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Findings from a 5-year Research Project on Pathways to Treatment for Substance Use

Disorders: Implications for EAPsPresenters:

Elizabeth L. Merrick, Ph.D., MSWBernie McCann, M.S., CEAP

Brandeis UniversityVanessa Azzone, Ph.D.

Harvard Medical School

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

MA/RI Chapter of EAPA Symposium 2011Waltham, MAMay 13, 2011

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Brandeis/Harvard Center on Managed Care and Drug Abuse Treatment

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

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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Context

Much unmet need for behavioral health assistance, including substance abuse

Workplace = opportunity to intervene Need to understand facilitators, barriers,

patterns and experience of care in contemporary EAP model

EAPs now frequently provided by managed behavioral health care organizations, sometimes in conjunction with managed behavioral health care benefits

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Subsidiary of HealthNet, Inc. (NYSE: HNT)

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

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

Provides services to apx. 5.4M individuals in 50 states

Products include: EAP Managed behavioral health care (MBHC) Integrated EAP/MBHC (Both EAP and MBHC benefits;

goal is seamless transition if both are accessed)

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EAP-Related Research Questions1. How are EAP benefit features related to access, utilization, and costs?

1a. MBHC versus integrated EAP/MBHC products

1b. EAP benefit generosity within integrated product

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

3. How are workplace characteristics and program promotion activities related to utilization?

4. How do EAP users learn about EAP services and what do they use EAP for?

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Study focused on: Comparisons of service use patterns between MBHC and integrated EAP/MBHC products

Sample: 286,750 enrollees, weighted sample, integrated and MBHC only, 2004

Data source: Administrative benefits and enrollee claims data files

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

Q1a – How Does Utilization of Any BH Services Vary Within Integrated Versus

MHBC Only Products?

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Q1a: Integrated vs. MBHC Products: Any Claim

Integrated MBHC Only

Perc

ent o

f Enr

olle

es

Any behavioralhealth claimAny substanceabuse claim

Integrated includes clinical EAP claims. * Differences between products are significant at p < .01

5.7%* 4.8%

0.21%* 0.17%

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Q1a: Integrated vs. MBHC Products: Any MBHC Claim

Integrated MBHC Only

Perc

ent o

f Enr

olle

es

Any behavioralMBHC healthclaimAny MBHCsubstanceabuse claim

*Differences between products are significant at p < .01

** p<.05

4.6%** 4.8%

0.19% 0.17%

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Q1a: Integrated vs. MBHC Products: Outpatient Visits

Integrated MBHC

Perc

ent o

f Enr

olle

es

Any outpatientAny clinical EAPAny outpatient MBHC

*p<.01, significant difference between products

4.4%*5.5%*

2.4%

4.6% 4.6%

0.0%

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Q1a - Implications

Greater proportion of enrollees use any services in integrated product – consistent with increasing access via EAP benefit

The greater proportion of service users in integrated stems from EAP use; proportion using MBHC is slightly lower in integrated – consistent with concept that EAP may help with earlier intervention

Caveats: Some MBHC enrollees may have EAP outside of MHN. We observed and discuss only plan services

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Study focused on: Whether the EAP session limit affects utilization and cost of outpatient mental health treatment; i.e., number of sessions and total annual spending

Sample: EAP/outpatient service users, in an EAP/MBHC integrated product during 2005 (n = 26,464)

Data source: Administrative and claims data

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

Q1b: Does EAP Benefit Limit Affect the Use and Cost of Outpatient BH Care?

