1. Click to edit Master subtitle style Aetna Behavioral Health Depression Initiatives June 2006

2. 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. 3 Aetna Behavioral Health Strategy Implementation Update Integrated 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. 4 Depression: Leading driver of overall cost at worksite Source: HERO Study. Goetzel et. al

5. 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. 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. 7 Impact of Depression on Aetna’s Medical Utilization: Diabetes With Depression Without Depression

8. 8 Impact of Depression on Aetna’s Medical Utilization: Low Back Pain With Depression Without Depression

9. 9 Impact of Depression on Aetna’s Medical Utilization: CHF With Depression Without Depression

10. 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. 11 Depression Program Results Medical 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. 12 Depression Program Results Med / Psych SF 12 (N=1571) 8.9% Physical Health Improvement 44.9% Mental Health Improvement 3.95 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. 13 Medical Psychiatric Care Management Program and Productivity Member response to intake and discharge questions: Mental Health Survey ConditionIntakeDischargeOutcome Depression79% 44%35% drop in Depression Energy Level49%75%26% increase in energy Work Limitations63%29% 34% drop in work limitations Social Limitations71%41%30% drop in social limitations Physical Health Survey ConditionIntakeDischargeOutcome General Health 5%9% 4% increase in General Health Work Limitations61% 48%13% drop in work limitations Does Less Work64%45%19% increase in work Bodily Pain12%5% 7% decrease in bodily pain

14. Click to edit Master subtitle style  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. 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. 16 PRIMARY CARE CLINICIAN MENTAL HEALTH SPECIALIST PATIENT Usual Care Aetna Depression Management Depression Care Models Patient Three Component Model

17. 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 Management Program Component