On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans U Squared Interactive December, 2013

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 2 What is Cognitive Behavioral Therapy? Why Is It Important For Health Plans? Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps consumers understand the thoughts and feelings that influence behaviors. CBT is commonly used to treat a wide range of disorders. Cognitive behavior therapy is generally short-term and focused on helping consumers address a very specific problem. During the course of treatment, these consumers learn how to identify and change destructive or disturbing thought patterns that have a negative influence on behavior. CBT is important to health plans because it has been identified as the treatment of choice in terms of both outcomes and cost for a wide range of disorders including depression, anxiety, stress-related physical health conditions, phobias, and some addictive disorders. For health plans, mental health disorders are among the most common, costly, and disabling of health problems. Depression alone has a massive impact on health: Depression is the third most important cause of disease burden worldwide and is the most important cause of disease burden in the developed world i Depression cost the U.S. economy $52 billion (in Year 2000 dollars) with half of the costs in medical expenses and half of the costs in lost productivity ii 7% of American adults suffer from major depression on an annual basis, which is the leading cause of disability for Americans aged 15 to 44 years iii More than 60% of individuals with common chronic diseases (e.g., arthritis, hypertension) also have depression iv Anxiety, which commonly co-exists with depression or may stand alone, is the most common mental health complaint worldwide in the general population, with approximately 18% of the U.S. population having an anxiety disorder in a given year v Annual health care costs related to anxiety exceeded $40 billion, with the majority of anxiety-related costs associated with general medical costs rather than psychiatric care vi As common as depression and anxiety are as stand-alone disorders, the impact is magnified when depression and anxiety co-exist. When these conditions co-occur, severity, chronicity, and functional impairment, as well as rates of alcohol abuse, attempted suicide, and psychiatric hospitalization increase. vii Depression and anxiety do not exist in isolation as mental disorders they have a profound impact on physical health conditions. The Center for Disease Control and Prevention (CDC) summarizes the wide-ranging impact: Mental illness exacerbates morbidity from the multiple chronic diseases with which it is associated, including cardiovascular disease, diabetes, obesity, asthma, epilepsy, and cancer. This increased morbidity is a result of lower use of medical care and treatment adherence for concurrent chronic diseases and higher risk for adverse health outcomes. Rates for injuries, both intentional (e.g., homicide and suicide) and unintentional (e.g., motor vehicle), are 2 to 6 times higher among persons with a mental illness than in the overall population. Mental illness also is associated with use of tobacco products and alcohol abuse. viii Despite the impact of mental disorders in general, and anxiety and depression in particular, on mental health and general health

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 3 costs, the current state of treatment of these disorders is highly variable. Only 47% of cases of depression in primary care settings are correctly identified ix Only 33% of cases are recorded in consumer medical records x Only 20% of consumers receive care meeting current evidence-based practice guidelines xi This is why CBT is important to health plans. CBT is the most effective treatment and most cost effective treatment for depression and anxiety. Many clinical guidelines recognize CBT as a preferred treatment for these disorders. xii What Is On-Line CBT & Where Has It Been Used? On-line CBT can be defined as the delivery of CBT therapeutic services using an internet-based interface. The service delivery can be synchronous (real time with a tech-enabled clinical professional) or automated using expert systems technology. While technology-based therapeutic services such as on-line CBT are relatively new in the U.S. market, they are longestablished in Europe and other parts of the world. For example, the on-line CBT Program, Beating The Blues, has been used in the United Kingdom for a decade. As consumers increasingly turn to internet-based health information and services, the acceptance of clinical services delivered on electronic platforms will likely increase. Cisco reported on a global survey of consumer attitudes and found that a significant majority of consumers are currently accessing health-related applications on-line, and 75% of respondents indicate that they are comfortable with virtual visits for receiving direct services. xiiii The ability to access behavioral health care in private may also reduce some of the reluctance to access care because of stigma, which remains potent. The Health Plan ROI Of On-Line CBT Payers of health care routinely address the merits of any innovations in the delivery of care with an evaluation of new treatment methodologies focused on both clinical effectiveness and cost effectiveness. While the clinical effectiveness of CBT is well-documented and the clinical effectiveness of on-line CBT is an emerging area of study, models that estimate the cost effectiveness of CBT particularly on-line CBT remain at an early stage. xiv An analysis by the consulting firm OPEN MINDS looked at the cost components that a health plan would consider in a return-on-investment (ROI) analysis of on-line CBT. Using a simple ROI model, the cost components of the model include: Program implementation costs On-going health plan beneficiary costs Program licensing costs For estimating savings or return to the health plan, given the limitations of claims data, three claims elements were identified as feasible for measurement: Reduced claims cost for mild depression Reduced claims cost for moderate depression Reduced claims cost for anxiety Program implementation costs and on-going beneficiary costs include the staff and

