1. Employer Perspectives Related to the Expense of Behavioral Health, and Substance Abuse Behavioral Screening and Intervention August 25, 2010 Jeff Kluever jkluever@journalcommunications.com

2. About Journal Communications 2800 employees, 1,000 pre-Medicare and Medicare-eligible participants nationally. Our strategic plan focuses on providing quality benefits while maintaining shareholder value. Like other employers, we struggle with managing:  Affordable coverage (employer and retiree)  The impact of medical inflation on our budget  The health status of medical plan participants

3. JOURNAL OUTCOMES

4. Impacting Medical Plan Trends Medical Per Member Per Month (PMPM) increased 8.4% from 2008 – 2009 Medical PMPM decreased 5.8% including high cost claimants from 2009-2010 Medical PMPM decreased 20.6% excluding high cost claimants from 2009-2010

5. Prevalence of Behavioral Risk Factors BRFSS, 2008 SAMHSA NSDUH 2006-2007

6. Our Experience 2006-2009 PharmacyInpatientOutpatientTotal Paid 2006 $301,456 $ 86,463$184,245$572,165 2007 $265,367 $ 73,857$145,984$485,208 2008 $247,945 $ 36,781$136,652$421,378 2009 $207,843 $ 21,214$ 64,738$293,795 Based on Plan Year April 1– March 31 Behavioral Health

7. Our Experience 2006-2009 PharmacyInpatientOutpatientTotal Paid 2006$ 337$ 3,670$ 8,684$12,691 2007$1,086$14,571$16,820$32,476 2008$1,285$16,946$22,768$40,999 2009$ 0$47,009$31,910$78,919 Based on Plan Year April 1– March 31 Substance Abuse

8. Our Experience

9. Strategy for all Offer medical plans requiring engagement;  PCP – coaching opportunity  Living Well – pharmacist coaching Reduce barriers; Give participants with chronic diseases tools and support to manage their condition. Increase compliance for disease-specific medications; and Provide wellness program that gives feedback

10. Coordination and Support for the Patient Tools: 1.Employee Assistance Plan – evaluation and referral 2.Medical Benefits – asses, medication and treatment 3.Living Well Program - face-to-face coaching and medication management 4.Wellness Program – telephonic or online support for lifestyle changes

11. Remove Barrier #1 – Benefit Limitations Implement behavioral health Parity  Removed day/visit limits  Remove lifetime limits Waive the HSA deductible for “preventive prescriptions” as defined by the IRS

12. Remove Barrier #2 – Lack of Primary Self-Care Provide preventive examinations at 100%  Encourage relationship with PCP  Screening and early diagnosis of behavioral health concerns, tobacco cessation, excessive drinking, and drug use Tobacco Cessation medications and coaching covered at 100% Increase reward for members who participate in HumanaBeginnings for early diagnosis of post-partum depression

13. Health Care Provider Form 13

14. Remove Barrier #3 – Complexity Integrated EAP (5 visits)  Same network as Medical Plan  Available to all employees, spouses and dependents PHQ9 administered by health coaches Connect STD and FMLA administration to Medical  Refer patients to Personal Nurse and Disease Management  Manage co-morbid health conditions

15. Behavioral health, tobacco use, excessive drinking and drug abuse is costly to the workplace Lost Productivity  Absenteeism  Presenteeism  Turnover and Training Costs Co- morbidity with other Diseases Overall Healthcare Costs Disability Worker’s Compensation Expense

16. Studies Show Treatment Improves Work Performance Nearly 86% of employees treated with depression with antidepressant medications reported improved work performance. 80% of those treated for mental illness report “high levels of work efficacy and satisfaction.” Studies prove that treatment of depression results about a 40-60% reduction in absenteeism/presenteeism. Source: Finkelstein SN et al: Improvement in Subjective Work Performance after Treatment of Chronic Depression: Psychopharmacology Bulletin, Vol 32,1996, pp 33-40. Therapy in America 2004: Poll shows Mental Health Treatment Goes Mainstream. Dunlop, DD Am J Pub Health 2005. Wag, PS am J Psych 2004. Simon, GE Gen Hosp Psych 2000, Claxton, AJ JOEM, 1999. Courtesy of Clare I Miller, Partnership for Workplace Mental Health.

17. Understanding Co-Morbidity Implemented Living Well ( Base on Asheville Project ) Provide members with a personal health coach (from a network of specially-trained pharmacists); Coordinate with the patient’s physician or other healthcare providers to help effectively manage their condition:  Diabetes  High Blood Pressure  Cholesterol  Asthma  Depression Provide medication and supplies without deductible and reduced copays.

18. Address Co-morbidity with other diseases Individuals with depression consume two to four times the healthcare resources of other enrollees. Chronic medical illnesses increase prevalence of major depression.  45% of people with asthma and 27% of people with diabetes have co-occurring depression Individuals with depression are twice as likely to develop CAD, twice as likely to have a stroke and more than four times as likely to die within six months from a myocardial infarction. Many chronic medical conditions are adversely affected by behavioral health conditions. Co-morbidity increases impairment in functioning and decreases adherence to prescribed regimens. An employer’s Guide to Behavioral Health Services, National Business Group on Health December 2005. Pincus HA. J Clin Psychiatry. 2001;62 Suppl 6:5-9; Schatzberg AF. J Clin Psychiatry. 2004;65 Suppl 12;3-4. Sederer Li et al: Integrating Care for Medical and Mental Illnesses. Preventing Chronic Disease, April 2006.

19. Patient Incentives – Living Well Program Face-to-face coaching  Improved reliability via direct observation  Interpersonal connection  Strengthens the patient-physician relationship HSA Medical plan deductible waived for preventive RX  100% coverage diabetes medication, test strips and supplies  Reduce copays by 50% for medication Cholesterol Asthma Blood Pressure Depression Free Glucometers & Insulin Pumps

20. Traditional Interventions are Limited Employees ride below the radar EAP – most employees with behavioral health, alcohol and drug disorders do not receive services Health Risk Assessments (HRA) – provide promotions only to those that self-report an issue or concern. Supervisors are not trained to recognize the symptoms or do not know how to approach.

21. The Bottom Line Behavioral health, excessive drinking, tobacco and drug use is  prevalent in working populations and  frequently co-morbid with other health conditions. Treatment works. Face-to-face coaching is cost effective. Primary Care Physicians have the opportunity to improve effectiveness of care.

22. Resources - Connections Center for Health Value Innovation  Cyndy Nayer 314-422-4385, cyndyn@vbhealth.orgcyndyn@vbhealth.org LifeSync  Grant Lee 469-759-4312, glee3@lifesynch.comglee3@lifesynch.com Piedmont Pharmaceutical Care Network  Larry S. Long RPh, 336-202-7146, Larry.Long@emailMM.comLarry.Long@emailMM.com Quality Health Solutions  Brian J. Thomas, 888-747-0708 ext 102, BThomas@qualityhealthsolutions.com BThomas@qualityhealthsolutions.com

23. Questions? Jeff Kluever jkluever@journalcommunications.com 414-224-2702