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Gender: Female - 58% Male - 42%

Status: Employee - 49% Spouse/dependent - 51%

EAP session benefit: 3 sessions/year - 31%4-5 sessions/year - 7%3 sessions/incident - 15%4-5 sessions/incident - 46%

Mean # of OP visits: 5.83 (7.86 SD)

Mean OP session payments: $467 ($699 SD)

Q1b: Study Sample

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0% 50% 100%

4-5 EAPsessions/incident

3 EAPsessions/incident

4 EAP sessions/year

3 EAP sessions/year

17%

12%

7%

*Controlled for: gender, region, age, status, diagnosis & enrollment duration

Q1b: Findings – Use of OP SessionsEffect of EAP benefit on regular OP sessions*

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0% 50% 100%

4-5 EAPsessions/incident

3 EAPsessions/incident

4 EAP sessions/year

3 EAP sessions/year

15%

17%

3%

*Controlled for: gender, region, age, status, diagnosis & enrollment duration

Q1b: Findings – CostEffect of EAP benefit on regular OP payments*

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Q1b - Implications

Within an integrated product, increasing a minimal EAP benefit to a more generous level is associated with lower utilization and costs for subsequent non-EAP outpatient sessions

Thus, when an EAP feature is included within an integrated EAP/MBHC benefit, it is not simply an added expense to employers

Users do seem to perceive some differences between EAP sessions and non-EAP outpatient sessions. This suggests that EAP sessions are not merely duplicating outpatient sessions, but are used differently

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Discussion/Q & A

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Study focused on: Employer size, industry, organizational type, 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, EAP workplace activity data and results from Account Manager questionnaires.

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

Q2 – 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 addressed purchasers’ 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.

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 set limits per issue/incident; 15% per benefit year; 2% no limits.

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

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

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Q2 - Employer Choices - FindingsEAP Worksite Activities & Services:

53% hosted onsite mental health and wellness educational presentations (Average annual hrs per worksite = 8.2)

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

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

Non-commercial & not-for-profit employers (i.e., health care, government agencies, public education) had the highest user rate of any worksite activities/services

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Q2: Implications

Employers do have a number of similarities in preferences when purchasing EAP products; such as number and allotment of “free” sessions, and for modes of delivery, but variations in demand for worksite services do occur – e.g. by industry, organizational type.

Understanding what each particular purchaser’s preferences and its unique workforce needs are valuable in selecting the right menu of program features and services, and thus to maximize 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 including claims and eligibility files, results from Account Manager questionnaires, and EAP workplace activity data.

Design/analysis: Cross-sectional; generalized estimating equations

Q3 – How do Organizational and Workplace Factors affect EAP Utilization?

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0.86**

0.96**

1.09*

1.14*

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

Higher Employer EAP Promotion

Q3 - Organizational Factors andEAP Utilization - Findings

EAP WorksiteActivities

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 worksite may be key to increasing utilization.

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

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Discussion/Q & A

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Study Focus: Facilitators, barriers and experiences with EAP services.

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

Data Source: Telephone survey of a stratified random sample of employees covered by MHN’s stand-alone EAP, conducted in 2009-10. EAP users were queried regarding beliefs, knowledge and experience with services in past year. Among potential respondents with current available phone numbers, 57% participated in survey.

Design/Analysis: Cross-sectional; descriptive statistics

Q4: What Are Employee User Perspectives on EAPs?

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18-34 14%

35-44 32%45-54

39%

55+ 15%

Age

Q4: EAP users

N = 361 employee users

Black 6% Asian

5%Other

6%

Race

White82%

Female 56%

Male 44%

Gender

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Q4: EAP users

Yes 30%

No 70%

*N = 361 employee users **N= 335 employee users

Not employed 

7%

Salaried 45%

Hourly 47%

Employment status*

Supervisory role?**

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Q4: EAP users

Excellent 27%

Very good 42%

Good22%

Fair/Poor 8%

10+ days 11%

1‐5 days 25%

6‐10 days 6%

None 58%

N = 361 employee users

Current smoker?

Yes 12%

No88%

Past yearrisky drinking?

