The Whole-Person Approach to Lowering Medical Costs

As a new study makes clear, disability will be a growing cost center for organizations in the years ahead. HR executives and professionals, who have taken a lead on wellness and related programs in the past, are ideally suited to help organizations and their employees rein in the coming costs associated with disability.  

Tuesday, January 15, 2013
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The Global Burden of Disease Study, released last December, is a landmark effort to describe and predict healthcare trends around the world. Produced over five years by 486 researchers at 302 institutions in 50 countries, the study is the most detailed look at health on the population level ever attempted. The study's authors reached a dramatic conclusion, as expressed by Christopher J.L. Murray, who headed the study: "We are in transition to a world where disability is the dominant concern as opposed to premature death."  People are living and working longer. But their lives -- and workplace performance -- are negatively impacted by all manner of disability.

To effectively address this reality, which is truly something new, policy makers, business leaders and human resource professionals must apply a wide-angle lens to employee health and wellness. This includes a coordinated strategy to meeting patients' -- meaning employees' -- health needs through a holistic approach that includes behavioral health solutions. HR executives and professionals, who have taken a lead on wellness, and related programs, are ideally suited to help drive this transition.  

We know that the most prevalent physical conditions, such as lower back pain, heart disease, diabetes, asthma and others have a comorbid psychiatric condition, depression. Ignoring this reality -- or, even worse, delegitimizing it -- is costly and results in both poor workplace and healthcare outcomes. For example, people with diabetes and depression have four times the healthcare expenditures as those with diabetes alone. Yet according to national epidemiologic surveys in the United States, the majority of people with symptoms that meet clinical criteria for having mental and substance use disorders do not receive any treatment at all for their condition.

And it gets worse. Lack of coordination and the absence of effective care management have clear implications for employee disability, including absenteeism and presenteeism, and return to work. People who suffer from chronic medical illnesses, along with co-occurring mental health conditions, account for a considerable portion of disability costs, in both the long-term and short-term. The Disability Management Employer Coalition has found that health plans and employers under-report levels of depression and anxiety in their populations compared to actual rates of prevalence. But this does not stop high levels of disability days, emergency room visits and acute care, all of which increase when mental illness is under-managed.

So what are some of the concrete solutions to increase employer-based whole person healthcare, including mental and behavioral health?

The first solution, with which HR professionals are very familiar, is the employee assistance program. Based on a 2012 DMEC Behavioral Risk survey, fully 97 percent of employers surveyed had an existing EAP program. But as prevalent as EAPs are, they can be woefully underutilized. Employers must do a better job of communicating the services they provide and, crucially, that EAP use is confidential and has no impact on an employee's work status -- just like other healthcare services. As stories about the U.S. armed forces attest, there is still a stigma against even acknowledging mental health issues in many workplaces. That view will not just go away. HR and other executives and professionals must overcome it through active education and communication.

When HR does effectively communicate about EAPs, the results are impressive. For example, employers can receive a significant ROI from outreach and enhanced treatment of depressed workers for a cost of only $100 to $400 for low-to-moderate-intensity interventions.

Further, effective and early use of EAPs facilitates return-to-work and stay-at-work outcomes. An EAP creates the bond that strengthens communication between an employee and their employer, and fosters a commitment to the workplace and a focus on return to work and high performance. Both at work and, crucially, away from work, an EAP communicates a supportive and employee-centered environment that encourages optimal productivity and retention. Active programs to retain key employees is especially important as continued economic recovery increases the opportunities for high performing workers to consider their options.

The second solution to identifying and properly managing behavioral health issues and their workplace effects is one that has been effectively applied to cancers and other diseases -- increased screening.  

Patients with diagnosed diabetes, arthritis, osteoporosis, musculoskeletal conditions, cancer, lower back pain, reflex sympathetic dystrophy hypertension and obesity develop depression and anxiety at rates 30 percent to 50 percent higher than the rest of the population. Research shows these patients are often non-adherent to treatment regimens, resulting in higher costs incurred for rescue treatments, increased and sometimes inappropriate use of narcotics and alcohol, increased inpatient and outpatient days, increased emergency room usage, and increased absenteeism and presenteeism. Varieties of behavioral health screeners are available, as are tools that measure the effect on functioning and work performance associated with health. If they have not done so, HR professionals owe it to themselves, the employees and their organizations to become familiar with behavioral health screening techniques.

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In addition to identifying issues early, screening tools are also effective in monitoring and managing chronic conditions and depression, stress levels, adherence to condition management, and even pain management. Increased screening results include better adherence to treatment programs, decreased use and abuse of narcotics and alcohol, lower inpatient and outpatient days, lower emergency room usage, and decreased absenteeism and presenteeism. Effective screening can help prevent minor employee issues from developing into debilitating health conditions, with all the costs those entail.

The third solution is a greater reliance on psychotherapy as part of workers' compensation. Several workers' compensation payers are already employing one of the leading forms of psychotherapy, cognitive behavioral therapy, for claimants who suffer from chronic pain and psychosocial issues that hinder their recovery and return-to-work. A recent study conducted in the Netherlands and published in the Journal of Occupational Health Psychology found that employees absent due to common mental health disorders returned to the job on average 65 days earlier and saved employers an average of $5,275 when provided work-focused cognitive behavioral therapy. As with screening, HR should become familiar with cognitive behavioral therapy, which focuses on changing thought patterns to change behavior. It is a very "results-oriented" approach to mental health.

 Finally, health plans and purchasers -- led by HR -- must call for inclusion of behavioral health in the broader application of total health management. This should include performance incentives that reward the time spent in assessing, evaluating and managing behavioral health issues, especially when managing chronic or acute care.

 Between the 2008 Mental Health Parity Equity and Addiction Act and the Affordable Care Act, nearly every aspect of the nation's healthcare system is undergoing significant change. Of course, given these changes are built on the existing private health-insurance market, this means large impacts on employers. Rather than a burden, these changes should be viewed as an opportunity for innovation. In particular, HR executives and professionals should seize the opportunity to accelerate their contribution to controlling healthcare costs, including by addressing disability. As the Global Study makes clear, disability will be a growing cost center in the years ahead.

Controlling its costs will entail a holistic approach that recognizes mental and behavioral health as important human resource realities and responsibilities. HR can impact both disability-related healthcare costs and increase organizational performance by focusing on the whole person approach to health and human resource management.

Marcia Carruthers is co-founder, CEO and president of the Disability Management Employer Coalition. Clare Miller is the director of the Partnership for Workplace Mental Health, a program of the American Psychiatric Foundation. Cyndy Nayer is founder and former CEO of the Center for Health Value Innovation and president of


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