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Search Terms: mental AND health AND parity, House or Senate or Joint

Document 19 of 103.

May 18, 2000, Thursday

SECTION: PREPARED TESTIMONY

LENGTH: 3699 words

HEADLINE: PREPARED TESTIMONY OF TARA WOOLDRIDGE MANAGER EMPLOYEE ASSISTANCE PROGRAMS DELTA AIR LINES

BEFORE THE SENATE COMMITTEE OF HEALTH, EDUCATION, LABOR AND PENSIONS

SUBJECT - PROVIDING GENEROUS MENTAL HEALTH BENEFITS AT DELTA AIR LINES: THE BUSINESS CASE

BODY:
I. Introduction

Mr. Chairman and Senators of the Committee:

Good morning. I am Tara Wooldridge, Manager of the Employee Assistance Program for Delta Air Lines. Delta is a leader in the transportation industry, serving the largest number of nonstop markets of any U.S. airline. Delta is a leader across North America as a result of the efforts of almost 80,000 employees. The Company provides employer- sponsored health care, including mental health and substance abuse care, for more than 165,000 employees, retirees, and family members. While our home office is located in Atlanta, Georgia, we have employees at job sites throughout the United States as well as internationally.

Delta prides itself in being a company that exemplifies best practices in employer-sponsored health care, including mental health and substance abuse care. We offer generous health and behavioral health benefits to our employees and their families. There are no separate annual or lifetime limits on mental health treatment. We do not have day or visit limits for mental health treatment and have worked hard to eliminate all barriers to appropriate, timely services. Our surveys of employee satisfaction with their behavioral health benefits suggest that they are pleased with the benefits they receive. We provide these benefits because they are consistent with the best interests of our company. Delta's success depends on ensuring the safety and comfort of our customers, and that depends on the productivity of our employees. Provision of quality mental health and substance abuse benefits is essential to employee productivity.

Delta supports the goal of working to improve and expand coverage for mental and addictive disorders. However, we believe that there are real limitations to the capacity of the Mental Health Parity Act of 1996 or other parity laws to address this goal. Such legislation focuses solely on benefit design, which is only one aspect of the complex question of providing access to quality mental health and substance abuse care for employees and their families. Those other factors include ensuring adequacy of the care delivery systems, plan management, education to foster recognition of symptoms of mental illness and combating the persistent stigma against seeking care, even when available. Ensuring access to quality care requires an array of tools: generous benefits, appropriate care management techniques, employee education and application of performance measures to assess quality of care. In our view these complex issues are not necessarily suited to legislative solutions.

The important message from large employers like Delta is that in the last decade we have introduced and implemented generous mental health and substance abuse benefits for our employees and their families, not in response to legislative mandate, but because it improves our corporate "bottom line." Delta is a member of the Washington Business Group on Health. WBGH is a non-profit membership organization supported by large employers like Delta, who are involved in public and private efforts to improve health care, including behavioral health care, delivery. Earlier this year, we along with AT&T, Eastman Kodak, American Airlines, Pepsico, IBM, GM, and the Massachusetts Group Insurance Commission participated in a WBGH project to assist the U.S. Office of Personnel Management (OPM) in planning for the implementation of mental health and substance abuse parity in the Federal Employees Health Benefit program. (OPM is also a WBGH member.) Although these companies have varying views on panty and generous, but diverse, mental health and substance abuse benefits, we were willing to share our experiences and best practices in the management of behavioral health benefits for our employees and their families with OPM, as it undertook its planning for implementation of mental health and substance abuse benefits to more than 9,000,000 federal employees, retirees, and their families.

It is also important to note that Delta, as well as these other large employers, have extensive corporate resources to devote to the complexities of providing quality behavioral heath care to their employees and their families. Our experiences and views are by no means typical or representative of employers in general, most of which are much smaller, than Delta Air Lines. Many of those employers may continue to purchase behavioral health care that still uses deductibles; limits and other demand-side mechanisms to limit access to mental health treatment.' Differences may be attributed to the real disparity in resources between large, self-insured employers and smaller companies. The value of parity is not diminished at these companies but the best methods of providing needed resources may vary.

