MHW 3&4 Qtr 2009

PUBLISHED BY THE AMERICAN PSYCHIATRIC ASSOCIATION AND THE AMERICAN PSYCHIATRIC FOUNDATION

Straight Answers toEmployer Questions About Mental Health Parity page 3

Employers Talk About Their Successes withMental Health Parity page 7

Everybody Wins WhenEmployers Help Employees Who Are in Personal Financial Distress page11

FIRST & SECOND QUARTERS 2009

Dear Reader,

The passage of the Paul Wellstone and Pete Domenici Mental Health Parity andAddiction Equity Act was the result of years of collaboration and careful nego-tiation among employers, insurers, health plans, mental health advocates, andprofessional organizations. It does not escape the Partnership for WorkplaceMental Health and the American Psychiatric Association that the majority ofemployers now face the challenge of redesigning their mental health benefitsto comply with the law. We hope you find this issue of Mental HealthWorkshelpful as you make your plans to do so.

In our conversations with employers, we try to emphasize the following threepoints.

Parity is affordable. Mental health treatment is an incredibly good bargain,especially when compared to treatment for other chronic illnesses. It yields a rel-atively quick return on investment and significant productivity gains. Weencourage you to think of mental health in the context of value-based benefitdesign (see research by Pitney Bowes on page 5) and/or benefit and servicesintegration (see approach by IBM on page 6).

Treatment works. Studies show that treatment for mental illness is effective.Unfortunately, two-thirds of people with a mental illness receive no treatment atall, and these individuals contribute disproportionately to productivity losses.Treatment remains the single, best solution.

You’re not alone. Starting on page 7, you will find stories about employers whohave already implemented parity and have found little or no increase in costs.Parity can work.

Irvin L. (Sam) Muszynski, J.D.

Editor

Clare I. MillerEditor

w w w . w o r k p l a c e m e n t a l h e a l t h . o r g

2 Mental HealthWorksFIRST & SECOND QUARTERS 2009

Mental HealthWorks

Mental HealthWorks is publishedquarterly by the Office of HealthcareSystems and Financing of the AmericanPsychiatric Association and theAmerican Psychiatric Foundation.

Mental HealthWorks is distributed freeof charge to APA members and the busi-ness community and is available onlineat: www.workplacementalhealth.org.

Business communications and addresschanges should be directed to MHW,Healthcare Systems & Financing,American Psychiatric Association,1000 Wilson Boulevard, Suite 1825,Arlington, VA 22209-3901.

Phone: 703-907-8561E-mail: [email protected]

Unless so stated, material containedherein does not reflect the endorsementor position of the American PsychiatricAssociation, the American PsychiatricFoundation, or the Partnership forWorkplace Mental Health.

Editorial Advisory GroupAlan A. Axelson, M.D.Pittsburgh, PA

Marcia K. Goin, M.D., Ph.D.Los Angeles, CA

Stephen H. Heidel, M.D., M.B.A.La Jolla, CA

Andrea G. Stolar, M.D.Houston, TX

EditorsIrvin L. (Sam) Muszynski, J.D.Director, APA Office of HealthcareSystems & Financing

Clare I. MillerDirector, Partnership for WorkplaceMental Health

Managing EditorMary Claire LeftwichProgram Manager, Partnership forWorkplace Mental Health

ConsultantSandra Hass Yamhure

Copyright by the American PsychiatricAssociation ©2009

3Mental HealthWorksFIRST & SECOND QUARTERS 2009

The American PsychiatricAssociation sent letters toPresident Obama and theSecretaries of Labor,Health and HumanServices, and Treasuryurging them to expediteguidance on the paritylaw.

See page 7 in this newslet-ter to read about employ-ers who have already suc-cessfully established mentalhealth parity in theirorganizations.

The full text of the PaulWellstone and PeteDomenici Mental HealthParity and Addiction EquityAct of 2008 can beaccessed athttp://tinyurl.com/qpqw78See pages 310-344.

Straight Answers toEmployer Questions About Mental Health Parity

On October 3, 2008, the Paul Wellstone and PeteDomenici Mental Health Parity and AddictionEquity Act was signed into law. This new mentalhealth parity law does not mandate coverage ofmental health and/or substance use disorders. Itsimply says that when mental health and/or sub-stance use disorders benefits are offered, they mustbe offered on par with medical/surgical benefits.

Parity Basics. The new law applies to grouphealth plans with 50 or more employees that pro-vide both medical and surgical benefits and men-tal health and/or substance use benefits. Theseplans must ensure that financial requirements andtreatment limitations applicable to mentalhealth/substance use disorders benefits are nomore restrictive than those requirements and lim-itations placed on medical/surgical benefits. Thismeans that deductibles, copayments, coinsurance,out-of-pocket expenses, frequency of treatment,number of visits, days of inpatient coverage andother cost-sharing mechanisms must be no morerestrictive for mental health and/or substance usedisorders benefits (assuming they are offered)than they are for medical/surgical benefits.

