Aetna’s Primary Care Based Behavioral Health Program Hyong Un, M.D. Chief Psychiatric Officer

1. Aetna’s Primary Care Based Behavioral Health ProgramHyong Un, M.D.Chief Psychiatric Officer CHFA Annual Meeting 2011

2. We Are in a Dynamic Time Economic Conditions Political Environment Customer Needs Health Care System

3. Forces Driving Our Strategy • Well-being/Wellness • Global Benefits and Talent Management Strategy • Health Information Technologies Industry Trends Legislation • Health Care Reform • Mental Health Parity • Demographic Trends • Unsustainable Cost Trends • Global Competition 3 EAP Master Strategy Plan Executive Summary

4. Rising Health Care Costs Health System Forces • Contributing Factors • Opaque system • Bias toward new and expensive • Cost shifting • Provider payment challenges • Demographic challenges • Taxes, fees, compliance • Medical Liability • Unhealthy Lifestyles $4.2T Annual health care spending in the U.S. is estimated to surpass $4.2 trillion in 2018.1 $2.5T $75B 2009 2018 1970 1 Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. http://www.cms.hhs.gov/NationalHealthExpendData/ ; Historical data from CY 1960-2008; Projected data from NHE projections 2009-2018. 4

5. 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.

6. Prevalence of Depression and Chronic Mental Illness Percent With Depression Medical Condition Pincus HA. J Clin Psychiatry. 2001;62 Suppl 6:5-9; Schatzberg AF. J Clin Psychiatry. 2004;65 Suppl 12;3-4.

7. Leading Driver of Reversible Cost at Worksite Source: HERO Study. Goetzel et. al

8. Behavioral Health in Primary Care • Significant portion of primary care visits are associated with stress, lifestyle management or a psychological disorder • Behavioral health disorders are often under-diagnosed • Screening tool availability/reimbursement alone are insufficient • Behavioral health support is required for optimal treatment

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

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 • Care Management • Integration with PCPs • Depression • Pediatrics • SBIRT • Med. Assisted RX • Intensive Case Management • Med/Psych Case Management • Eating Disorder CaseManagement • Autism Advocacy Program • Disease Management • Depression • Alcohol Use Disorder • Anxiety Disorder • Bipolar disorder Primary Prevention Tertiary Prevention

11. Integrated Primary Care Behavioral Health Program • Integrates behavioral health clinicians in primary care • Addresses behavioral health, health/wellness issues • Facilitates access to behavioral health services • Brief/problem-solution focused intervention • Max of 3 sessions in PCP office • Referral /continued treatment outside PCP office if needed

12. Aetna Support • Identify PCP practices • Substantial Aetna membership • Practice infrastructure • Open to an integrated approach • Identify behavioral health practices • Geographic location • Practice size • Availability of psychiatrist • Complete behavioral health clinician contract amendments • Reimbursement combination coding: Diagnosis Code: V40.9 (Unspecified mental or behavioral problem) ; Procedure code: 99242 - Office consultation for a new or established patient

13. Implemented Sites Family practices • 7 sites in Philadelphia, PA area • Including Jefferson University & University of Pennsylvania primary care Pediatric practices • 1 site in Columbus, OH area • 2 sites in Philadelphia, PA area • Including Children’s Hospital of Philadelphia location • Includes reimbursement for pediatrician screening and pediatrician/psychiatrist telephonic consultations