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Understanding and Facilitating EAP Behavioral Health Utilization:

Research Findings

Presenters:Brandeis University: Elizabeth L. Merrick, Ph.D., MSW

Bernie McCann, M.S., CEAP

MHN: Arlene Darick, LCSW, CEAP

EAPA’s 2010 Annual World EAP Conference Tampa, FL

October 8, 2010

Brandeis/Harvard Center on Managed Care and Drug Abuse Treatment (Funded by the National Institute on Drug Abuse P50 DA010233)

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Substance Abuse Treatment Pathways in Employer-Sponsored Programs: Research Team

Brandeis/Harvard Center on Managed Care and Drug Abuse Treatment

Brandeis University:Elizabeth L. Merrick, Ph.D., M.S.W. (Project PI)

Constance M. Horgan, Sc.D. (Center PI)Dominic Hodgkin, Ph.D.

Sharon Reif, Ph.D.Bernard McCann, M.S., CEAP

Harvard University:Thomas G. McGuire, Ph.D.

Vanessa Azzone, Ph.D.

MHN:Deirdre Hiatt, Ph.D.

Arlene Darick, LCSW, CEAP

Brandeis/Harvard Center on Managed Care and Drug Abuse Treatment (Funded by the National Institute on Drug Abuse P50 DA010233)

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Project Overview

5+ year project within NIDA-funded Brandeis/Harvard Research Center on Managed Care and Drug Abuse Treatment

Multi-faceted study of access and utilization instand-alone EAP, stand-alone managed behavioral healthcare (MBHC), and integrated EAP/MBHC products

Focus especially on substance abuse but also looking at behavioral health overall

Multiple, complementary data sources– existing administrative data and primary data collection

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An Overview of MHN, Inc.

Subsidiary of HealthNet, Inc.

Founded in 1974

Affiliates: 1100 associates; 45,000 network providers; 1400 hospitals and care facilities

850 clients (Employers, Unions, Insurers, etc.)

Products: Employee Assistance Programs, Work Life Services, Managed Behavioral Healthcare, Wellness & Prevention programs – these products are offered in various configurations; i.e., stand-alone or integrated.

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Research Questions on EAP Use

1. What do EAP clients say about what issues the EAP helped with, how they learned about the EAP benefit, and how much it helped?

2. What choices in EAP design and worksite services do employers make?

3. What effects do organizational and workplace factors have on EAP utilization?

4. What differences in client utilization are seen in integrated and stand-alone MBHC products? What role does the EAP play within an integrated product?

5. Do EAP benefit limits or number of EAP visits used affect the use of outpatient behavioral healthcare?

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Q#1: What are employee/client perspectives on EAP?

Study focused on: Facilitators, barriers and experiences with EAP and behavioral health services use

Sample: 361 employee EAP users of EAP-only product; had EAP claim past year and self-reported as EAP user.

Data Source: Telephone survey (stratified random sample of MHN enrollees) conducted 2009-2010. Service users queried regarding experience with EAPs and BH treatment use over past 12 months; attitudes/knowledge about EAPs. Among sample for whom current phone numbers were available (about half), 57% participated in the survey

Design/analysis: Cross-sectional; descriptive statistics

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Q1: Respondents Reported Getting Services from EAP for Varied Issues

Family Issues/Other Personal Concerns

2%

3%

34%

48%

82%

Mental Health/Emotional Issues

Job Stress/Workplace Issues

Issues with Alcohol/Drug Use

None of Above

N = 361 with EAP claim and self-reported EAP use

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Q1: Sources of Information About the EAP

Employee Orientation/Training Session/Workshop

13%

33%

38%

58%

77%

71%Company Website

Posters/Flyers/HR Communications

Coworker

Union

N = 361 with EAP claim and self-reported EAP use

Supervisor

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Q1: Respondents’ View of EAP Services Received: How Much EAP Helped with Concerns

4%11%

25%60%

Some

N =228 with scheduled sessions and non-missing data

Not at all

A lot

A little

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Q1: Implications

EAP assistance with family/personal and mental health issues is most common, but EAP helped with job stress/workplace issues for 1/3 of clients – EAP retains workplace focus in eyes of many clients.

Obtaining EAP help for drug/alcohol issues was not frequently reported by enrollees; may be masked.

Employer communications, including via its internal website were a key source of information on EAP benefits.

Most employees who used clinical EAP services reported they helped a lot and were a valued benefit.

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Study focused on: Employer size, industry, organizational type, EAP benefit features, workplace substance abuse policies, and level of health insurance benefits.

Sample: 103 purchasers each with 1,000+ covered employees, EAP-only product.

