Employers who want to spend wisely to obtain high-quality mental health and substance abuse services for their employees face not only a complex and changing provider market but also a burgeoning literature describing evidence-based practices and treatments. To help employers examine their current behavioral health benefits and services and develop contracting requirements to guide their selection of health plans, the National Business Group on Health, with the support of the federal Center for Mental Health Services, has created a "blueprint for action."
Approximately 217 million days of work are lost annually because of declines in productivity related to mental and substance use disorders, costing U.S. employers $17 billion each year, according to research cited in the report. Major depression, social phobia, and alcohol abuse result in the greatest number of lost workdays. Even though employers understand that behavioral health benefits are essential and have made important progress in improving service delivery, current approaches to managing cost and quality are insufficient, according to the report. Employer-sponsored behavioral benefits are fragmented, uncoordinated, duplicative, and uneven in access and quality.
"Employers have been at the forefront of improving the quality of health care services they sponsor for their workers," said Kathryn Power, director of the Center for Mental Health Services at a news conference when the guide was released. "In the past, most employers have focused their attention on general health care services. Now, as our study and the statistics clearly indicate, employers need to focus on the behavioral health services they provide."
Specifically, the 95-page guide provides information for employers to:
• Improve coordination among health management programs and vendors
• Standardize the delivery of behavioral health services and programs, whether in the general medical setting or the specialty behavioral health system
• Include evidence-based treatment modalities in behavioral health benefit structures
• Develop enhanced programs and measures of continuous quality improvement
• Promote quality and accuracy in the practice of prescribing psychotropic drugs
• Improve the efficacy of disease management programs for chronic medical conditions by including behavioral health screening and treatment.
The National Business Group on Health, which represents 240 mostly large employers, is the only nonprofit organization devoted exclusively to finding solutions to large employers' health care and related benefits issues. Members of the group provide health coverage for more than 50 million U.S. workers, retirees, and their families. In January 2004 the group convened a 24-member committee to review the current state of employer-sponsored behavioral health services and to develop recommendations to improve their design, quality, structure, and integration. The committee included academic researchers, disability management professionals, employee assistance professionals, benefits specialists, representatives from managed behavioral health organizations, pharmacology experts, and medical directors and benefits managers from member companies of the National Business Group.
The committee's review resulted in 12 key findings, and the guide provides extensive information on these findings, including seriousness and scope of the problem, especially the high costs to employers; the effectiveness of behavioral health treatments; the substantial role played by primary care providers in delivering mental health care, which results in an emphasis on medication treatment; the lack of parity in benefit design for mental health care and its consequences; the need for better managed care for behavioral health; and the lack of coordination among different managed care vendors, such as employee assistance plans, mental health plans, and pharmacy benefit plans. These findings guided the committee's development of recommendations.
The recommendations are based on administrative and clinical practices that have years of evidence to support their immediate and widespread implementation, according to the guide. Adoption of the recommendations will require employers to change their vendor contract language and benefit structures. For example, to improve delivery of mental health care in the general medical setting, critical steps to take are documenting a diagnosis upon treatment initiation and addressing the high risk of comorbid psychiatric disorders among individuals with chronic medical illnesses through screening protocols. Other recommendations in this area emphasize the importance of tracking patients' progress with evidence-based instruments and using collaborative care models for patients with co-occurring mental and substance use disorders.
Recommendations to improve the accuracy and quality of prescribing psychotropic medications in both general and specialty settings include the adoption of a national best practice guideline for prescribing and monitoring, annual assessment of providers' performance in relation to accepted practice, and periodic review of the formulary. To improve the collaboration of general medical and mental health care providers, specific recommendations focus on the handling of referrals to specialty care and the responsibilities of the collaborating parties for communications and patient monitoring.
Specific recommendations for persons with serious mental illness include coverage for evidence-based treatment modalities, such as targeted clinical case management, assertive community treatment, therapeutic group homes, and therapeutic nursery services. Employers should require providers to conduct an annual review of the treatment modalities used to ensure that new modalities are added
Other recommendations are directed at disability management vendors and employee assistance programs.
An Employer's Guide to Behavioral Health Services is available on the Web site of the National Business Group on Health at www.businessgrouphealth.org.
Eight percent of U.S. adults report depression: An estimated 17 million adults aged 18 years and older (8 percent) reported having experienced a major depressive episode during the past year, according to a new report from the Substance Abuse and Mental Health Services Administration (SAMHSA). About two-thirds of them reported receiving treatment for that depression, which consisted of seeing or talking to a physician or other health professional or taking prescription medications. The data are from the 2004 National Survey on Drug Use and Health, which for the first time asked adults questions reflecting DSM-IV criteria for a major depressive episode. Past-month illicit drug use was nearly twice as high among adults who had experienced a major depressive episode (14.2 percent) as among adults who had not (7.3 percent). In addition, 39.7 percent of adults with major depression were current cigarette smokers, compared with 25.9 percent of adults without major depression. Women were almost twice as likely as men to report major depression (10.3 percent compared with 5.6 percent), and these women were more likely to receive treatment than their male counterparts (70.1 percent compared with 55.2 percent). The full report is available at http://oas.samhsa.gov.
SAMHSA suicide prevention toolkit for program use: SAMHSA, in conjunction with the National Suicide Prevention Lifeline, has produced a free toolkit for crisis centers and other programs that want to increase their efforts in this area. The toolkit, which provides practical step-by-step guidelines on launching a suicide prevention campaign, includes press releases that programs can customize, materials for educating media about prevention programs and resources, and suggestions on how to build partnerships with other groups and organizations. Materials to target high-risk groups, such as men over the age of 65, are included, as well as a customizable PowerPoint presentation to be used at meetings with potential partner organizations. The toolkit is available at www.suicidepreventionlifeline.org/campaign/kit/default.aspx.
First national survey of school mental health services: One-fifth of students receive some type of school-supported mental health services during the school year, according to a new national survey released by SAMHSA. Elementary, middle, and high schools all cite social, interpersonal, and family problems as the most frequent reasons for providing services. Mental health problems were broadly defined in the survey—from relatively mild problems, such as difficulty adjusting to a new school, to serious psychiatric and developmental disorders. Virtually all schools reported having at least one staff member whose responsibilities included providing mental health services to students, most commonly a school counselor, a nurse, a school psychologist, or a social worker. School nurses spent approximately a third of their time providing mental health services. The report also describes major sources of funding for school services and arrangements for delivering them, including collaboration with community-based providers. The data are from a representative sample of about 83,000 schools. School Mental Health Services in the United States, 2002-2003 can be obtained, free of charge, from SAMHSA's National Mental Health Information Center by calling 800-789-2647 or can be ordered online at http://store.mentalhealth.org.
Recommended changes in disability benefits to promote work: The National Council on Disability has released a report outlining specific policy changes that Congress and the Social Security Administration (SSA) must undertake to ensure that more people with disabilities who receive Social Security benefits can be gainfully employed. The report notes that Americans with disabilities remain underemployed despite the fact that many are willing and able to work. Many fear losing benefits if they become employed, and incentives instituted by government programs to reduce such obstacles have had little impact, because few beneficiaries are aware of them. The report is based on a comprehensive literature synthesis and structured interviews with key stakeholders. A preliminary list of findings, evidence-based practices, and recommendations based on the literature review and interviews was used to develop seven topic papers, which were then used to facilitate discussion and obtain reaction from participants who were invited to a consensus-building conference in January 2005. The Social Security Administration's Efforts to Promote Employment for People With Disabilities: New Solutions for Old Problems is available at www.ncd.gov/newsroom/publications/2005/publications.htm.