Although there was a time when behavioral health issues were of minimal concern to employers and their associated costs seemed limited and manageable, this is no longer the case. Behavioral health issues now:
- Cause 217 million missed workdays annually,
- Account for 7.6 percent of health care dollars,
- Generate indirect costs of approximately $105 billion annually,
- Are the fifth leading cause of short-term disability (STD) and
- Are the third leading cause of long-term disability (LTD).
- Depression is the second most chronic illness in the U.S.,
- One in five Americans is affected by mental illness,
- Nine percent of the full-time "working population" is treated for mental illness, and
- Ten percent of the full-time "working population" is treated for chemical dependency1.
An additional concern is that although there are effective and well-tolerated treatments for most behavioral health problems, many go undetected and untreated. Even in cases where a behavioral health problem is diagnosed, it is often under-treated. Only 13 percent of those diagnosed with depression receive minimally adequate care and 52 percent are treated solely by primary care physicians1. Moreover, the lack of coordination among behavioral health programs, prescription drug benefits, employee assistance programs (EAPs), disability services and Family and Medical Leave Act (FMLA) programs creates significant quality and accountability problems.
Poor Behavioral Health Hurts Productivity
Most organizations are just now becoming aware of the link between employee productivity and behavioral health (see Behavioral Health Defined). Basically, behavioral health problems cause "withdrawal behaviors," where employees become disengaged for one reason or another. Employees who withdraw may not show up for work (absenteeism), may show up but not be productive ("presenteeism") or may leave the organization (turnover).
Consider that at a typical organization, 5 percent of the workforce may be absent on any given day for an unscheduled event and 10 percent may be out for vacation and other reasons. On top of that, 30 percent of the people who do show up may not be fully engaged in their work. The result is that 45 percent of the organization's workforce nearly half may be absent or not working up to speed.
Poor Behavioral Health Increases Co-Morbidity Problems
Co-morbidity describes the effect of other diseases a patient might have in addition to a primary disease. The link between behavioral health and physical illness is gaining increased attention from researchers and clinicians. What is now clear is that employees who have both medical conditions and behavioral health problems have longer durations of disability and use more health care resources and dollars. The table below provides a good example of how behavioral health issues in this case, depression and anxiety can increase costs.
|Without Depression2||With Depression3|
|Acid Peptic Disease||1,811||3,034||67|
1 These numbers are affected by the fact that Medicaid patients are enrolled in managed care programs that usually control utilization more tightly than employer-sponsored health care programs do. In addition, Medicaid populations have a mix of patients who have not taken care of themselves in the same way that a commercial population has; they are sicker and more costly. Nevertheless, the numbers demonstrate the fact that regardless of the population dynamics or physical ailment, co-morbid depression results in higher costs.
2 Mean yearly cost of Medicaid expenditures for patient with a single chronic condition
3 Mean yearly cost of Medicaid expenditures for patients with two concurrent chronic conditions, one of which is depression
Poor Behavioral Health Causes Longer Absences
One of the most common behavioral health problems, depression, leads to longer absences for disability, according to a 2006 analysis of claims by Aetna2. (See the graph below.) In fact, durations of absences can be as much as 100 percent longer when the patient is depressed.
How to Improve an Organization's Behavioral Health
The first step in developing appropriate solutions for the organization's behavioral health problems is to determine the costs they are generating and segment the results for different employee demographic groups. Look for high-cost areas that have the capacity for high impact. For example, although employees who are on antidepressants may represent only 10 percent to 15 percent of the population, they likely represent more than half of all costs. The next step is to find the root causes. Once the organization understands what is driving its costs, it can develop creative solutions to address the root causes.
Be sure to estimate the return on investment to help guide the decision-making process. Before an organization can build a business case for change, it must determine the potential savings it can achieve by attacking the sources of its employees' behavioral health problems.
Strategies That Work
Many organizations look for ways to increase the quality and/or decrease the cost of care. For example, they use data-mining analyzing claims to identify patterns or relationships to determine what percent of employees are treated for depression by primary care providers versus behavioral health professionals (the literature strongly indicates that the best treatments for depression combine counseling and medication).
In one recent case, an organization with 12,000 employees determined that 79 percent of those who had been prescribed anti-depressants had never been seen by a behavioral health professional. Its response was to eliminate co-payments for the first eight counseling sessions and for all medication consultations with behavioral health prescribing providers. It also launched a communications campaign to educate employees about this issue. As a result, a large number of employees who had their depression treated with medication alone were migrated to the appropriate behavioral health professionals, resulting in more effective treatment.