Data sources: EAP administrative data, workplace activity data, and results from Account Manager questionnaires.

Design/analysis: Cross-sectional; bivariate tests of association

Q#2 – What choices in EAP design and worksite services do employers make?

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Account Manager Questionnaire – Distributed to MHN Account Managers, this 25 item questionnaire provided numerous details of workplace substance abuse policies, drug testing practices, level of unionization, nature/ extent of health coverage, EAP program features, benefits eligibility of workforce, workplace focus on health promotion, level of worksite stress.

Account Activities Database - Number and type of EAP worksite activities; i.e., employee orientations, mental health and wellness presentations, substance abuse prevention and policy presentations, supervisory training, and management consultations.

Q#2 - Data Sources

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Q2: Employer Choices in EAP Limits

34%

21%

45%3-4 sessions

8+ sessions

5-7 sessions

N = 103 employers

Percent of Employers

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Q2 - Employer Choices - Findings

84% of employers chose EAP session limits per issue/incident; 15% chose a per benefit year limit; and 2% chose no limits to number of sessions.

72% selected a flexible service delivery mode with the option of either in-person EAP sessions or telephone counseling for enrollees.

Employers in the mining, manufacturing, transportation and utilities industries were more likely to provide enrollees with a more generous EAP benefit (e.g., a higher number of sessions, per concern/incident rather than annual limit).

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Q2 - Employer Choices - FindingsEAP Worksite Activities:

53% of employers received worksite mental health and wellness educational presentations (Average annual hours per worksite = 8.2)

48% scheduled workplace substance abuse prevention or policy training (Average annual hours per worksite = 6.9)

37% received advanced training and/or organizational consultation for management or supervisors (Average annual hours per worksite = 8)

Non-commercial and not-for-profit employers (i.e., those in the healthcare, government, public education sectors) had the highest user rate for any worksite activities.

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Q2: Implications

Employer purchasers do have some similarities in preferences when purchasing EAP products -- such as number/allotment of “free” sessions and modes of delivery. However, variations in demand for EAP delivered worksite services are evident – e.g., by industry and work organizational type.

Understanding what each particular purchaser’s preferences may be and its unique workforce needs will be valuable in selecting the right menu of EA program features and services, and thus contribute to maximizing its benefit to the organization.

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Study focused on: Four factors - level of workplace stress; overall level of employer focus on wellness/health; extent of employer EAP/MBHC promotion; level of workplace EAP activities

Sample = 742,937 enrollee (weighted) in EAP-only or integrated product (26 employers), 2005

Data sources: EAP administrative data: eligibility files and claims data, results from Account Manager questionnaires, and EAP workplace activity data.

Design/analysis: Cross-sectional; generalized estimating equations

Q#3 – How do organizational and workplace factors affect EAP utilization?

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1Odds Ratio (98% CI) *p<.01; **p<.05

Higher EAP Promotion by Employer

Q3 - Organizational Factors andEAP Utilization - Findings

EAP provided Worksite Activities

Higher Workplace Stress

Higher Employer Focus on Wellness

When EAP Utilization is linked to Workplace Factors…

0

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Q3: Implications

Raising program visibility through employer promotion and conducting EAP-provided worksite activities may be key to increasing client utilization.

However, when experiencing major stresses or critical incidents, our finding of an association with lower rates of utilization suggests in these situations, it may be necessary to increase and/or better target outreach efforts and worksite activities to those in need.

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Study focused on: a) Comparisons of service use patterns between both products; b) utilization of EAP in integrated product for enrollees with substance abuse diagnosis

Sample: 286,750 weighted for demographics, integrated and MBHC users only in 2004; 1158 enrollee service users in integrated product with a primary SA diagnosis

Data source: Administrative benefits and enrollee claims data files

Design/analysis: Cross-sectional; logistic regression, weighted for eligibility and demographics

Q#4 – What differences in service use occurbetween integrated and stand-alone MBHC plans?

What is role of EAP within integrated product?

