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

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Challenges in Integrating Specialty Behavioral
Health in Primary CareHyong Un, M.D.
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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
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Prescribing patterns by provider type
Mark, Tami et. al. Psychiatric Services September
2009 vol. 60 no. 9 1167
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Chronic Health Conditions Underliethe Bulk of
Health Care Costs in 2007
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)
(lt724)
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.

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Disease Prevalence and Impact on Work Impairment
Work Impairment Because of Illness
Prevalence
Reason
Population ()
Days Impaired per 1000 Employees
Kessler RC, et al. J Occup Environ Med.
200143218-225.
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Direct costs only the tip of the iceberg

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

Direct (medical) costs1/3 of total costs
6,020 PEPY

• Absenteeismlost work time due to illness/injury
• Presenteeismimpaired performance
• Turnover
• Flagging product quality
• Overtime
• Temporary staffing, training
• Replacement training
• Employee and customer dissatisfaction
• Administrative costs

Indirect (productivity) costs2/3 of total
costs 12,000 PEPY
Loeppke, et. al., JOEM, July 2007 45349-359
and Brady, et. al., JOEM, July 2007 39224-231
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!
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Primary Care Behavioral Program Enhance
collaboration and increase capacity
Usual Care
Collaborative Care
PRIMARY CARE CLINICIAN
PATIENT
Patient
PATIENT
MENTAL HEALTH SPECIALIST
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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

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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

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Aetna Behavioral Health Strategy
Integrated Clinical Programs
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PCP Depression Program Clinical Outcome

• PHQ 9 results on 182 enrollees
• 45 of enrollees have moderate to severe
  depression (PHQ9gt14)
• 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)

PHQ 9 Scores Count Initial PHQ9 Second PHQ9 Change ()
Minimal Symptoms (5-9) 41 7 6 1 (14)
Major Depression, mild / Dysthymia (10-14) 59 12 7 5 (42)
Major depression, moderate (15-19) 51 17 7 10 (59)
Major depression, severe gt19 31 23 8 15 (65)
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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

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Primary Care Based Behavioral Health
Aetnas 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