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 4 communication costs for adding an on-line CBT program benefit for all health plan beneficiaries. License costs are the fees for intellectual property licensing and related systems support. On the savings due to reduced claims, the claims costs for both psychotherapy and medication for the treatment of anxiety and of mild and moderate depression are recommended elements for inclusion in the model. Five situational factors were also included in the design of the ROI model for on-line CBT: The percentage of the population with access to the Internet The literacy rate of the population The consumer adoption rate of the techbased treatment over the first three years, and Provider service duplication rates (the proportion of clinical professionals who would use both on-line CBT while continuing treatment us usual) The proportion of the population over 16 years of age The Health Plan ROI Of On-Line CBT: A Case Study Using Beating The Blues In order to estimate the impact of on-line CBT as a new and innovative intervention for the treatment of depression and anxiety, U Squared Interactive developed treatment cost estimation scenarios based on the OPEN MINDS study references above the Beating The Blues Return- On-Investment Calculator. Using the data from two prototypical health plans, estimated returns were calculated. For a health plan with 100,000 covered lives, the estimated return on an investment in on-line CBT ranged from 180% to 350% over a three-year time period with the variance dependent on the level of adoption of the on-line CBT by both plan members and by clinical professionals. On-Line CBT Case Study ROI Estimates Health Plan Health Plan Scenario #1 Scenario #2 Year 1 ROI: 63.7% Year 1 ROI: -6.7% Year 2 ROI: 410.7% Year 2 ROI: 251.1% Year 3 ROI: 857.6% Year 3 ROI: 410.7% Three-Year ROI: 378.4% Year 1 Consumer Adoption: 10% Year 2 Consumer Adoption: 20% Year 3 Consumer Adoption: 35% Year 1 Professional Duplication Of Services: 75% Year 2 Professional Duplication Of Services: 60% Year 3 Professional Duplication Of Services: 40% Three-Year ROI: 179.6% Year 1 Consumer Adoption: 8% Year 2 Consumer Adoption: 15% Year 3 Consumer Adoption: 20% Year 1 Professional Duplication Of Services: 85% Year 2 Professional Duplication Of Services: 70% Year 3 Professional Duplication Of Services: 60% The primary driver of health plan returns on online CBT investments is due to decreased use in psychotherapy and medication for mild/moderate depression and anxiety disorders. The differential in ROI over the initial three years is