Healthstatus

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Q4: EAP Users’ Information Sources About the EAP

From employee orientation/ Training session/workshop

13%

33%

38%

58%

77%

71%From employer website

From posters/Flyers/HR communications

From coworker

From Union

From supervisor

N = 361 employee users

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Q4: EAP Users’ Beliefs About the EAP

Alcohol or drug use

Family & relationship issues

Believes EAP can help with:

Child/elder care & work/life*

Believes EAP is confidential:

Work stress & job performance

Mental health issues

100%

98%

95%

95%

96%

82%

N = 361 Employee users *N = 357 Employee users with W/L benefits

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Q4: Reasons for Accessing EAP

Family issues/Personal concerns

2%

3%

34%

48%

82%

Mental health/Emotional issues

Job stress/Workplace issues

Alcohol or drug use issues

None of above

N = 361 Employee users

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Q4: Who Influenced Decision to Use EAP?

14%

5%

25%

56%

Family or Friends

N = 229 users with initial scheduled EAP session

None of these

Healthcare provider

Employer/ Supervisor

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Q4: EAP Services Users Received

In-person sessions only

86%

78%

74%

24%

50%

24%Telephone only

Telephone & in-person

EAP referred to mental health services

EAP was 1st behavioral health service used

*N = 361 Employee users

Had scheduled EAP session

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Q4: How Much EAP Helped Users With Concerns

4%

11%

25%60%

Some

N = 228 users with initial scheduled EAP session

Not at all

A lot

A little

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Q4: Summary Findings

EAP assistance with family/personal and mental health issues is most common, but 1/3 of users reported EAP helped with job stress/workplace issues; indicates EAP provides a workplace-focused benefit to a significant number of users.

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

Employer communications, including via 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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Q4: Implications

Ensuring that EAP providers are well-versed in addressing job stress and workplace issues remains critical, even in today’s broad-brush, network-based programs.

Enhancing employer communications regarding EAPs is important, since so many employees learn about the EAP and its services in that way.

Focusing on additional ways to identify risky drinking and other substance use disorders is a challenge and an opportunity for EAPs.

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17%32% 33%

35%36%60%

44% 40%27%

14%

23% 24% 27%38%

50%

0%

20%

40%

60%

80%

100%

Family/Friends SA/MHprofessional

General medprovider

EAP Self-helpsupport group

Not likely Somewhat likely Very likely

SA Treatment Non-Users’ Likely Source of Assistance

N = 133 non-users of SA treatment

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Limitations of Our Findings

We cannot determine causality from the collected data -- given the various studies’ observational, cross-sectional and non-experimental design.

We cannot generalize our findings to all EAP or behavioral healthcare service users, given that our sample and data came from only one large EAP/MBHO provider.

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Next Steps

Linking employee survey findings to actual claims data; e.g., how responses of service users relate to service utilization patterns.

Investigating the full range of behavioral health-related services used by clients, both in and out of covered health plan benefits.

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For more on methods & findings cited:Q1a: Merrick EL, Hodgkin D, Horgan CM, Hiatt D, McCann B, Azzone V, Zolotusky G, Ritter G, Reif S,

and McGuire TG. (2009) Integrated employee assistance program/managed behavioral healthcare benefits: Relationship with access and client characteristics. Administration and Policy in Mental Health 36(6):416-423.

Q1b: Hodgkin D, Merrick EL, Hiatt D, Horgan CM, McGuire T. (2010) The effect of employee assistance plan benefits on the use of outpatient behavioral health care. Journal of Mental Health Policy and Economics. 13(4):167-174.

Q2: McCann B, Azzone V, Merrick EL, Hiatt D, Hodgkin D, Horgan CM. (2010) Employer choices in EAP design and worksite services. Journal of Workplace Behavioral Health. 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. PMC Journal – In Process

Q4: Merrick EL, Hodgkin D, Hiatt D, McCann B, Horgan CM. (2011) EAP service use in a managed behavioral health care organization: From the employee perspective. Journal of Workplace Behavioral Health. [Forthcoming]

MORE INFO: merrick@brandeis.edumccannbag@gmail.comazzone@hcp.med.harvard.edu