A. Delta's Decision to Provide Generous Mental Health and Substance Abuse Benefits- -The Business Case

Background:

Mental health and substance abuse coverage has long been characterized by limits that do not apply to health coverage generally. The support for parity in mental health benefits has been strongly supported on the grounds of basic equity in treatment for individuals with mental illness or suffering from addictions. But from Delta's perspective it is even more important to recognize that failure to identify and treat mental illness and addiction imposes great costs and emotional burdens on individuals and their families, and results in lost productivity. Further, the success of administrative, financial and care management mechanisms used by managed behavioral health care firms has demonstrated that costs can be held down while providing an expanded scope of services and better continuity of care compared to unmanaged indemnity plans?

Delta's Care Goals: Ensuring Access and Productivity:

In 1994, Delta turned to care management tools as a better way to provide mental health and substance abuse care to our employees. Our goal was to ensure that employees had timely access to quality care. Like many other employers, we began to realize that looking simply at the cost of treatment did not recognize the much greater costs to our company when employees were absent from work or at work with impaired functioning as the result of mental or addictive disorders.

We also realized that failure to diagnose and appropriately treat mental illnesses, in particular depression, resulted in high levels of absenteeism, related health care costs, and reduced productivity at work. Employees who were coping with untreated illness experienced by family members were also adversely affected at work. Published studies confirm the adverse impact of untreated mental illness on employee productivity. Studies also confirmed that employers who used benefit design to tightly limit access to mental health care did not in fact experience overall savings, because they had higher psychiatric disability costs and productivity losses; while companies with less restricted access to outpatient mental health services had lower disability costs. Similarly, companies that limited access to mental health treatment experienced higher medical care costs.

3 Delta also believes that substance abuse treatment must be included as part of an appropriate overall behavioral health program, particularly in light of the findings that the incidence of co- occurring mental and addictive disorders is as much as 3% of the U.S. population.

Access and Care Management:

Thus, in contracting for managed behavioral health care, our primary focus was not solely on reducing treatment costs - but also on managing care to assure that employees received substantially unlimited access to appropriate care. This meant that there had to be a continuum of care with access to such intermediate care modalities as halfway houses, community-based services, intensive outpatient treatment, and partial hospitalization in addition to traditional inpatient hospitalization or residential treatment and outpatient therapy. It also meant that inpatient treatment needed to be followed by aftercare and programs of outpatient treatment to reduce readmission and relapse. There also needed to be mechanisms for access and referral to appropriate treatment.

We required our care management vendor to be responsible for developing and contracting with a network of appropriately licensed and trained providers, individual treatment practitioners and facilities, who could provide the services needed by our employees and their families. We expected that all our employees and their families would have access to appropriate treatment with reasonable waiting times for treatment depending on urgency of care, as well as access to providers located within a reasonable distance. And we require our vendor to provide us with data to measure such access to care. The licensed clinicians in the Employee Assistance Program (EAP) evaluate the data and recommend changes as appropriate to ensure timely access to quality service.

The Impact of Expanding Access to Care on Cost: Treatment costs

Prior to passage of the 1996 Parity Act, many analysts expressed concern that the introduction of parity mental health benefits would be very costly. However, we found that through the use of appropriate care management we have been able to ensure employee access to high quality services without cost increases. More recent actuarial cost- prediction models are also consistent with our experience, concluding that costs associated with mental health parity are controllable. A 1998 report by the National Advisory Mental Health Council found that in systems already using managed care, implementing parity results in a minimal (less than 1 percent) increase in overall health care costs during a one year period. In addition, in systems not using managed care, introducing parity with managed care can result in a substantial reduction in total mental health costs.5

At Delta, where we had generous, but unmanaged, fee for service benefits, our costs went down with the introduction of parity coupled with management. This was primarily because our employees received more services in lower cost outpatient and alternative care programs, and spent less time in high cost inpatient and residential treatment. Please understand that alternate care was not used because it was less expensive but because with early intervention it was the most appropriate type of care. At the same time we believe that the care employees and their families received was better tailored to meet their needs, and more focused on assisting them in returning to productive functioning at work and school. Further, costs associated with increasing utilization of mental health services were offset by decreases in medical treatment cost. Other large employers who provide generous parity or near parity benefits in concert with introduction of care management have experienced similar cost reductions.6

Productivity Costs

Delta is also making a concerted effort to assess the impact that mental illness and addiction disorders have on employee productivity. We have found that depression and other mental illnesses account for more employee disability days than any of the other major causes of disability: diabetes, hypertension, back pain, and heart disease.7 Our company's experience is entirely consistent with many studies of the impact of depression on productivity.' For this reason, Delta has been actively involved in introducing depression awareness and education programs to encourage our employees and their families to seek appropriate treatment. Doing so is cost effective for our company. We have expanded our view of mental health and substance abuse treatment. As is the case with many other large employers,/9 we are placing less emphasis on managing access to behavioral health care services and focusing more on employee education, early intervention mechanisms, disability prevention, and return-towork programs.

