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Aetna Behavioral HealthDepression Initiatives

June 2006

2

Aetna sells HAI to Magellan

Magellan contract amended to consolidate Aetna services

Transition year, contractual services provided by Magellan until 12/31/05

1997 2005

Aetna enters market as 5th largest BH provider

2006

Aetna History

2003

Aetna announces decision to launch full-service BH and EAP business

2004

Aetna owns Human Affairs International (HAI)

1985

3

Aetna Behavioral Health StrategyImplementation UpdateIntegrated Clinical Programs

Employee Assistance Program

Continuum of Behavioral Health Services

Specialized Behavioral Health Service

Counseling Worksite Consultation Work / Life Support Legal / Financial Support Crisis Debriefing

Network Care Management Integration with PCPs

Intensive Case Management Med/Psych Case Management Disease Management

• Depression• Alcohol Use Disorder• Anxiety Disorder

Primary Prevention

Tertiary Prevention

4

Depression: Leading driver of overall cost at worksite

0%

10%

20%

30%

40%

50%

60%

70%

80%

Depression High stress High bloodglucose

Overweight Currenttobacco

use

High bloodpressure % Increase in

Costs

Source: HERO Study. Goetzel et. al

5

Depression and Medical Illness

Co-Occurring depression is common in medical illness– 40-65 percent of heart attack– 10-25 percent of stroke– 25 percent of cancer survivors

Risk of medical events increase with depression– 4 fold increased risk of MI – 3 fold increased risk for stroke in African Americans– 68 percent increased risk of stroke in Caucasian male

Source: NIMH and Centers for Disease Control and Prevention

6

90% of the 10 most common presenting complaints/symptoms in the primary care setting have no organic basis.

Half of HMO patients identified as “high utilizers” are psychologically distressed – the top 10% account for:– 52% of all specialty visits– 40% of all inpatient days– 29% of PCP visits– 26% of all prescriptions

1 Katon W, VonKorff M, Lin E, et al: Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen

Hosp Psychiatry. 12:355-362, 1990

Distress and Medical Illness

7

Impact of Depression on Aetna’s Medical Utilization: Diabetes

819.88

670.88

0

100

200

300

400

500

600

700

800

900

Admits/1000

4,934.06

3,199.21

0.00500.00

1,000.001,500.002,000.002,500.003,000.003,500.004,000.004,500.005,000.00

Days/1000

941.58

746.3

0100200300400500600700800900

1000

ER/1000

6.02

4.77

0.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

Average Length of Stay (days)

With Depression

Without Depression

8

Impact of Depression on Aetna’s Medical Utilization: Low Back Pain

With Depression

Without Depression

1,252.03

924.32

0.00

200.00

400.00

600.00

800.00

1,000.00

1,200.00

1,400.00

ER/1000

551.38

473.74

420.00

440.00

460.00

480.00

500.00

520.00

540.00

560.00

Admits/1000

2,512.93

1,848.18

0.00

500.00

1,000.00

1,500.00

2,000.00

2,500.00

3,000.00

Days/1000

4.56

3.90

3.503.603.703.803.904.004.104.204.304.404.504.60

Average Length of Stay (days)

9

Impact of Depression on Aetna’s Medical Utilization: CHF

With Depression

Without Depression

1,191.98

1,024.25

900.00

950.00

1,000.00

1,050.00

1,100.00

1,150.00

1,200.00

Admits/1000

7,724.65

5,610.96

0.00

1,000.00

2,000.00

3,000.00

4,000.00

5,000.00

6,000.00

7,000.00

8,000.00

Days/1000

862.10

587.35

0.00100.00200.00300.00400.00500.00600.00700.00800.00900.00

ER/1000

6.48

5.48

4.80

5.00

5.20

5.40

5.60

5.80

6.00

6.20

6.40

6.60

Average Length of Stay (days)

10

Moms-to-Babies

Disease Management

Asthma

Coronary Artery Disease

Chronic Heart Failure

Diabetes

Low Back Pain

Cardiac Post DC

Coronary Artery Disease

Integrated Health Disability

Antidepressant Pharmacy Data

Simple Steps HRA

PULSE

Depression Screening Resources

Our patient and disease management team screen for depression in all of the existing Aetna plans and programs. Up to 8000 members are screened per month.

11

Depression Program ResultsMedical Psychiatric Case Management

Program Description: Focused on members with co-occurring chronic medical

disorder (e.g. CHF, Diabetes) and depressive disorder Depression screening and referral process for all members

in Aetna’s medical case and disease management program Use of pharmacy and PULSE data to identify potential

enrollees Collaboration between medical and behavioral health case

managers Coordinate medical and behavioral care and enhance

adherence Minimum monthly member outreach by behavioral health

care managers Facilitated access to BH specialists with expertise in Medical

/ Psychiatric issues

12

Depression Program Results

Med / Psych SF 12 (N=1571)8.9% Physical Health Improvement44.9% Mental Health Improvement3.95 Average work days gained per month

Program Results

Utilization Impact

ER Utilization Reduction

Inpatient Length of Stay Reduction

Outpatient Visits – No change

Total Pharmacy Cost – Increase

Antidepressant accounted for 28% of increase

Net Medical Cost Reduction with 2:1 ROI

13

Medical Psychiatric Care Management Program and Productivity

Member response to intake and discharge questions:

Mental Health Survey

Condition Intake Discharge Outcome

Depression 79% 44% 35% drop in Depression

Energy Level 49% 75% 26% increase in energy

Work Limitations 63% 29% 34% drop in work limitationsSocial Limitations 71% 41% 30% drop in social limitations

Physical Health Survey

Condition Intake Discharge Outcome

General Health 5% 9% 4% increase in General Health

Work Limitations 61% 48% 13% drop in work limitations

Does Less Work 64% 45% 19% increase in work

Bodily Pain 12% 5% 7% decrease in bodily pain

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50% of mental health care is provided by PCPs

Two thirds of psychopharmacological drugs are prescribed by PCPs

Prescription drug costs make up 50% of all mental health costs

On average, only 3-6% of the insured population will seek treatment from a behavioral health specialist

Primary Care Physician as the frontline for Behavioral Health

15

Inadequate Detection and Treatment of Depression

Although 50% of those with depression are seen by PCPs, one-third to one-half go undiagnosed and under treated.

stigma Inadequate time – 7 minutes per office visit insufficient screening Reimbursement

Low adherence rates to antidepressants

Underutilization of psychotherapeutic intervention

16

PRIMARY CARECLINICIAN

MENTAL HEALTHSPECIALIST

PATIENT PATIENT

Usual Care Aetna Depression Management

Depression Care Models

Patient

Three Component Model

17

Aetna’s Depression Management:Program Components

Enhanced reimbursement to PCPs for assessment and treatment

Web and CD-ROM based CME program Empirically validated standardized depression assessment

tool (PHQ9) Care management support for members and PCP’s Psychiatric consultation to PCP’s National dissemination Outcomes measures and program effectiveness evaluation

Aetna Depression Management: Program Component

Aetna Depression ManagementProgram Component