Workplace mental health issues often go unreported and unnoticed. The cost to employee health and employer productivity, however, can be every bit as substantial as that caused by physical illness.

"When a person is experiencing a personal issue outside of work, it often spills over into the workplace and influences other employees' productivity and morale," says Bert Alicea, executive vice president of EAP+Work/Life Services for Health Advocate in Plymouth Meeting, Pennsylvania. The company offers a range of employee assistance programs (EAPs) and wellness benefits.

"For example, if an employee is experiencing substance abuse in their family and needs to make frequent phone calls during the workday to address the issue, the employees around them may also feel distracted, stressed or upset by the situation at hand," he says.

Judi Braswell also sees a link between mental and physical health problems. Braswell is vice president, business development, for Behavioral Health Systems Inc. in Birmingham, Alabama, which administers a comprehensive suite of behavioral programs for employers nationwide.

"Research bears out the correlations between behavioral health issues and attendance, productivity and safety," she says. "There is high comorbidity of behavioral health issues and chronic medical conditions, long recognized by employers as having an impact on workplace productivity and health care costs. A behavioral health program that can reduce non-compliance, provide education and actively engage members impacts not only the success and cost of those services but also physical health, prescription costs and workers compensation claims."

Statistics show that a well-designed and implemented EAP can provide significant benefits to both workers and employers, says Rahul Mehra, M.D., CEO and chief physician executive for the National Center for Performance Health in Tampa.

"In larger, self-insured employer groups, a robust and responsive EAP can help save at least 30 percent in mental health claims, reduce emergency visits and reduce medical and pharmacy claims," he says.

Bumps in the road

This leads to an obvious question: If mental health is such a pressing issue and EAPs are part of the solution, why are they often not as effective as they could be? Mehra has three general answers:

Stigma, which is improving but still faces huge hurdles.
Lack of awareness and education, such as health care literacy in mental health.
Access issues. Only 55 percent of practicing psychiatrists take private health insurance, which is the lowest number of any physician specialty.

The structure of many EAPs, which are embedded in medical plans, is another part of the problem, Alicea says. "While some people with mental health or substance abuse issues may utilize the service, those with temporary setbacks in life may not reach out for assistance. The medical benefit may be viewed as something to use only in the instance of a serious problem. If employees view the service as something that is only available for issues on the severe end of the spectrum, they may not reach out in the earlier stages when it is possible to address issues before they escalate."

Braswell points out that before medical parity, most health plans covered mental health and substance abuse on a limited basis, often capping exposure at a set dollar amount for outpatient and number of days for inpatient care.

"EAPs began to reduce their cost, and competition resulted in very low cost for services on a capitated, per-employee, per-month fee," she says. "That also resulted in little to no promotion or employee communications, limited network options or services provided by a limited number of providers employed by the EAP. As a result, they are very underutilized. Some companies felt the program's low utilization meant they had no value in the workplace, with no return on investment from the capitated cost. While some companies continue with EAPs and accept this as just the way it is, others elected to not provide the services."

The good news is that many employers are gaining a better understanding of the benefits of mental health EAPs.

"We are beginning to see a shift in employers recognizing the need for behavioral health services in the workplace beyond a poster with an 800 number," Braswell says. "With mental health and substance abuse benefits now on the same cost-sharing structure as physical health benefits, and with arbitrary limits removed, employers are recognizing the need to provide services to assist in earlier problem identification, easy access to quality providers and workplace support, such as management consultation on problem employees, critical incident response and development of effective communication campaigns."

Reducing the stigma

One of the biggest challenges for brokers and employers is the stigma often attached to engaging mental health services. Employees who would not think twice about seeing a doctor for an illness or injury often are reluctant to seek help with depression or a stressful situation at home. Alicea recommends shifting the focus to temporary setbacks.

"Position the EAP as an educational resource with mental health and substance abuse components without focusing entirely on mental health," he says. "This can help employees feel more comfortable reaching out for help by not putting a label on what they may be experiencing."

Just as with any other benefit, communication is essential. "EAP utilization is driven by communications that are relevant and at the point the member is experiencing difficulty," Braswell says. "Management acceptance and their knowledge about EAPs is a major factor in utilization by employees. Supervisors who are supportive of seeking assistance and know how the process works help dispel the myth that we shouldn't need assistance. Normalizing seeking assistance for personal problems by integrating it in wellness initiatives can be very helpful."

Employers should position mental health benefits as part of an overall health and wellness plan.

"It is important to recognize that mental health issues do not happen in a silo," Alicea says. "By integrating the EAP with other services, including advocacy and wellness, it not only makes managing benefits programs simpler for employers, but it can also help to identify issues much earlier.

"We've found that a large percentage of referrals to our EAP originate from a medical issue with underlying emotional concerns. While the member may not have originally reached out for EAP support, it was still possible to connect them to services that could help them holistically address the issue at hand."

Role of brokers

Brokers can do several things to help their clients maximize their return on a mental health EAP.

Do the homework. "Brokers who have an understanding of the components of the EAP are better able to match employers to the program that can best meet their needs," Braswell says. "It's helpful for brokers to at least know how account management is handled; who takes the calls and makes the referrals; how much flexibility exists in plan design; what the capacity is for training and communication campaigns; if that is driven by the company or if the EAP works with company personnel to monitor events that may warrant education; and if utilization trends are considered.

"It's also important to know if the company values the cost savings and flexibility that come from self-insuring or the budget consistency of a capitated program that must clearly define what is included in the plan and set a rate that will cover the cost of delivering all of the services that could be utilized, even if they are not."

Demonstrate value. "If you have 5 percent utilization for EAP services, it is possible to achieve a 10-to-1 return on investment, which does not take into account services beyond clinical utilization, including manager consultations, on-site training and support, and more," Alicea says. "Look at other aspects of the EAP and not solely clinical utilization in order to appreciate and understand the true value."

Make it specific. "There are a number of EAP models," Braswell says, "including assess and refer, where a treatment plan is developed and the member is referred for the treatment within their insurance or as private pay; those that allow members to use all sessions available before referral; those that offer access to a network; those that allow access only to their employed staff; programs that offer access only to mental health professionals; those that also include psychologists and psychiatrists; models that allow access only for non-clinical issues, such as grief, marital and family but not clinical issues such as eating disorders and manic depression; as well as variances in communication and training capabilities."

Maximize access. "We have found that making it easier for people to access EAP resources from anywhere helps drive utilization," Alicea says. "Employees want to know that when they access the EAP, it is confidential and their privacy is protected. For example, offering videos, self-assessment tools, webinars and more enables them to get the information they need from the comfort of home or anywhere, really. This also extends to how employees access live support, including chat functionality on EAP websites, to protect their privacy and make the experience easier."

Be visible. Mehra and his team make a conscious effort to be the face of the EAP.

"We attend open enrollment meetings, do lunch-and-learns and educate HR staff of supervisory referrals," he says. "We also provide responsive on-site crisis counseling related to traumatic events in the workplace. NCPH also meets with senior management. A lot of effort is spent in building trust with the leadership of the organization such that a culture is created that supports emotional well-being."

"EAPs can be a valuable partner to HR, managers and employees and dependents they serve if they have a seat at the table and are a visible presence," Braswell says.

Engaging employees in effective mental health EAPs is simply the right thing to do from a human perspective. It also is a smart choice for employers trying to boost productivity and brokers looking to expand their product portfolios.

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Creating a new normal with EAPs

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