Incorporating Behavioral Health Into the Health Planning Process to Improve Value

1. Incorporating Behavioral Health Into the Health Planning Process to Improve Value Jack Mahoney, MD, MPH SummitQuestions@valueoptions.com

2. About Pitney Bowes • 80+ year legacy • Fortune 500 company • $5.9 billion global provider of integrated mail and document management solutions • global team of more than 35,000 employees • presence in more than 130 countries worldwide • more than 2 million customers

3. Mailstream Preparation &Finishing Receive & Integrate Store/ Retrieve Creative Services Data Management Presort & Distribution Printing Create Produce Distribute Manage Corporate Responsibility Values Culture Programs Purchasing Health Plan Design Healthy, Productive Employees

4. Optimizing Employee Health Benefits for a Healthier and More Productive Workforce • Rule 1: The health of your organization begins with your people. • Rule 2: To realize total value, you must understand total cost. • Rule 3: Higher costs don’t always mean higher value. • Rule 4: Health begins and ends with the individual. • Rule 5: Avoid barriers to effective treatment. • Rule 6: Carrots are valued over sticks. • Rule 7: Total value demands total teamwork.

5. Pitney Bowes Health Services Organization HealthPlanning DirectDelivery Consultation Medical• Pharmacy Behavioral Health • Workers Compensation • Safety • Crisis Management • Product Stewardship • Benefits Administration • On-site Clinics • Wellness Programs & Screenings • Disability Management • Benefit Design • Funding / Underwriting • Vendor Sourcing & Management

6. Behavioral Health Integration Benefit Plan Management and Design

7. Behavioral Health: PB Overview Plan design • carved out of all self-funded plans • > 80% of population is self-funded • exceeds parity • unlimited in-network inpatient and outpatient services • no deductible, co-insurance for in-network services • specialist co-pays at PCP level

8. Enrollee Annual Cost Distribution Participants Total Cost

9. Predictive Model Results More than $10,000 Non Users $1,000 to $10,000 Up to$1,000

10. Predictive Model Results More than $10,000 Non Users $1,000 to $10,000 Up to$1,000

11. Key Learning: Engage People in Managing Their Health Remove access barriers to all health plans • free or limited cost of preventive/screening services • eliminate front-end deductibles • robust EAP services • 8 session face-to-face free EAP • 3 sessions combined with unlimited telephonic for Enterprise Services • EAP utilization currently at 5%

12. Behavioral Health Integration Benefit Plan Management and Design Condition Management

13. Predictive Model Results More than $10,000 Non Users $1,000 to $10,000 Up to$1,000

14. Predictive Model Results More than $10,000 Non Users $1,000 to $10,000 Up to$1,000

15. Key Predictors for Migration From Normal Spend to High-Cost Tier Individuals with chronic conditions and low medication-compliance rates • asthma • more than 1 fill of albuterol in a 30-day period • diabetes • less than nine 30-day fills in a 12-month period • hypertension • less than nine 30-day fills in a 12-month period • depression • less than six 30-day fills in a 12-month period

16. If: And: And: Then: low possession rates of target medications is key predictor of future disease burden and cost chronic disease prevalence is growing RX is an integral part of managing most chronic conditions company’s future health claims can be reduced by keeping employees with chronic disease on their medications If: And: And: Then: Rx drugs are subject to price elasticity of demand Rx drug demand elasticity is a function of cost medication compliance is a function of drug access and affordability put target chronic disease medications on most affordable tier to increase compliance with disease management program Pharmacy Benefit Design Decision How to keep employees taking their chronic disease medications?

17. Tier 1 Tier 1 Most generic drugs Most generic drugs and and all brand name drugs for: 10% Coinsurance • asthma • diabetes • hypertension Tier 2 • Most preferred brand • name drugs, including • those for: 10% Coinsurance • asthma • diabetes • hypertension Tier 2 Most preferred brand name drugs 30% Coinsurance Tier 3 30% Coinsurance • Non-preferred brand • name drugs, including • those for: Tier 3 Non-preferred brand name drugs • asthma • diabetes • hypertension 50% Coinsurance 50% Coinsurance Solution: Rx Access Benefit Design “Traditional” Rx Benefit New Rx Access Benefit

18. Depression and Mood Disorders • depression prevalence and costs significant for PB • prevalence and cost equivalent to diabetes • co-morbidity for many chronic conditions • antidepressants second in “Top 25” prescription drug listing • 2nd leading cause of short-term disability • inappropriate possession rates of medication identified by predictive modeling as indicator of future cost • less than six 30-day scripts

19. Depression and Mood Disorders (cont.) • prevalence • 37 per thousand • 14% above national benchmark • 1.45 admits per thousand • 9.5% above benchmark • 277 office visits per thousand • 26% above national benchmark

20. Depression and Mood Disorders (cont.) Implementation issues if value-based pharmacy design implemented: • prescribing patterns for filled Rxs • 20% of Rx written by psychiatrists • typically for 180 days • 80% written by PMDs • majority (> 80%) not refilled • significant compliance issues • care management • role of cognitive therapy

21. Depression and Mood Disorders (cont.) • mood disorder patients have high rates of co-morbidities by MDC • musculoskeletal • skin and breast • ENT • circulatory • metabolic • digestive • nervous system • comorbid with other target conditions • asthma: 13% • diabetes: 17% • cardiovascular: 19%

22. Mood Disorder Patients: Comorbidities % of Population with MDC Diagnosis

23. Alternative Approach Building Foundation • reduce access barriers to behavioral healthcare • plan design • EAP • direct services • awareness/education program • work with managed care vendors to influence care delivery • eValue8 • integrated disability management • no formulary change

24. Behavioral Health Integration Benefit Plan Management and Design Condition Management Health Plan

25. Health Plan Management for Quality Quality Purchasing • used by business health coalitions and national employers to assess and manage the quality of available HMO/POS and PPO plans • eValue8 raises the bar for health care performance and moves the market to deliver greater value for the purchaser's health care dollar • gathers information on hundreds of benchmarks • standardized performance reports are prepared for comparison

26. Health Plan Management for Quality Goal of eValue8™ • quality health care • administrative excellence • consumer satisfaction • cost-effective prices

27. Quality Purchasing Outcomes Courtesy NYBGH

28. Behavioral Health Integration Benefit Plan Management and Design Condition Management Health Plan Direct Delivery

29. Depression and Mood Disorders On-site Services • depression awareness campaigns • stress • EAP • EAP practitioner has scheduled time at all on-site clinics • EAP practitioner available to management in all locations for critical incident/ER issues

30. Integrating Behavioral Health and Disability: Results • all behavioral health disability claims referred to Value Options for evaluation and assessment of work capacity • disability clients with secondary behavioral health diagnoses also referred • final work decision rests with PB disability department • results • 40% reduction in average duration of disability first six months • average duration of disability: 50-60 days, prior to Pitney Bowes/Value Options program

31. Behavioral Health Integration Benefit Plan Management and Design Condition Management Health Plan Consultation Direct Delivery

32. Summary • behavioral health issues pervade all aspects of health planning • “carve-out” should not promote “silos” • integrated approach to client problems yields significant results • partnership of all parties essential for success SummitQuestions@valueoptions.com