLINICIAN
Patient
PATIENT
PATIENT
MENTAL HEALTH
SPECIALIST
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
Aetna Behavioral Health Strategy:
Integrated Clinical Programs






Counseling
Worksite Consultation
Work/Life Support
Legal/Financial Support
Crisis Debriefing
SBIRT
Specialized
Behavioral
Health
Service
Continuum of
Behavioral
Health
Services
Employee
Assistance
Program



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
−
−
−
−
Primary
Prevention
Depression
Alcohol Use Disorder
Anxiety Disorder
Bipolar disorder
Tertiary
Prevention
PCP Depression Program:
Clinical Outcome

PHQ 9 Scores
Count
Initial
PHQ9
Minimal
Symptoms (59)
41
7
Secon
d
PHQ9
Chang
e (%)

6
1
(14%)



Major
Depression,
mild /
Dysthymia (1014)
59
12
7
5
(42%)
Major
depression,
moderate (1519)
51
17
7
10
(59%)
Major
depression,
severe >19
31
23
8
15
(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