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 5 due largely to increased consumer adoption rates and increased acceptance of the technology by clinical professionals, which resulted in a decrease in duplication of treatment. 1000% 900% 800% 700% 600% 500% 400% 300% 200% 100% 0% -100% 3-Year Return-On-Investment For Beating the Blues Scenario #1 % ROI Scenario #2 % ROI TAU Year 1 Year 2 Year 3 The estimated savings in both 100,000-member health plan scenarios are based solely on assumptions about the rate of substitution of online CBT for treatment as usual (TAU). Scenario #1 includes an assumption of a gradual increase in adoption by health plan members with either depression or anxiety 10% adoption in Year One, 20% adoption in Year Two, and 35% by Year Three. The scenario also predicts a duplicate service rate of 75% in the first year to 40% in Year Three. Respectively in Scenario #2, the scenario includes an assumption of a slightly slower adoption rate by health plan members with either depression or anxiety 8% adoption in Year One, 15% adoption in Year Two, and 20% by Year Three. The scenario also predicts a duplicate service rate of8% in the first year to 60% in Year Three. The Beating The Blues Return-On-Investment Calculator is a simple ROI model based on program costs and claims savings offset. For that reason, only the direct system costs and the most tangible quantifiable financial savings are included in the calculations. Other models, using value analysis, would generate additional positive financial effects. In particular, the documented impact of treatment of depression and anxiety on disability and workplace absenteeism and presenteeism can be expected to amplify the financial impact for individuals, employers, and wider society. On-Line CBT Case Study ROI Assumptions Variable Average Cost of Psychotherapy Session Average # of Sessions In Course Of Psychotherapy Average Annual Cost For Psychotherapy Average Annual Costs For Medication & Primary Care Management Average Annual Cost For Combined Psychotherapy Plus Medication Rate Of Diagnosis/Treatment Of Depression In Primary Care Rate Of Diagnosis/Treatment Of Anxiety In Primary Care Annual License Cost For Beating The Blues Per Covered Life Expected Value $95 8 $760 $991 $1,751 50% 33% $0.60 per covered life

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 6 Beating the Blues: Reduction In Depression/Anxiety Treatment Costs Per 100,000 Covered Lives $12,500,000 $12,000,000 $11,500,000 $11,000,000 $10,500,000 $10,000,000 $9,500,000 Annual Treatment Costs For Depression & Anxiety Scenario #1 Annual Treatment Costs For Depression & Anxiety Scenario #2 TAU Year 1 Year 2 Year 3 Appendix A shows the detailed impact of Beating The Blues showing scenarios contrasting baseline costs for TAU and three years of utilization. Using empirically-derived, but conservative assumptions, these scenarios show the strong potential for cost-reduction to health plans that add on-line CBT treatment programs, such as Beating The Blues, to the traditional psychotherapy and medication-assisted interventions available to consumers with depression and anxiety. What the model does not capture, but will be addressed in future research, is the effect of on-line CBT on reducing the costs of comorbid physical health conditions among health plan members. The integration of on-line CBT into the emerging coordinated care management models is the next development in clinical best practice. Beating the Blues: Net Savings In Depression/Anxiety Treatment Costs Per 100,000 Covered Lives $1,800,000 Net Savings $1,600,000 Scenario #1 $1,400,000 $1,200,000 $1,000,000 $800,000 $600,000 $400,000 $200,000 $0 -$200,000 Net Savings Scenario #2 TAU Year 1 Year 2 Year 3

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 7 Appendix A: Beating The Blues Return-On-Investment Using a simple ROI model, the cost components of the Beating the Blues model include: Program implementation costs On-going health plan beneficiary costs Program licensing costs For estimating savings or return to the health plan, given the limitations of claims data, three claims elements were identified as feasible for measurement: Reduced claims cost for mild depression Reduced claims cost for moderate depression Reduced claims cost for anxiety Program implementation costs and on-going beneficiary costs include the staff and communication costs for adding an on-line CBT program benefit for all health plan beneficiaries. License costs are the fees for intellectual property licensing and related systems support. On the savings due to reduced claims, the claims costs for both psychotherapy and medication for the treatment of anxiety and of mild and moderate depression are recommended elements for inclusion in the model. Five situational factors were also included in the design of the ROI model for on-line CBT: The percentage of the population with access to the Internet The literacy rate of the population The consumer adoption rate of the techbased treatment over the first three years Provider service duplication rates (the proportion of clinical professionals who would use both on-line CBT while continuing treatment us usual) The proportion of the population over 16 years of age The Beating the Blues ROI Calculator estimates savings that would accrue to a health plan over a three-year period compared to TAU (outpatient psychotherapy, medication, or both) based on increased utilization of Beating the Blues over time. The assumption is made that the system would in early adoption be used in addition to TAU, followed by increasing reliance over time on Beating the Blues as a primary modality for treating depression and anxiety as professional and consulter familiarity and confidence grows. Health plan costs are calculated based on evidence-based estimates of yearly costs for existing treatments. Health plan costs of existing treatments are generated based on expected rates of diagnosis and treatment at industryaverage expenditures. Projected annual savings from three-year estimates of Beating the Blues utilization become the basis of return-on-investment calculations using the following formula: ROI = (Employer net benefit from Beating The Blues Beating The Blues Cost)/Beating The Blues Cost