Essentially, the new law picks up where the 1996law on mental health parity left off. Plus, the newlaw includes substance use disorders.

The parity bill that passed received broad supportfrom the business and insurance community,including the U.S. Chamber of Commerce,National Retail Federation, American BenefitsCouncil, and America’s Health Insurance Plans.The Chamber issued this statement inwww.uschamber.com upon the bill’s passage:“The U.S. Chamber of Commerce supports thiscarefully crafted mental health parity provisionbecause it is a balanced and reasoned approachfor addressing mental health insurance coverage.”

Effective Date. For most employers, the lawtakes effect January 1, 2010. (That date may bedifferent for collectively bargained health plans,

depending on when their current agreementsexpire.) The law directs the U.S. Secretaries ofLabor, Health and Human Services, and Treasuryto publish “guidance and information” on the Actby October 3, 2009. However, if the federal gov-ernment fails to meet its deadline, employersmust still be in compliance with their deadline.

There are several other important provisions inthe 2008 parity law.

• If a group health plan experiences an increase inactual total costs with respect to medical/surgical andmental health/substance use benefits of 1% (2% inthe first plan year that the law is applicable), the plancan be exempted from the law. Plans may only optout for one year, and may be under audit by theDepartment of Health and Human Services, theDepartment of Labor, and actuarial analysis to assuretransparency.

• The parity law is extremely protective of statelaw. Only a state law that "prevents the applica-tion" of the law will be preempted, which meansthat stronger state parity and other consumer pro-tection laws remain in place.

Corporate Reaction. Some companies see thenew legislation as an opportunity to take a secondlook at their entire healthcare package. HyongUn, M.D., National Medical Director forBehavioral Health at Aetna, said, “We believethat employers will benefit from an evaluation oftheir total healthcare package to optimize theintegration of mental health on a parity basis. Weknow that improved access to quality mentalhealth treatment leads to better health outcomesand that better outcomes are linked to increasedproductivity. These all contribute positively to thebottom line.”

Below is a summary of frequently asked ques-tions about the law and key points from conversa-tions with employers.

Q. These are tough times for us. We’ve had lay-offs. Isn’t this the wrong time to be talking aboutrevising our approach to mental health?

A. No. It’s precisely the right time. To preservea company’s ability to adapt to challenges, NancySpangler, a prevention and health management




Twenty percent ofAmericans experience amental health disorder inany given year, but onlyone-third of those seekcare. –Mental Health: AReport of the Surgeon General,US Dept. of Health and HumanServices.

The Partnership onWorkplace Mental Healthrecently surveyed employ-ers about what impact thenew parity law will haveon their benefit offerings.Most employers (74%)said they would not droptheir mental health cover-age, and 77% said theyhave no plans to discon-tinue their substance usedisorders coverage. As aresult of the new law,38% plan to increase pro-motion and use of EAPservices. To learn more,go to www.workplace-mentalhealth.org.


consultant, reminds employers that the mentalhealth of their workforce is vital to the company’shealth. “During difficult economic times, espe-cially when there are large reductions in theworkforce, is not the time to abandon the mentalhealth of your workforce,” Spangler said.“Instead, it’s precisely the time to revise benefitsto get optimal value from preventive care and toprovide quality behavioral treatment.”

For example, J. Brent Pawlecki, M.D., CorporateMedical Director at Pitney Bowes, pointed to hiscompany’s decision this year to make a financialadvisor available to all employees. Paul Heck,Manager, Global EAP at DuPont, emphasizedfocusing on resilience-based training. Heexplained, “We know that employees who have amental illness can have a negative impact onbusiness. Conversely, we know that businessannouncements bearing bad news can have a neg-ative impact on employees. To break this cycleand optimize the well-being and performance ofour employees, we must be proactive in trainingmanagers to recognize the symptoms of mentalillness.” Neither of these two approaches is par-ticularly costly to implement, but the payoff canbe substantial.

Q. Couldn’t we just drop our mentalhealth/substance abuse coverage altogether andcome out ahead?

A. You can, but you’ll end up paying for it any-way … and then some. Mark Attridge, Ph.D., aresearcher and consultant with expertise indesigning outcome studies for workplace healthservices, told Mental HealthWorks that employershave a choice. “Employers can pay for mental ill-ness/substance use disorders up front,” he said,“where they have some control over the processand can intervene before the problems get worseor they can pay for them down the line inincreased medical and disability costs, increasedabsenteeism, and increased presenteeism. Eitherway, they are going to pay.”

Many studies have demonstrated the link betweenpoor quality mental health treatment andincreased medical costs. For example, thePartnership for Workplace Mental Health notesthe following in its publication A Mentally

Healthy Workforce—It’s Good for Business:“Aggressive efforts to contain mental healthcarecosts at one large corporation resulted in a declineof mental health services use and costs by morethan one-third, but triggered a 37% increase inmedical care use and sick leave.”