- Improved Work Performance The intervention group demonstrated a 2.6-hour-per-week (6.5 percent of a 40-hour week) improvement in overall work functioning, which Sibson calculates would translate into an annualized value of $2,600 per employee making $40,000 per year. This compares to approximately $100 to $400 outreach and care management costs associated with lower to moderate intensity interventions used in the study.
- Lower Depression Scores The intervention group had lower six-month Quick Inventory of Depressive Symptomatology Self-Report scores of 10 percent vs. 11 percent for the control group and lower 12-month scores of 8.9 percent for the intervention group vs. 10 percent for the control group.
- Improved Symptoms At the 12-month mark, 30.9 percent of the intervention group reported improved symptoms vs. 21.6 percent of the control group.
- Greater Recovery Rate At the 12-month mark, 26.2 percent of the intervention group experienced recovery vs. 17.7 percent of the control group.
- Greater Use of Mental Health Specialty Treatment Intervention group participants were more likely than those in the control group to receive mental health specialty treatment (but somewhat less likely to obtain any depression treatment in primary care).
What else can organizations do? Some employers:
- Collect and combine data from all behavioral health resources health claims, prescription drug claims, EAP, STD/LTD, FMLA programs to address utilization trends and treatment patterns,
- Combine data from health risk assessments and wellness and disease management programs to identify triggers that indicate a behavioral health issue that needs to be addressed,
- Add resources specific to behavioral health to existing wellness and disease management initiatives, including depression and anxiety screenings and self-help information,
- Analyze all existing benefit programs to determine how vendors work together and identify overlaps and gaps,
- Hold vendor summits to get vendors to coordinate their services more effectively,
- Hold vendors accountable by requiring them to tie performance guarantees to specific desired outcomes related to early detection, patient education and support and utilization results,
- Change benefit design to include the impact of behavioral health issues and encourage early intervention.
- Train managers to better identify behavioral health issues and help employees get the help they need, and
- Launch efforts to demystify behavioral health issues in the workplace.
Finally, all organizations should check for internal problems that may be exacerbating their employees' behavioral health problems. Diagnosing behavioral health problems can be tricky. For example, low cost levels of behavioral-health-related issues could mean that services are not being coded appropriately or that the underlying issues are not being properly diagnosed. Checking one or more of the boxes in the following list may indicate that an organization has a behavioral health issue:
A lack of coordination among the its heath insurance, its EAP, its STD/LTD insurance and its wellness plan.
Reduced spending on behavioral health services a cost-cutting tactic that eventually backfires by causing an increase in overall health care expenditures.
Low EAP utilization (i.e., less than 10 percent).
A stigma associated with using the organization's EAP and/or with behavioral health issues in general.
Employees with a behavioral health diagnosis who are not treated in a behavioral health setting.
A general lack of respect for coworkers and subordinates and their personal needs.
Little organizational understanding about the financial impact of behavioral health issues.
It is important to remember that many behavioral health problems lead to significantly lower productivity if they are not addressed. A diagnosis of costs and causes must precede any effort to improve behavioral health. This will help ensure the development of appropriate solutions. Although every employer has unique circumstances, this basic strategy for improving behavioral health is widely applicable.
1 An Employer's Guide to Behavioral Health Services: A Roadmap and Recommendations for Evaluating, Designing and Implementing Behavioral Health Services, National Business Group on Health, Washington, DC, 2005. Data cited with permission.
2 The Impact of Depression as a Comorbidity on Disability Outcomes by Aetna. Aetna analyzed short-term disability claims from January 1, 2002, to June 30, 2004, and long-term disability claims from January 1, 2002, to June 30, 2003. Data cited with permission.
3 "Telephone Screening, Outreach and Care Management for Depressed Workers and Impact on Clinical and Work Productivity Outcomes: A Randomized Controlled Trial," conducted by Harvard Medical School, Group Health Cooperative's Center for Health Studies and OptumHealth Behavioral Solutions, published in The Journal of the American Medical Association, September 26, 2007 (Vol. 298, No. 12, pgs. 1401-1411). Data cited with permission. Copyright © 2007, American Medical Association. All rights reserved.
4 Participating employees who screened positive for depression were divided into two groups. The first group received minimal intervention a letter informing them they tested positive for depression and highlighting the possible treatment options. The latter group received more vigorous outreach telephonic intervention by the study's facilitators, who asked them to participate in treatment options such as in-person therapy or telephone therapy. The employees' progress was monitored throughout therapy and their needs were reassessed throughout the process.
About the author:
Steven F. Cyboran, ASA, MAAA, FCA, is a Vice President and Consulting Actuary in the Chicago office of Sibson Consulting. He specializes in the area of behavioral health. He can be reached at 312.984.8558 or at firstname.lastname@example.org