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 8 ROI Model Variables Beating The Blues: ROI Assumptions In Scenario #1 Treatment As Beating The Beating The Usual Blues Blues Year 1 Year 2 Beating The Blues Year 3 # Covered Lives 100,000 100,000 100,000 100,000 % Of Patients Whose Depression Is 50% 50% 50% 50% Both Diagnosed &Treated % Of Patients Whose Anxiety Is Both 33% 33% 33% 33% Diagnosed & Treated % Adoption Beating The Blues 0% 10% 20% 35% % Clients With Combined Care 100% 75% 60% 40% (Therapy And/Or Medication % Of Population Under 18 Years 23.5% 23.5% 23.5% 23.5% % Of Population Illiterate Of Unable 10% 10% 10% 10% To Access Computer Total Annual Treatment Costs For $12,290,350 $11,764,754 $11,373,206 $10,658,206 Depression & Anxiety Projected Annual Savings From 0 $425,596 $817,144 $1,632,144 Beating The Blues ROI: Beating The Blues* 0 63.7% 410% 857% ROI Model Variables Beating The Blues: ROI Assumptions In Scenario #2 Treatment As Beating The Beating The Usual Blues Blues Year 1 Year 2 Beating The Blues Year 3 # Covered Lives 100,000 100,000 100,000 100,000 % Of Patients Whose Depression Is 50% 50% 50% 50% Both Diagnosed &Treated % Of Patients Whose Anxiety Is Both 33% 33% 33% 33% Diagnosed & Treated % Adoption Beating The Blues 0% 8% 15% 20% % Clients With Combined Care 100% 85% 70% 60% (Therapy And/Or Medication % Of Population Under 18 Years 23.5% 23.5% 23.5% 23.5% % Of Population Illiterate Of Unable 10% 10% 10% 10% To Access Computer Total Annual Treatment Costs For $12,290,350 $12,047,761 $11,728,564 $11,473,206 Depression & Anxiety Projected Annual Savings From 0 $-17,411 $401,786 $817,144 Beating The Blues ROI: Beating The Blues* 0-6.7% 251% 410%

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 9 Appendix B: About Beating The Blues U Squared Interactive, a joint venture between UPMC Insurance Services and Ultrasis, PLC, has introduced Beating The Blues to the United States market with the intention of offering effective, affordable, and empirically-tested psychotherapeutic interventions. Beating The Blues is designed to improve access to employers, payers, and individuals who currently lack adequate availability of care. Developed in the United Kingdom as a means to improve the lengthy wait for specialty behavioral health care and inadequate access to evidence-based interventions, Beating The Blues has more than a decade of research and application in primary and specialty health settings. Beating The Blues Design: On-line system for delivering cognitive behavior therapy (CBT) Eight personalized sessions for treatment of depression and anxiety in adults Includes education, self-assessment, goal setting, & homework Guided interventions to identify and change thoughts, beliefs, and perceptions associated with depression and anxiety Accessed on-line via personal computer and internet access in health care setting or home Beating The Blues role in the United States health care system provides significant relief for current system limitations: Health Care Reform is expected to add 30 to 50 million Americans to insured status Only 50% of depression is correctly diagnosed in primary care Less than 20% of care provided meets evidence-based standards Medication is often the only option available to primary care doctors Beating The Blues provides improved availability of affordable evidence-based care Beating The Blues can be accessed in primary care or delivered direct-to-consumer Beating The Blues improves access to needed care without limitations of specialist availability, geographic shortages, or time/appointment constraints Available to payers and employers at $0.60 annually per covered life, Beating The Blues is significantly less costly than medication or psychotherapy Beating The Blues offers a significant opportunity to expand access to evidence-based care for depression and anxiety in a manner that is safe, effective, affordable, and scalable. Ideally, Beating The Blues is delivered in conjunction and coordination with the client s primary health care system, whether that is an individual physician, a medical home, or clinic setting. Additional access can be gained by availability through other systems of employer-sponsored benefits such as employee assistance plans or employee wellness programs. In addition to the primary benefit of reducing suffering, the effective treatment of depression and anxiety has significant measured impact on productivity, absenteeism, and non-psychiatric medical costs.

