Gruttadaro and Conforti discuss what employers and brokers should know about behavioral health and substance abuse coverage, which are costing employers increasingly more.
What do employers need to know generally about mental health coverage and healthcare in the workplace?
Gruttadaro: It’s costly to ignore. Mental health costs employers $200 billion annually. It impacts not only the cost of care but also lost productivity—not coming to work or showing up but working at a subpar level.
Mental health conditions impact one in five employees at all levels of an organization, including the C-suite. We know mental health conditions don’t discriminate based on education level, race, ethnicity or income. And about half of all employees with depression aren’t getting the care they need. This is common in the workplace.
Conforti: We are starting to see both mental health and, more specifically, substance use pop up among employers’ high-cost claimants. I worked with an employer where the care for one member over a three-month period at one treatment facility was $250,000. Those kinds of costs are getting people’s attention.
We also do have a shortage of psychiatrists, and we have for the last five to eight years. We are starting to see that many therapists aren’t joining managed care panels, because they realize they can get paid more on an out-of-network basis. If you look at it broadly, we are seeing an increase in costs and a shortage of good, solid clinicians.
The Center for Workplace Mental Health recently released guidelines employers can use to improve access to mental health services. Why now? Didn’t the Affordable Care Act and federal mental health parity laws improve coverage in this space?
Gruttadaro: The ACA required that all small group and individual market plans that were new had to cover 10 essential health benefits, and mental health and substance use were included for the first time. The federal parity law required parity for medical/surgical care and behavioral health if you offer that coverage.
But we have found from repeated reports and studies that employers and health plans aren’t complying with parity. A Milliman report released in 2017 made it clear it’s not happening with psychiatrists’ payments and network adequacy.
Employers need to be asking why they don’t have an adequate network of behavioral health providers. They should be asking how much insurers are seeking providers to join their networks and if plans are connecting with the local psychiatry and social work associations to recruit providers to insurance networks. Employers also need to know how much they are paying for services and what the criteria are for those payments.
The non-compliance we are seeing could be from confusion and a lack of understanding about how to comply. But this has been an ongoing concern, and we are finally seeing the U.S. Department of Labor and state insurance commissioners looking at compliance and going after those that aren’t in compliance. And employers, if they are self-insured, are liable if they are not in compliance. The buck stops with them.
What should a plan look like that has true parity between medical and behavioral health benefits?
Gruttadaro: In a broad sense, it exists when insurance for mental health and substance use benefits are the same as their medical/surgical benefits. If a plan provides unlimited visits for someone with diabetes, it should do the same for mental health. This includes treatment limits, co-pays and deductibles.
Where employers are getting tripped up is in areas of non-qualitative treatments, like in pharmacy benefit management using step therapies. If they are using that for mental health but not on the medical side, they could be at risk of being out of compliance. Other areas are health plan management criteria, utilization review and when medical necessity is applied more strictly in mental health.
Another area is provider payment levels. The Milliman report found there was a disparity in provider payment levels for primary care doctors and psychiatrists. In the report, primary care doctors were paid 20% more on average than psychiatrists for evaluation and management office visits.
The other aspect is network adequacy. Plan participants shouldn’t be required to go out of network to see a behavioral health provider more often than they do for a primary care or specialty physician. It’s the responsibility of the health plan to ensure network adequacy, because if it is not adequate, [employees] won’t have access to the care they need.
To help employers, the Department of Labor released a set of frequently asked questions that are helpful in describing the qualitative treatment limitations and non-qualitative treatment limitations where there are common violations occurring.
Stigma tends to be a consistent barrier to people seeking mental health treatment. What can employers do to reduce this and encourage use of needed care?
Gruttadaro: The good news is more employers are engaging in workplace mental health and seeing it as an important topic to include when talking about broader health and wellness. They are raising awareness and bringing in speakers to talk about mental health when they have a health fair. It normalizes behavioral health issues as health conditions that are common and also makes it safe and OK to talk more about it. It’s about creating a culture where there are those conversations, and if an organization’s leadership can speak to it, whether it’s personal or a close friend or family member, it creates a safer culture and climate for employees to get the help when they need it.
What do brokers need to know about ways to improve mental health access for their employer clients?
Conforti: Behavioral healthcare tends to consistently be about 3% to 5% of overall spend, and employers may have to end up spending more to ensure employees get the help they need. What we talk a lot about internally is making sure the programs in place are being utilized and set up appropriately. If you have a program but it isn’t communicated, how do you get that information to them? Utilizing more web- or app-based services is important.
Many employers bundle behavioral health with disability in their EAP [employee assistance program], but it generally doesn’t get communicated. They often just offer an 800 number for anyone that needs the service.
There are lots of programs where we integrate vendors, and you have to make sure employees know what programs are in place. If you have an employee who is struggling with sleeping and their Ambien usage is increasing, it might be helpful for them to know they have a cognitive behavioral therapy program online that helps them create better sleep patterns so they get more rest. You have to push through the vendors to make sure people are aware the benefits are there and available, and that is critical.
The other piece is better navigation. When employers have an EAP, wellness program, medical coverage and behavioral health coverage all in different areas, they need to make sure people know where to go to get help. Many times people are going to need help not at noon but at 3 a.m. Employers need to make sure the treatment is accessible and people know how to use it.
They can also offer broad programs like talking about substance use through the lifetime. For instance, a big concern now is kids vaping when they are young. Employers could put information out there about the topic or say they are offering a webinar where people can go online and listen on the topic. They can take what critical, relevant issues are going on and talk about them.
Are there any new or innovative programs out there that brokers or employers are using in this space?
Conforti: Some are doing things like positioning behavioral health clinicians at on-site and near-site clinics. They are incorporating medical and behavioral health in one space and not keeping them separate. That’s something I’ve seen to help increase usage and reduce stigma by having it all there in one location.
Some companies are providing access and navigation services—bringing someone there to help employees wade through the system. I work with one employer that likes to put in specialized programs, and it is paying in the six figures to bring in mental health clinicians to help employees navigate through the system and get the care they need.
There are also home-based services being used. One example is bringing someone to a person’s house to provide something like applied behavior analysis treatment for autism. They are trying to figure out how to keep someone out of the hospital, and there are some enhanced options that help abate crises we see that keep people out of inpatient care.
You mentioned EAP plans. Have those been effective in helping to treat behavioral health conditions?
Gruttadaro: Only about 5% of employees in general are going to access support in an EAP. Employers are looking at more innovative approaches to get people involved with EAPs, including packaging behavioral health around other things like offering caregivers for the aging. They are bundling issues together so people feel comfortable calling and are more engaged and more encouraged to open up.
Conforti: Creating policies and procedures with an EAP has been effective as a resource for people having issues. It allows employees to get help and not worry about confidentiality or termination. Employers can say, “We have this program, and we don’t need to know why you are going. But we just want to know that you are getting help for whatever the reason is that you are always leaving early or you may not be showing up on Mondays.”
One employer I worked with was affected by three suicides in one of its locations, so it enhanced its EAP program around stress reduction and mental healthcare and resiliency. Sometimes [an employer] implements things around a specific problem like that, and sometimes it’s just by trial and error. It depends on what the threshold is in terms of what an employer can and can’t do. And it will look different for various employers. What a hospital will do is going to be different from what you might see at a construction company or a technology firm.