With funding from the Robert Wood Johnson Foundation, the National Health Care Purchasing Institute issued the monograph "Making the Business Case for Improving Mental Health Care: How to Maximize Corporate Resources" in September.
The institute, which is part of AcademyHealth, was founded to improve the purchasing practices of major corporations and government agencies.
Patricia Pittman, senior manager at AcademyHealth, and Veronica Goff, former vice president of the Washington Business Group on Health, wrote the report.
The authors opened with the statement, "The mental health of employees needs to be a key concern for employers who wish to improve employee productivity and work quality. Mental disorders are highly prevalent and enormously costly, but they are also exceedingly treatable."
They cited a study by E.R. Berndt that found that total medical expenditures of those with mental disorders were 4.5 times higher than those with no disorders (Health Affairs, July/August 2000). (Costs of treatment for mental illness are included in the total medical expenditure figure.)
Indirect costs associated with mental illness, according to the authors, appear to be even greater than the money spent on treatment.
R.C. Kessler published an economic analysis that found that when the costs of depression treatment were compared with the costs of lost productivity, 45 percent to 98 percent of treatment costs were offset by increased productivity (Health Affairs, September/October 1999).
Former APA president Daniel Borenstein, M.D., lauds a health policy think tank for helping to promulgate the business case for mental health.
He commented that "although the devil is in the details," the report is particularly useful in the examples offered of companies that are providing good mental health benefits and in the references that help make the business case for mental health.
Borenstein said that the report was timely because there is a greater public awareness of the value of mental health services. The potential importance of that trend, however, is threatened by rising costs of insurance premiums and of health care overall.
During his presidency, Borenstein launched APA’s Business Initiative.
The authors offered action steps for employers in four areas:
• Care seeking: Empower employees to seek care through education and outreach programs.
• Benefits design: Facilitate access to care through benefit designs and contracts with vendors that emphasize early intervention, appropriate treatment, and continuity of care.
• Vendor accountability: Promote strategies that hold vendors accountable for improved coordination of delivery and evaluation of behavioral health and medical benefits.
• Disability: Reduce disability and turnover through active disability management, return-to-work plans, and job accommodations.
Pittman and Goff noted that employers often use behavioral health carveouts and wrote that "such arrangements may make coordination among plans more complex." Nonetheless, "they also usually improve access to behavioral health services and result in an overall reduction in employer costs."
Lloyd Sederer, M.D., New York City’s executive deputy commissioner for mental hygiene, told Psychiatric News, "Although sometimes access is improved by carveouts, the duration of treatment generally is shorter, and its quality is uncertain."
In March 2002, APA’s Board of Trustees approved a position statement stating that "the separation of the funding and delivery of psychiatric and/or substance abuse services (carveouts) from general medical services is detrimental to providing high-quality comprehensive care." The statement was approved by APA’s Assembly in November 2001.
Sederer facilitated APA’s Business Initiative when he was the association’s director of clinical services.
The authors acknowledged that spending on psychiatric medications has risen steadily, although behavioral health spending now totals just 3 percent to 5 percent of all health care expenditures.
The report recommended that employers ask their pharmacy benefit managers (PBMs) to provide a formal clinical review of new drugs, including recommendations for placement in the formulary and evidence-based utilization protocols. The report also stated that drug formularies should have more than one medication in each class and offer variety in pricing.
Sederer said, "Employers should not be encouraged to hand off review of new drugs to PBMs, which have an economic motivation to encourage use of the least expensive medications."
He added that access to a broad range of antipsychotic medications is important because adherence problems with those medications are greater than with other kinds of medications and the consequences of nonadherence can be devastating.
The authors also encouraged the use of PBM databases to examine and improve prescribing patterns, treatment compliance, and patient outcomes.
"Excellent idea," commented Sederer. "PBMs have data that can be used to analyze how utilization affects results for patients."
The report is posted on the Web at www.nhcpi.net. ▪
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