Last year researchers writing in PsychiatricClinics of America showed that untreated or inef-fectively treated patients who had mentalhealth/substance use disorders were high users ofgeneral medical health services.

Editor’s Note: All sources cited in this article are includ-ed in a reference list posted at the Partnership’s Web site,www.workplacementalhealth.org/mhparity.aspx. Look for“Reference List: Straight Answers to Employer QuestionsAbout Mental Health Parity.”

Conversely, an articlein the J0urnal of theAmerican MedicalAssociation made thelink between appro-priate treatment andincreased produc-tivity. Researchersfound that employ-ees diagnosed with depression who received“enhanced treatment” showed nearly a three-hourimprovement in their work performance eachweek. Job retention also improved significantly.

Q. Will parity cost us more?

A. Not necessarily. The Congressional BudgetOffice estimates that the new parity law willincrease premiums by an average of about two-tenths of one percent. That amounts to penniesper employee per month. When productivity isalso taken into account, the business case is evenstronger. And there are real-life examples fromorganizations that already have a history of suc-cess with parity of mental health and substanceabuse coverage.

For eight years, the Federal Employee HealthBenefits Program has offered mental health pari-ty benefits to 8.5 million federal employees andmembers of Congress without a significantincrease in costs. Researchers reported theirfindings in the New England Journal of Medicine.




Parity cost data also exist from the states—most ofwhich have already enacted some form of parity.

• New Hampshire implemented parity in 1994. Theysurveyed 11 of the state’s insurance carriers andhealth plans and found that none of them attributedany change in premiums due to parity.

• North Carolina instituted parity for state employ-ees in 1992, and mental health payments as a portionof total health payments decreased from 6.4% to3.4% for the fiscal year ending in 1996.

Rhonda Robinson Beale, M.D., Chief MedicalOfficer at OptumHealth Behavioral Solutions (for-merly United Behavioral Health), recently led a ret-rospective analysis of Optum clients who operate instates that have already enacted mental health pari-ty laws. She reports that during the first year someemployers experienced increases in the use of serv-ices and cost, but by the second year costs began toreturn to normal.

Q. Can we still manage care?

A. Yes. The law’s intent is for health plans toretain their ability to manage benefits. Healthplans are permitted to continue use of medicalnecessity criteria, utilization management, andother care management techniques.

A word of caution when implementing managedcare tools: Researchers writing in the MedicalClinics of North America called attention to theexperience of one company that reduced behav-ioral healthcare benefits, which simply shiftedcosts from mental health to physical/surgery med-icine. At the same time, the company experienceda 22% increase in absenteeism among users ofbehavioral health services. The conclusion wasinescapable: The company ended up paying morefor an inferior product that also increased its dis-ability costs.

Q. Can managed mental health plans providequality health services?

A. Yes, by offering value-based benefits thatfocus on positive outcomes as well as cost. PitneyBowes recently studied the effects of value-basedbenefit design on improving medication compli-ance. John J. Mahoney, M.D., M.P.H., a consult-ant for Pitney Bowes, wrote in the Journal ofManaged Care Pharmacy that the total-value

“The primary concern hasbeen that the existence ofparity would result in largeincreases in the use ofmental health and sub-stance abuse services andspending on these servic-es. With respect to theseven FEHB [FederalEmployee Health Benefits]plans we studied, thesefears were unfounded.”–Behavioral Health InsuranceParity for Federal Employers, H.H. Goldman, et al., NewEngland Journal of Medicine,March 30, 2006, pp. 1378-1386.

"Enhanced" care in theCIGNA study referred toan intensive outpatientcare management pro-gram.

"Enhanced" treatment inthe JAMA article noted onpage 4 included a tele-phonic outreach and caremanagement program thatencouraged workers toenter outpatient treatment,monitored treatment quali-ty continuity, and attempt-ed to improve treatment bygiving recommendations toclinicians.

approach of using disease management and pro-moting preventive care translated into significantsavings for Pitney. He concluded that employerscannot just cut costs or copayments to achievecompliance; such action must be taken as part ofa concerted program.

The concepts of maximizing the “value” ofemployer-provided healthcare benefits and meas-uring the return on investment (ROI) have gainedconsiderable currency among employers and theirbroker/consultants and vendors. As pioneered byPitney Bowes in the early part of this decade, theconcepts seek to eliminate plan design barriersand incentivize employees to seek the best, high-value, evidence-based care.

A group of Kansas City employers affiliated withthe Mid-America Coalition on Health Care is cur-rently pursuing this approach, and an initialanalysis of their baseline data identified mentalhealth needs as one of the four key health risksamong their workforce.

“Our employers understand the impact depressionhas on the workplace,” says William L. Bruning,president of the Coalition. “The concepts of pre-senteeism and depression’s impact on productivi-ty resonate intuitively with employers. However,employers are distrustful of many of the ROI fig-ures appearing in the business press. What theywant to see demonstrated is a return that is slight-ly better than break-even on their mental healthinvestment. They know that an additional, but dif-ficult to measure, return will be in the areas ofproductivity and absence management.”