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Q4: Integrated vs. MBHC Products: Any Claim

4.8%

0.17%0.21%*

Integrated MBHC Only

Perc

ent o

f Enr

olle

es

Any behavioralhealth claimAny substanceabuse claim

Integrated results include clinical EAP claims. N = 286,750 weighted/matched on demographics;

*Differences between products are significant at *p<.01

5.7%*

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Q4: Integrated vs. MBHC Products: Any MBHC Claim

4.8%4.6%**

0.17%0.19%*

Integrated MBHC Only

Perc

ent o

f Enr

olle

es

Any behavioralMBHC health claim

Any MBHCsubstance abuseclaim

N = 286,750 weighted; matched on demographics

*Differences between products are significant at *p<.01; ** p<.05

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Q4: Integrated vs. MBHC Products: Outpatient Visits

4.6%

2.4%

0.0%

4.6%

Integrated MBHC

Perc

ent o

f Enr

olle

es

Used any regular outpatient - MBHC +/or EAPUsed any clinical EAPUsed any regular outpatient MBHC

N = 286,750 weighted, matched on demographics; *p<.01

4.4%*

5.5%*

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Q4: Enrollees with Primary Substance Abuse Diagnosis: Benefit Utilization Within Integrated Product

MBHC only72%

Both EAP and MBHC

20%

EAP only8%

N = 1,158 service users

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Any MBHC SA Service

61%

EAP 23%

Any MBHC MH Service

16%

N = 606 service users with “new episode” (no claims in prior quarter)

Q4: Enrollees with Primary Substance Abuse Diagnosis: Initial Service in Integrated Product

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Q4 - Implications

A greater proportion of enrollees use any services in the integrated product – which is consistent with increasing access via EAP benefit.

The greater proportion of service users in the integrated product stems from EAP use; the proportion using MBHC benefit is slightly lower in an integrated product – which is consistent with the concept that EAP may facilitate earlier interventions.

Caveats: Some MBHC enrollees may have access to an EAP outside of MHN. We were able to observe and discuss only MHN plan services.

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Study focused on: Whether amount of EAP visits allowed or the number of EAP visits used affect outpatient behavioral health care: i.e., number of visits and total annual spending.

Sample: 26,464 outpatient/EAP service users, integrated product, 2005

Data source: Administrative; Claims data

Design/analysis: Cross-sectional, generalized linear models with log link

Q#5 – Do EAP benefit limits or EAP use affect utilization of outpatient behavioral

health services?

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Q5 - Findings

Per-incident EAP models had fewer outpatient sessions than those with a per year EAP model.

Having an EAP benefit of 4-5 sessions per incident predicts a lower use of regular OP sessions, compared with an EAP benefit of 3 sessions per year.

Use of one additional EAP session was associated with 11 percent fewer outpatient sessions; and annual costs for MBHC outpatient behavioral healthcare were reduced by 16 percent.

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Q5 - Implications

Increased EAP benefit generosity (relative to a 3-session model) and actual use of EAP are associated with some reduction in MBHC outpatient use and costs.

EAP and MBHC outpatient visits appear to be partial substitutes.

Investment in EAP within the integrated product is not simply an addition to employer costs, and clients appear to perceive some difference in EAP and MBHC (not complete substitution).

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Limitations of Research Findings

1. Cannot determine causality from data (due to observational/non-experimental design)

2. Generalizability (used data from only one large MBHO)

3. Some limits to clinical data; i.e., unobserved variables including non-MHN EAP use in MBHC product.

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Next Steps Analysis of non-service user responses: their

knowledge of, perception and inclination to use an EAP

Linkage of survey to claims data; e.g., how factors service users told us about relate to their utilization patterns

Understanding the full range of services that clients use, including those out of health plan

MORE INFO: merrick@brandeis.edubernard.mccann@rcn.com

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For more on methods & findings cited:Q1: Merrick EL, Hodgkin D, Hiatt D, McCann B, Horgan, CM. Manuscript

in preparation.

Q2: McCann B, Azzone V, Merrick EL, Hiatt D, Hodgkin D, Horgan CM. Employer choices in EAP design and worksite services. Journal of Workplace Behavioral Health 2010; 25(2):89-106.

Q3: Azzone V, McCann B, Merrick EL, Hiatt D, Hodgkin D, Horgan CM. Workplace stress, organizational factors and EAP utilization. Journal of Workplace Behavioral Health 2009; 24(3):344-356.

Q4: Merrick EL, Hodgkin D, Horgan CM, Hiatt D, McCann B, Azzone V, Zolotusky G, Ritter G, Reif S, and McGuire TG. Integrated employee assistance program/managed behavioral healthcare benefits: Relationship with access and client characteristics. Administration and Policy in Mental Health 2009; 36(6):416-423.Merrick EL, Hodgkin D, Hiatt D, Horgan CM, Azzone V, McCann B, Ritter G, Zolotusky G, McGuire TG and Reif S. Patterns of service use in two types of managed behavioral healthcare plans. Psychiatric Services 2010; 61(1):86-89.

Q5: Hodgkin D, Merrick EL, Hiatt D, Horgan CM, McGuire TG. Manuscripts under review and in preparation.