challenges in integrating specialty behavioral health in primary care hyong un m d l.
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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.

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low behavioral health treatment rates
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
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
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















% 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
Disease Prevalence and Impact on Work Impairment


Work Impairment Because of Illness


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

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!**


Primary Care Behavioral Program: Enhance collaboration and increase capacity

Usual Care

Collaborative Care








challenges and responses primary care
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
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


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
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
  • 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


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%)

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
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