Employee Benefit News covered a study byCIGNA Behavioral Health that looked at clientswho had been hospitalized for a psychiatric ill-ness. CIGNA compared those clients dischargedto “usual” outpatient care with those dischargedto “enhanced” outpatient care and found thatthose in the enhanced care group had 53% lessrecidivism while those in the usual care group hadan increase of 11% in readmissions.

Beale, too, advises employers to focus on ways toachieve the greatest possible value by offeringnew or improved behavioral health servicesand/or initiating treatment earlier. As employersmake benefit changes, Beale suggests they ana-lyze cost drivers, review the history of complex


cases, and identify gaps in coverage and net-works. Optum uses informational and coachingmodels effectively to promote earlier treatment.

Researchers who analyzed the Federal EmployeeHealth Benefits Program also looked at the quali-ty of the mental healthcare delivered. Even thoughcare in all seven plans was managed, the quality ofmental health services did not decline. In fact,quality improved slightly in three of the plans.

Q. Does the law require us to cover all psychi-atric diagnoses? If not, couldn’t we save moneyby picking and choosing diagnoses?

A. No and no. The bill that passed does notrequire employers to cover all the diagnoses list-ed in the Diagnostic and Statistical Manual ofMental Disorders (DSM). However, selectingwhich diagnoses to cover from the DSM is notrecommended.

The most important issue here is not the specificdiagnoses, but the severity of symptoms, theimpairment in function, and the specific type oftreatment that is required. “It makes more sense,”according to Irvin I. (Sam) Muszynski, J.D.,Director of the American PsychiatricAssociation’s Office of Healthcare Systems &Financing, “to focus on ‘medical necessity.’ Arethe patient’s symptoms severe enough and thepatient’s functionality impaired enough to war-rant treatment? If the answer is yes, that patientshould be treated.”

Q. We’re concerned about increased costs.Does parity extend to out-of-network coverage?

A. Yes. Parity for out-of-network coverage,however, does not need to increase costs.Researchers writing in Health Affairs said,

“If parity for out-of-network benefits isrequired, estimates from Stephen Melek [atMilliman] and colleagues are that 20% of pro-fessional services nationally would be providedout of network, associated with an aggregate0.6% cost increase if unmanaged and virtuallyno increase if managed. These data combinedwith the data from our study indicate that ensur-ing access to an out-of-network benefit couldbe essential to facilitating access to mental

healthcare, given the large amount of out-of-network use.”

Q. In addition to value-based benefits, arethere other cost-saving measures we can make atthis time?

A. Yes. Integrating benefits and services canlower costs and improve outcomes. Juan Prieto atIBM told Mental HealthWorks in 2004 that IBM’sCare Advocacy Model, which integrated mentalhealth, other medical illnesses, pharmacy, disabil-ity, disease management, as well as its employeeassistance program, saved IBM $500,000 in out-patient costs in one year. Earlier this year Prietotold Mental HealthWorks that IBM will beexpanding the philosophy of its Care AdvocacyModel into an overall healthcare delivery model,focusing on behavior change.

Researchers at Milliman lend support to IBM’smove toward more integration. They wroterecently in a Milliman document, “Those that canachieve and document measurable savingsthrough integrated medical-behavioral care man-agement may gain a market advantage throughlower healthcare costs, lower employer costs, andimproved clinical outcomes.”

Aetna’s Chairman Ronald Williams spoke to thebenefit of integration and parity coalescing andpredicted in Managed Healthcare Executive thatparity is likely to improve health outcomes“through integrated medical and behavioral bene-fits and services.”

Q. So, mental health parity will be awin/win/win for employers, employees, and theentire healthcare system?

A. Yes. Mental health parity will work for thelong haul—it’s sustainable. IBM’s Juan Prietosummed it up best: “Everyone can benefit fromhaving a healthcare system that offers the samelevel of care for mental health and medical care.” u

Sources: The sources cited in this article are included in a completereference list posted at the Partnership’s Web site, www.workplace-mentalhealth.org/mhparity.aspx. Look for “Reference List: StraightAnswers to Employer Questions About Mental Health Parity.”

If you have questions about the parity law, send an e-mail to MaryClaire Leftwich at the Partnership for Workplace Mental Health,[email protected].


The informational modelused by Optum involvesreaching out to memberswith print or Web-basedmaterials about specific men-tal conditions, appropriatetreatment, availableresources, and benefits. Thecompany’s coaching modelincludes regular outboundphone calls and personalsupport for behavior changeand adherence to treatmentplans.

DSM, published by theAmerican PsychiatricAssociation, lists psychiatricdisorders. Each disorder isaccompanied by a set ofdiagnostic criteria thatrequire clinically significantdistress or impairment.Medical and other insurancecompanies use these criteriafor audits and medicalrecords.