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 10 Beating The Blues, with its documented capacity to provide clinical outcomes equivalent to faceto-face psychotherapy for mild to moderate depression and anxiety, offers the capability to expand cost-effective access to behavioral health care. As consumers increasingly turn to internet-based health information and services, Beating The Blues is also in sync with technology trends in health care. Cisco reported on a global survey of consumer attitudes and found that a significant majority of consumers are currently accessing health-related applications on-line, and 75% of respondents indicating that they are comfortable with virtual visits for receiving direct services. xv The ability to access behavioral health care in private may also reduce some of the reluctance to access care because of stigma, which remains potent. Some progress has been made in reducing the stigma of mental illnesses among the general population as well as within the self-perception of those affected. However, the problem of stigma remains real and highly influenced by current events and media portrayal, particularly in rare but shocking events of mass violence associated with mental illness. Survey research indicates that more than half of respondents state that they would be unwilling to socialize with, work with, or have family ties with an individual with mental illness. xvi While Beating The Blues has only made a recent transition to the United States, the value of Beating The Blues has been recognized by Substance Abuse and Mental Health Substance Administration (SAMHSA) as a leading example of technology-assisted behavioral health care: Beating The Blues Recognized In The National Registry of Evidence-Based Programs & Practices September, 2012 Reviewed by SAMHSA Scored 3.0 out of 4.0 in Quality of Research Scored 3.8 out of 4.0 on Readiness for Dissemination) xvii Summary & Conclusions: Designed as a remedy for the problems of excessive time on waiting lists for behavioral health care in Great Britain s National Health Service, Beating The Blues is a computerized cognitive behavior therapy (CCBT) program that delivers evidence-based care to individuals experiencing depression and anxiety. Introduced with an orientation and instruction video, Beating The Blues offers an eight session multi-media course of self-administered therapy requiring minimal personnel assistance. The model was developed to address the dual problems of waiting lists and availability of skilled practitioners in primary and secondary health settings. Beating The Blues has more than a decade of published research establishing its effectiveness

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 11 compared to routinely available care (medication and counseling): Beating The Blues has been tested in primary care, psychiatric clinics, and specialty medical and student health services Beating The Blues shows statisticallysignificant improvement over ordinary care Progress is maintained through 6 month follow-up Beating The Blues is effective with mild to severe depression and anxiety Drop-out rates are comparable to face-toface therapy Beating The Blues produces statistically significant reduction in cost of lost employment and a significant increase in depression-free days Beating The Blues patients show reduced use of emergency department and outpatient medical services xviii xix xx xxi xxii xxiii Beating the Blues offers expanded evidencebased options for the treatment of mild to moderate depression and anxiety to health plans, health care professionals, and consumers. The system s demonstrated effectiveness, affordability, and accessibility can provide payers and employers new options for managing health care costs while increasing consumer choice.