Good data exists to support parity from a productivity perspective. The World Health Organization reports that in the major industrialized countries major depression accounts for 24% of the disability days in adults.10 My colleagues in the EAP at Bank One have done a phenomenal job of documenting the tangible cost associated with depressive disorders. Their 1989 - 1992 disability study armed them with the financial data which motivated senior management to place high priority on health and wellness." The EAP manages all mental health disability to ensure appropriate care is provided. Bank One represents an excellent example of one of the many fine corporate initiatives which exist to help employees achieve and maintain balanced, healthy lives. Where we lack sufficient study is on the value of the programs and services which encourage utilization and address stigma.

B. Continuing Issues

Understanding of the Impact of Mental and Addictive Disorders on the Workplace:

Our experience and the approaches that we use parallel those of similar large employers, including some of those who participated in making recommendations to OPM. We are convinced that provision of generous mental health and substance abuse benefits is cost effective. Nevertheless, we recognize that there is still work to be done to make the business case for adequate access to appropriate mental health and substance abuse care. It is difficult to associate specific cost avoidance or cost savings figures with the earlier return to full functioning evidenced in those who receive early and appropriate intervention. It is equally cumbersome to convince financial decision makers that real dollar savings are directly attributable to the provision of the programs and services which, in concert with comprehensive mental health benefits, make a difference in the health and productivity of employees. No one will argue against the premise that healthy employees are more likely to come to work and produce more. However, finance still wants to know exactly how much is saved.

Despite our experience and that of many comparable large employers, nearly half of all employers still have significant limits on inpatient and outpatient mental health treatment.12 In addition, large employers like Delta have the capacity to manage and address the cost effectiveness of their behavioral health benefit programs that may not be true of smaller employers.

Stigma and the Need for Employee Education and Assistance Programs:

Perhaps even more important than cost concerns is the persistent and pervasive stigma against those with mental and addictive disorders. For Delta and other large employers like those identified above, the goal continues to be to encourage employees to get treatment early and to be sure that they will receive appropriate, comprehensive care when they access it. Indeed, under the Delta behavioral health benefit, we provide the first outpatient treatment visit free. We want to be sure that cost will not be a barrier to identifying problems and seeking resolution.

Nevertheless, despite very generous mental health as well as substance abuse benefits, the continuing stigma attached to mental and addictive disorders, and the fear of adverse consequences from seeking treatment, still discourages some of our employees from accessing available care. To address this issue, Delta has enhanced and expanded its EAP to focus on programs to help employees know when they might benefit from accessing treatment for themselves or their families, and to make sure that employees know how to access their benefits. Education about the impact of emotional and mental health issues on wellbeing is essential. For example, there are far too many individuals who did not understand that clinical depression is more than feeling sad and is in fact a treatable illness. The EAP plays a vital role in providing education for line employees as well as management. In addition, the accessibility of onsite EAP clinicians reinforces the Company's commitment to employees.

We also work toward eliminating stigma while addressing employees concerns about information sharing and confidentiality. Other large employers also place great emphasis on developing comprehensive programs for employee education and communication to encourage access to appropriate care and fight the stigma against seeking treatment.

13 As a result of the strengthening of the EAP, we at Delta have found that employee utilization of their mental health and substance abuse benefits have doubled. Some may view greater utilization as simply a cost increase; we regard it as a sign that we are reaching individuals who have a need for services. Our ability to identify and treat early is clearly associated with cost savings. As with medical care, the earlier the intervention the less impairment the individual experiences and the less expensive the required treatment. However, we recognize that the continuing stigma against seeking such treatment adversely affects the willingness of some individuals too seek care. Our ongoing efforts include consistent education about the importance of health, physical and mental, and the productivity results which can be achieved by healthy employees. This is an issue we all must continue to address on a corporate as well as national level for it is not Delta employees who are wary of mental illness stigma but our nation."