The American MedicalAssociation defines “medicalnecessity” as healthcare servic-es or products that a prudentphysician would provide to apatient for the purpose of pre-venting, diagnosing, or treat-ing an illness, injury, diseaseor its symptoms in a mannerthat is 1) in accordance withgenerally accepted standardsof medical practice; 2) clinical-ly appropriate in terms of type,frequency, extent, site, andduration; and 3) not primarilyfor the convenience of thepatient, physician or otherhealthcare provider.


Mental Health Americaand Mental HealthAmerica of GreaterHouston provided a portionof the information includedin the descriptions ofWeingarten RealtyInvestors, the HoustonChronicle, and the HoustonTexans. Additional informa-tion about parity is includ-ed on the Mental HealthAmerica of GreaterHouston Web site,www.mhahouston.org.



When Parity Means“Business as Usual”By Nancy Spangler, M.S., OTR/L

Adapting to changes in mental health parity leg-islation may be a challenge for some employers,but to others, parity is not terribly new. In fact, anumber of U.S. workplaces have been offeringmental health benefits on par with their medicalplans, or very close to it, for many years. Insome cases, their mental health coverage is evenbetter than their medical coverage (i.e., co-pay-ments or cost-sharing are lower for mentalhealth than for medical/surgical treatment).

The Partnership for Workplace Mental Healthtalked with several employers to learn moreabout their experiences with offering strongmental health benefits and the impact that thishas had on their organizations. (Read aboutthese employers and others in the Partnership’sdatabase, Employer Innovations Online atwww.workplacementalhealth.org/search.aspx.)

Weingarten Realty Investors In theHouston area, a number of employers began amove toward parity in 2002 through the leader-ship and encouragement of Stanford Alexander,Chairman of Weingarten Realty Investors.Weingarten is a self-insured Fortune 500 firmwith more than 400 employees in 23 states.Alexander’s family was touched by mental ill-ness, and when he learned that a number of hisemployees who had mental conditions were notseeking the professional help they needed due tolimitations of medical coverage, he was deter-mined to do something about it.

Weingarten’s plan includes coverage for alcoholand substance abuse and for treatment of fami-ly/marital problems. There are no caps on men-tal health treatment, and deductibles are thesame as they are for general medical treatments.Mickey Townsell, Vice President of the compa-ny’s Human Resources, says that Weingartenbudgets about $10,000 per employee per year for

benefits. Mental health represents approximately1.5% of annual benefit costs.

“Every company is obviously looking for waysto reduce costs, but with all the demands wehave to deal with in this day and age, you haveto see what you can do to help employees,” saysTownsell. Assisting the company’s employees,which Weingarten considers its “key assets,”adds value long term. Here is just one exampleof how this program paid off for Weingarten.

An employee, who had been with the companyfor 15 years, was struggling with a mental healthissue and took a leave of absence. Access to pro-fessional care helped this employee work thingsthrough, and he was able to return to work. “Youdon’t want to lose those long-standing employ-ees or their family members if you can helpthem,” Townsell stated. “Getting them the carethey need may help the employee’s overall abil-ity to be at work.”

Weingarten assesses the results in a number ofways. “Yes, you can look at turnover—and ourturnover is about half of the industry standard—that’s a meaningful measure. But peace of mindis immeasurable. Employees being more produc-tive, more thankful to the organization: Thoseare meaningful outcomes that are not easy toquantify.”

Townsell says that Alexander treats employeeslike family. Parity was another step toward giv-ing people the help they need. Alexander valuesand develops good leaders. Senior managershave grown up together, many for 20 years ormore. That gives the leadership team comfortwith each other. “Employees here want to do agood job for these leaders; they have a sense ofpride in this organization,” says Townsell.“People work hard, they know what they need todo—but at the same time family is highly val-ued. If I need to leave early to get to my son’sgame, I know that’s all right.”

Alexander has served on several hospital boardsand will contact the hospital himself to use his



influence on behalf of an employee or familymember if needed. Employees know that theycan count on him to help in many ways. They allcall Weingarten a family-owned, publicly tradedcompany.

Houston Chronicle After WeingartenRealty Investors set the stage for mental healthparity, a number of other Houston employersjoined in, including the Houston Chronicle andthe Houston Texans (featured in MentalHealthWorks, 4th Quarter, 2008).

The Chronicle employees 1,400 people in theHouston area and is led by Jack Sweeney,President and Publisher. Their organization is self-insured. In 2002, the Chronicle implemented men-tal health parity and increased promotion of theirEAP, which provided 24-hour access to mentalhealth support and three in-person visits at no cost.

The Chronicle's total healthcare costs remainedflat, and Sweeney reports they experienced anumber of additional benefits. The parity effortand increased attention on mental health hashelped improve worker performance, enhancedcommunication between managers and employ-ees, and reduced the stigma of accessing treat-ment. “It’s a win-win for the company and theemployees,” he said. “People seek help earlierand get back to health and to work quicker if youshow respect for their issues.”

