Too Costly to Ignore
Gruttadaro and Conforti discuss what employers and brokers should know about behavioral health and substance abuse coverage, which are costing employers increasingly more.
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.
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.
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.
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.
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.
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.