Quality of Care:

While parity laws focus on reducing benefit plan barriers to access to mental health and substance abuse treatment, they do not address quality of care. Similarly, although managed care has been an essential tool to assuring that employers are able to afford to provide for more generous access to mental health and substance abuse treatment, there is still widespread concern that managed behavioral health has not assured sufficient access or quality of care. Appropriate behavioral health care must be timely, it must be tailored to the individual needs of the consumer, and it must offer a continuum of services through access to high quality provider networks.

These expectations require improvements in the care delivery system that will take time and cannot happen over night. Like other large employers, we at Delta are still struggling with the limits on availability and access to performance information that can tell us whether the care we are purchasing in fact is providing quality care for our employees and their families. And we are in a much better position to address this issue than smaller employers.

We want to be sure that we are purchasing health care from a consumer centered, performance-based system, where behavioral health is well integrated into the overall system of care. And we need to be able to quantify the value of our investment in our employees' health and well being. While we look at access measures and utilization of treatment, we recognize that there is still far to go before we can be certain that the care we are purchasing provides quality services to our employees. The EAP is charged with monitoring our delivery of services and implementing recommendations designed to ensure the best possible product for our employees. Their oversight provides the essential focus on quality care vs. cost savings.

C. Conclusion

In summary, Delta is a strong advocate of the goal of expanding employee access to high quality behavioral health services. We believe early, appropriate treatment of mental and addictive disorders is essential to productivity in the workplace, is costeffective, and is vital to our employees and their families. However, we are not confident that the complicated factors involved in providing and managing high quality employer-sponsored behavioral health care are amenable to solution through legislative mandates.

FOOTNOTES:

1 Sturm and J. McCulloch, (1998) "Mental Health and Substance Abuse Benefits in Carve-out Plans and the Mental Health Parity Act of 1996," Journal of Health Care Finance 24(3), 82-92.

2 U.S. Dept. of Health and Human Services (1999), Mental Health: A Report of the Surgeon General, 411428.

3 D. Salkever (1998), Predictors and descriptors of psychiatric duration, cost and outcomes study, UNUM Life Insurance Company, Portland, Maine; M. Olfson, et al, 'Mental Health/Medical Care Cost Offsets: Opportunities for Managed Care," Health Affairs 18(2): 82-86; M. J. England, "Perspectives: Capturing Mental Health Cost Offsets." Hearth Affairs 18(2), 91-93.

4 Report of the Surgeon General, 46.

5 U.S. Dept. of Health and Human Services, National Institute of Mental Health (1998) Parity in Financing Mental Health Services: Managed Care Effects on Cost, Quality and Access: An Interim Report to the Congress by the National Abuse Benefits," U.S. Dept. of Health and Human Services, Substance Abuse and Mental He Advisory Mental Health Council; also, M. Sing, et ai, (1998) The Costs and Effects of Parity for Mental Health and Substance Abuse, Mental Health and Substance Abuse Administration (1998)

6 K. Apgar, (2000) Large Employer Experiences and Best Practices in Design, Administration, and Evaluation of Mental Health and Substance Abuse Benefits - A Look at Parity in Employer-Sponsored Health Benefit Programs, Washington Business Group on Health. 7 The Report of the Surgeon General cites estimates that approximately 20% of the population experiences mental illness during any given year. Report of the Surgeon General (1999) 46.

8 A.D. Lopez, in C. J. L Murray (ed.) (1996) The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries and Risk Factors in 1990 and Projected. Harvard School of Public Health: Cambridge, MA.

9 England (1999).

10 World Health Organization, (1999) "The Double Burden: Emerging Epidemics and Persistent Problems, The World Health Report, Ch. 2, 16.

11 A. R. Mcllvaine, "Fighten' the Blues," Human Resource Executive, May 2000 Special Issue, 46.

12 Kaiser Family Foundation and Health Research and Education Trust (1999) Employer Health Benefits, 1999 Annual Survey, 94-96.

13 Apgar (2000)

14 The Report of the Surgeon General, 8-9.

END

LOAD-DATE: May 20, 2000

Document 19 of 103.


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