Just implementing parity is not enough, though.Sweeney suggests leaders need to set examplesand address emotional issues right along withexercise and other physical health issues. Healso encourages employers to think of the workperformance side, not simply direct costs, whenevaluating parity. “Emotional problems drive uphealth costs on the primary care side if you donot deal with them. Companies need to push forhigh quality, well coordinated care, and get theirvendors to work together to address costs andcost drivers,” says Sweeney.

Houston Texans To implement mentalhealth parity, the Texans sought an insurance

carrier to work with them hand-in-hand design-ing a plan with co-pays and deductibles equalacross behavioral and medical/surgical areas. Totheir surprise, carriers predicted their healthcarecosts would increase 20%-25% if they offeredsuch generous coverage in behavioral health.

In 2002, the first year of operations for theTexans, parity was instituted. Cigna agreed toequalize the plans and charged 2% more thanexpected costs without parity with the under-standing that additional charges would be addedat the end of the year based on increased costs.Employees did use the mental health benefits,but total costs did not increase. The base rate andpremiums stayed the same.

JPMorgan Chase With headquarters inNew York and Chicago, the JPMorgan Chasebenefits crew is evaluating adjustments neededfor parity for their many different medical andbehavioral health plans across the country. Thebehavioral health plans covering their 140,000U.S.-based employees are strong, and althoughmost plans already meet parity requirements, allmust be reviewed to ensure agreement with themeasure. The complexity of plan designs makesthe revision challenging for large employerswith many locations.

Daniel J. Conti, Ph.D., Managing Director ofEAP & Work-Life for JPMorgan Chase, says,"Really, the message of parity is old news tous—we’ve known for a long time that goodmental health coverage is critical to businesses.What employers should know is that psychiatricillness has a profound impact on work. This isnot speculation. There is strong research show-ing that psychiatric illnesses drive more disabil-ity and longer periods of disability ... so it wouldonly make sense that a corporate-sponsoredhealth plan would pay close attention to mentalhealth."

Pitney Bowes J. Brent Pawlecki, M.D.,Corporate Medical Director of Pitney Bowes,told Mental HealthWorks that Pitney Bowes has


certified alcohol/substance abuse counseling toinpatient care. EAP is not just a benefit but alsoa hands-on manager of quality of care. With anemphasis on improving quality of care, not justcost, DuPont developed a grid to guide EAPreferrals to the right level of care, matching needto level of intervention.

In the 1990s when others were seeing 9%-12%increases in overall healthcare costs, DuPont’sincreases were 0%-3%. Recidivism from treat-ment was also lower than other employers.“We’re still offering a robust EAP/behavioralhealth program because we’ve been able tojustify that better management and qualityof mental healthcare reduces total costs,”Heck said. “This is very important to self-insured companies.”

Integrating behavioral health also extendsto disability management. DuPont’s EAPcoordinates psychiatric disability manage-ment, and the EAP is often involved as a consult-ant to the employee and the manager as workersgo out on leave and as they return. “Our wholephilosophy is that if a person is too sick to work,it is a personal crisis. Our model is based onmanaging disability, getting people back towork, and helping them return to better health.People self-actualize through positive workexperiences.”

Heck made the following recommendations. Asemployers implement mental health parity, theyshould think beyond simply improving mentalhealth coverage—the effort has to be value-driv-en. Workplaces need to reduce financial barriersand stigma. People with mental health condi-tions that are unaddressed will often act out inthe workplace in ways that employers don’t con-sider, e.g., by excessive emotionality and con-frontation that leads to work team disruptions,presenteeism, lawsuits, loss of intellectual prop-erty, increased turnover rates, etc.

State of Ohio The State of Ohio has had ajoint labor management group for many yearswith equal representation from bargaining units,



had parity for many years, and “we don’t expectto have to make many changes” to comply withthe new law. He noted that Pitney Bowes hasworked hard over the years to create a “cultureof health,” which is tied to mental health. “Wedon’t separate mental health from physicalhealth,” he said.

Pawlecki emphasized that while some compa-nies may look at each of their programs as a wayto contain costs, Pitney Bowes tends to look atthe entire culture of health and see quality healthbenefits as an investment in their employees.

The cornerstone of Pitney Bowes’ approach tohealthcare is the integration of value-based ben-efits and services. Even with good health bene-fits, though, Pitney Bowes’ annual costs are ris-ing at a substantially lower rate than the othercompanies it benchmarks against. “We believethese results are testimony to the return-on-investment of our integrated approach to healthand wellness,” Pawlecki said.

To keep tabs on employee morale, Pitney Bowesuses an employee engagement measuring tool,which asks questions about how engagedemployees are, how effective the leadership is,which benefits they value, and so on.

The leadership at Pitney Bowes believes thatinvestment in the health of its employees hasproven important for the overall success of thecorporation, providing value for both itsemployees and shareholders.