On-Line Cognitive Behavioral Therapy: The Return-On-Investment For Health Plans 12 Appendix C: References i World Health Organization. (2008). The Global Burden Of Disease: 2004 Update. Retrieved June 16, 2013, from World Health Organization: http://www.who.int/healthinfo/global_burden_disease/gbd_re port_2004update_full.pdf ii Greenberg, P. K. (2003). The Economic Burden of Depression in the United States: How Did It Change Between 1990 and 2000? Journal of Clinical Psychiatry, 64: 1465 1475. iii Conti, R. M., Berndt, E. R., & Frank, R. G. (2006, May). Early Retirement and Public Disability Insurance Applications: Exploring the Impact of Depression, Working Paper 12237. Retrieved June 20, 2013, from National Bureau of Economic Research: http://www.nber.org/papers/w12237 iv Wells, K.B., Burnam, A., Greenfield, S., Ware, J.E., How the medical comorbidity of depressed patients differs across health care settings: results from the Medical Outcomes Study, American Journal of Psychiatry. 1991 Dec;148(12):1688-96 v National Institutes of Mental Health. (n.d.). The Numbers Count: Mental Disorders in America. Retrieved June 18, 2013, from National Institutes of Mental Health: http://www.nimh.nih.gov/health/publications/the-numberscount-mental-disorders-in-america/index.shtml vi Centers for Disease Control and Prevention. (2011, July 1). Burden of Mental Illness. Retrieved June 16, 2013, from Centers for Disease Control and Prevention: http://www.cdc.gov/mentalhealth/basics/burden.htm vii Hirschfeld, Robert M. A., The Comorbidity of Major Depression and Anxiety Disorders: Recognition and Management in Primary Care, Prim Care Companion, Journal of Clinical Psychiatry. 2001; 3(6): 244 254 viii Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Mental Illness Surveillance Among Adults in the United States, 60(03), 1-32, September 2, 2011 ix Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Mental Illness Surveillance Among Adults in the United States, 60(03), 1-32, September 2, 2011 x Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Mental Illness Surveillance Among Adults in the United States, 60(03), 1-32, September 2, 2011 xi Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, Mental Illness Surveillance Among Adults in the United States, 60(03), 1-32, September 2, 2011 xii Cognitive Behavior Therapy for Depression and Anxiety Disorders, SAMSHA s National Registry of Evidence-based Programs and Practices, from http://www.nrepp.samhsa.gov/cbt.aspx xiiii Cisco. (2013, March 4). Cisco Study Reveals 74 Percent of Consumers Open to Virtual Doctor Visit. Retrieved June 20, 2013, from Cisco: http://newsroom.cisco.com/release/1148539/cisco-study- Reveals-74-Percent-of-Consumers-Open-to-Virtual-Doctor-Visit xiv Corrigan, P. W. & Watson, A. C., Understanding the impact of stigma on people with mental illness, World Psychiatry. 2002 February; 1(1): 16 20 xv Eells, T., Wright, J. & Thase, M., Computer-Assisted Cognitive- Behavior Therapy for Depression, Psychotherapy. Advance Online Publication. Doi:10.1037/a0032406, September 23, 2013 xvi Substance Abuse & Mental Health Services Administration. (2012, September). Computer-Based Cognitive Behavioral Therapy, Beating the Blues. Retrieved June 20, 2013, from National Registry of Evidence-based Programs & Practices: http://nrepp.samhsa.gov/viewintervention.aspx?id=318 xviii Gonzalez, H.M., Vega, W.A., Williams, D.R. et al, Depression Care in the United States: Too Little for Too Few, Archives of General Psychiatry, 67 (1): 37-46, 2010 xix Proudfoot, J., Swain, S., Widmer, S., et al., The development and beta-test of a computer- therapy program for anxiety and depression: hurdles and lessons, Computers in Human Behavior, 19, 277 289, 2003 xx Proudfoot, J., Goldberg, D., Mann, A., Everitt, B., et al., Computerized, interactive, multimedia cognitive-behavioural program for anxiety and depression in general practice, Psychological Medicine, 33, 217 227, 2003 xxi Learmonth, D., Rai, S., Establishing the effectiveness of computerised cognitive behavioural therapy for secondary/tertiary mental health care service users with and without physical co-morbidities, Health Psychology Update, Volume 16, Issue 3, 2007 xxii Learmonth D., Trosh, J., Rai, S., Sewell, J., Cavanagh, K., The role of computer-aided psychotherapy within an NHS CBT specialist service, Counseling and Psychotherapy Research, 8:2,117 123, 2008 xxiii Mitchell N., Dunn, K., Pragmatic evaluation of the viability of CCBT self-help for depression in higher education, Counseling and Psychotherapy Research, 7:3, 144-150, 2007