DuPont Paul Heck, EAP Director, shares thatDuPont has had mental health parity since 1991.“In the U.S., DuPont pays 90% for any mentalhealth treatment, up to $1.5 million per year,with no deductible as long as care is accessedthrough the EAP. This is better coverage thanour medical/surgical plans, though the differ-ence would depend upon which plan is chosenby the employee.”

EAP referrals are required for all in-networktreatment, from intensive outpatient therapy to


costs only increased from $7.1 million in 1995 to$10.6 million in 1996. This is still less than whatthe state paid for 23,000 lives in 1989. Next year,the state will be moving to a self-insured plan.

Polk County, Florida Before 2008, PolkCounty’s carve-out plan for mental health andsubstance abuse treatment limited the number ofhospital days or outpatient visits allowed. As theCounty analyzed chronic conditions among itsemployees and their dependents, they discoveredthat mental health problems were affecting peo-ple’s ability to improve physically, and workabilities were declining. The County beganimplementing disease management programs,primarily for diabetes and hypertension, in 2005.They found tremendous value in the case man-agement approach and in treating the whole per-son, not just a part of the problem. In addition,they determined that most mental health treat-ment is now being delivered in outpatient for-mats, and they felt their risk was low in movingto full parity for mental health coverage.

Risk Management Director Mike Kushner saidthat in January 2008 the County began workingwith Aetna for its EAP and behavioral healthtreatment. Aetna also became the third-partyadministrator for the County’s self-funded gen-eral medical/surgical plan. There is now no dis-tinction between mental health and medical vis-its. Although there are some elements of utiliza-tion management, such as focusing on outpatientcare, there are no limits on hospital days or thenumber of psychological or psychiatric outpa-tient visits. The plan does cover treatment in res-idential facilities for drug addiction and with-drawal, but the incidence of these cases has beengreatly reduced.

The County’s disease management approachremoves several barriers to treating chronic con-ditions. For people with diabetes, for example,easier access to pharmacy services is providedby a clinical pharmacist onsite in their healthclinic. To reduce financial barriers, all co-paysfor treatment are waived, as long as participantsroutinely complete their hemoglobin A1C


management, and union employees. The uniondrove the effort to equalize mental health andsubstance abuse benefits with their medicalplans. In 1990, a behavioral health carve-out planwas initiated in one of the state’s 17 health plans.Ohio was among the first states, and perhaps the

very first, to include parity of substance abuse.

In 1990, behavioral health care expendituresfor the 23,000 covered lives included in thisplan dropped from $11 million in 1989 to$7 million.

Benefit manager Gary Hall was hired in1990 to manage the transition to the newbehavioral health vendor. At the time ofhis hire, Hall was working as a psychi-

atric nurse. He was able to use his clinicaland health system skills when talking withemployees who were concerned about having toswitch from a current clinician to a clinicianwithin the behavioral health network. To smooththe transition and to ensure proper coverage asthe regional networks were developed, the ven-dor worked with employees on a case-by-casebasis. In some cases, the vendor allowedemployees 12 additional visits with their currentclinician, and patients were allowed the right tonominate their clinicians for inclusion in thevendor’s network, upon review of credentials.Hall also has a business degree and a back-ground in human resources.

Hall says that before parity, coverage in somecases was too restrictive, but in other cases wasoverly generous and without accountability.Through the new plan, the state finally had somekind of handle on what their dollars were cover-ing. Anecdotally, Hall feels the quality of behav-ioral healthcare improved as well through theconcerted effort and attention. He says “Mentalhealth parity is still saving us money.”

In 1995, all mental health and substance abusecoverage came under one behavioral health planmanaged by the vendor now operating asOptumHealth Behavioral Solutions. Coverageincreased from 23,000 lives to 134,000 lives, yet


Upcoming issues of ResearchWorks will cover employeeengagement and the newfederal parity law. Issues willbe available for freedownload atwww.workplacemental-health.org.



checks, eye examinations, and foot checks. Allmedications are covered at a 100% level, includ-ing those for common co-morbidities, such asdepression, bipolar disorder, and hypertension.

Screening for depression is included in both thediabetes and hypertension management pro-grams. Participants are referred to mental healthprofessionals for psychotherapy as needed.Aetna has a “gap-in-care” approach that allowsthem to determine through claims analysis whenadherence with treatment has dropped. Lettersare then sent to the individual and to his or herphysician to alert physicians to potential prob-lems in discontinuing treatment.

In terms of costs, the County had expected to seemental healthcare utilization rise in the first yearafter parity, and it did increase slightly. Totalhealthcare costs, however, have not increased.

Common Themes. Several themes recuramong the examples of employers who are lead-ers in the move toward parity in mental healthbenefits.

• Equalizing benefits is a good fit with the company’sworkplace culture and/or company leadership values.Leaders visibly support mental healthcare.

• Features of enhanced health management are fre-quently implemented concurrently with parity. Theseinclude cost control (case management), qualityimprovement (integrated benefits, coordinated care),and/or enhanced consumer involvement (early identi-fication, enhanced communication with employeesand family members about benefits, and enhancedsupport for mental health conditions).

• Those who have offered strong mental health bene-fits tend to provide them in the context of a range ofproactive health and wellness programs or otheremployee-centered programs, such as work/life bal-ance initiatives or safety programs.

• Employers assess a wide variety of outcome meas-ures, including total healthcare costs, employeeengagement and satisfaction, attendance, and workperformance. u

Ms. Spangler, president of Spangler Associates, Inc. and consultant tothe Partnership for Workplace Mental Health, is a prevention andhealth management specialist in Kansas City.

Everybody Wins WhenEmployers Help EmployeesIn Financial Distress

The current financial crisis is taking a toll on peo-ple’s mental health, not just their pocketbooks,according to Research Works, a new series ofissue briefs published by the Partnership forWorkplace Mental Health. “Our goal with thisnew series of issue briefs,” says the Partnership’sDirector Clare I. Miller, “is to translate researchinto action for employers. Each issue will includea review of the literature, action steps, andemployer case examples.”

The first issue brief, “Employee PersonalFinancial Distress and How Employers Can Help”covers research about the impact financial educa-tion and counseling can have on improvingemployee health, work performance, and atten-dance. It recommends steps for employers to taketo alleviate employee distress about finances. Forinstance, employers can offer employees personalfinancial education and ensure access to mentalhealth counseling. The brief also includes caseexamples from companies such as IBM, PepsiBottling Group, The Home Depot, and USAA.

“Today’s troubling economy makes a focus onmental health all the more important,” said AlanA. Axelson, M.D., Co-Chair of the Partnership’sAdvisory Council and Medical Director ofInterCare Psychiatric Services in Pittsburgh, PA.“Job retention concerns often translate to peoplenot taking care of their health, especially theirmental health.”

William L. Bruning, J.D., M.B.A., Co-Chair ofthe Partnership’s Advisory Council and Presidentand CEO of the Mid-America Coalition onHealth Care in Kansas City, Missouri, notes, “Asthe economy worsens and employers streamlinetheir workforces, it is critical to maximizeemployee productivity. We hope employers takeadvantage of this exciting new resource.” u

Research Works is distributed online and posted on the Partnership’sWeb site at www.workplacementalhealth.org. To be included on thedistribution list, e-mail [email protected]. Include “mailing list”in the subject line and contact information in the body of the e-mail.

Conference Focuseson Productivity Amid Economic Decline

The Disability Management EmployerCoalition’s 14th Annual InternationalDisability and Absence ManagementConference, "Expanding Our Horizons:Cost Savings through Collaboration &Innovation in Workforce Management,"takes place July 19-22, 2009, at theDoubletree Hotel-Lloyd Center inPortland, Oregon.

This year's conference focuses on inno-vative, cost-saving disability andabsence management strategies for anew economy. The conference includes44 sessions covering a broad range oftopics, e.g., managing workforce pro-ductivity during economic decline,meeting the new FMLA and ADAAAchallenges, and understanding Hispanicclaimants in the disability world. Morethan 70 companies will share their sto-ries, including Harley-Davidson,Boeing, Puget Sound Energy, andOwens Corning.

To view the complete program, visitwww.dmec.org. Published conferenceregistration fees start at $599.Members of the American PsychiatricAssociation are eligible to receive a$100 discount; simply register onlineat www.dmec.org and use promotionalcode APA2008.

For more information about the DMEC AnnualConference, go to [email protected] or call 800-789-3632.

American Psychiatric Association1000 Wilson Boulevard, Suite 1825Arlington, VA 22209-3901Phone: 703-907-8561E-mail: [email protected]



Free tools and resources available

www.workplacementalhealth.org or call 703-907-8561

• Academy of Organizational and Occupational Psychiatry

• American Psychiatric Association

• AstraZeneca Pharmaceuticals LP

• Caterpillar

• The Center for Health Value Innovation

• Center for Mental Health Services

• Centers for Disease Control and Prevention

• Cisco

• Coca-Cola Company

• Constellation Energy Group

• Cyberonics

• Delta Air Lines

• Depression and Bipolar Support Alliance• Disability Management Employer

Coalition (DMEC)• Dow Chemical • DuPont• Employee Assistance Professionals

Association• Families for Depression Awareness

• FirstEnergy• GlaxoSmithKline• Global Business and Economic Roundtable

on Addiction and Mental Health• Goldman Sachs• Hughes Electronics Corporation• IBP Corp• Johnson & Johnson• JPMorgan Chase• Meritain Health• Merrill Lynch • Mid-America Coalition on Health Care• National Association of Manufacturers• New York Mercantile Exchange• PPG Industries• Screening for Mental Health• Society for Human Resource Management• 3M• UnumProvident Corporation• U.S. Chamber of Commerce

The Partnership for WorkplaceMental Health advances effectiveemployer approaches to mentalhealth by combining the knowledgeand experience of theAmerican Psychiatric Associationand our employer partners.

Partners

MHW 3&4 Qtr 2009

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