Economic Grand Rounds: The Business Case for High-Quality Mental Health Care

For more than 20 years, APA, in collaboration with allied professional and advocacy organizations, has fought a steady battle for parity of health insurance benefits for psychiatric and substance abuse treatment while asserting the critical importance of access to high-quality mental health care. We consider parity to be coverage for psychiatric and substance use disorders that is equal to that for all other medical conditions.

We can take pride in the many gains that have been achieved. Medicare's discriminatory visit limit on federal reimbursement for outpatient treatment has been eliminated. Thirty-four states have passed parity legislation for health insurance coverage of mental disorders, although the laws vary in scope and eligibility requirements. The federal Office of Personnel Management has enacted parity by executive order. APA is studying the effectiveness of the implementation of parity, especially because of concerns about the role of managed care. Congress is seriously considering the passage of a new and potentially sweeping federal parity law that will not be limited to annual and lifetime dollars—the inclusion of hospital days, outpatient visits, co-payments, and deductibles remains our goal. But much more must be accomplished.

Stigma and misunderstanding about psychiatric patients and the care they require continue. The effectiveness of psychiatric treatments is not broadly recognized. Unfortunately, gains in insurance coverage for substance use disorders lag behind those for mental disorders. The management practices to which mental disorders are especially subject—for example, prior authorization, concurrent review, and utilization review—are a notorious deterrent to patients' receiving necessary and effective care. Even full parity will not ensure access to high-quality care, because parity does not encompass standards of care and does not offer quality assurances of access and optimal clinical practices. Why are we still so far from our goals?

Mental disorders, including substance use disorders, have a long history of stigmatization. The past decade has seen unprecedented levels of public education and information about mental illness and its treatments. But shame and denial of illness too often limit action. People who suffer from these disorders frequently fear stigmatization in their community and in the workplace. Moreover, American corporate leaders, often represented by their insurance vendors, chambers of commerce, purchasing groups, and government lobbyists, have long voiced concern about the cost of health care in general and have had a special concern about the cost of mental health care. The business community has not clearly and systematically been presented with information about the clinical and economic value of effective mental health care for their employees. Sometimes influential members of the business community may hear only about the most sensational and costly of cases, which may incline corporate leaders to dismiss persons with mental health problems rather than to urge that they receive good care.

To secure parity of benefits and access to quality mental health services, APA, in conjunction with other professional and advocacy organizations, must take its case beyond Capitol Hill and state legislatures. We must reach out to and persuade corporate decision makers that high-quality mental health care provides valuable human and economic returns. In concert with an informed and activated business community, we have a far greater chance of attaining our goals.

Psychiatric disorders affect nearly 30 percent of the U.S. population each year (1). The most common disorders are depression, anxiety disorders, substance use disorders—especially alcohol abuse and dependence—and bipolar disorder. The International Labour Office ranks depression as the third most important workplace problem in the United States, followed by family crises and stress (2). It has been estimated that 75 percent of persons with depression do not receive a diagnosis; of these, 72 percent are in the workforce (3). In fact, one major U.S. company found that almost 9 percent of its male employees and 17 percent of its female employees suffered from major depression and that 3 percent of men and 2 percent of women had an alcohol use disorder (4).

Remarkably, only a fraction of those afflicted seek care. Depression is highly underdetected and undertreated in a variety of clinical and workplace settings (5). In another study, only 10 percent of men and 15 percent of women who met the criteria for major depression and who reported social or occupational impairment took medication for their depression (6). Furthermore, only 26 percent of the men and 36 percent of the women consulted a mental health professional, a physician, or an employee assistance program.

Mental illness in the workplace typically manifests as a performance issue. Absenteeism increases, productivity is compromised, and employee turnover becomes greater. The number of short- and long-term disability claims increases, along with their attendant personal and corporate emotional and financial costs (7).

More workers are absent from work because of anxiety and stress than because of physical illness or injury. Employees with depressive, anxiety, and alcohol use disorders have lower productivity, more absenteeism, and more disability days than those who do not have these disorders. The Global Burden of Disease report from the Harvard School of Public Health places mental disorders third, after respiratory diseases and cancers (8). The cost of psychiatric disability claims is estimated at $150 billion a year; about half of long-term disability claims from all causes involve a contributing mental health disorder. The number of disability days for depression exceeds that for diabetes, hypertension, heart disease, and back problems combined. The greatest predictor of an employee's failure to return to work from short-term disability leave for any medical reason is the presence of moderate or severe major depression.

The cost to U.S. corporations of stress, anxiety, and depression is estimated at $8,000 per person per year (9). Employers report $24 billion a year in costs of absenteeism and reduced productivity from depression in the workforce; the cost of substance use disorders is estimated at $100 billion. The overall health care bills of employees who report depression are 70 percent higher than those of employees who do not.

Finally, we have ample evidence that mental health treatment is effective (1). More than 80 percent of persons with depression improve with appropriate care; 70 to 90 percent of those with panic disorder can improve with professional care; treatment for alcohol and illicit drug use disorders is more effective than treatment for nicotine dependence—50 to 60 percent compared with 30 percent —and comparable to rates of improvement for hypertension, diabetes, and asthma (10). Moreover, treatment for depression improves self-reported workplace performance and quality of life (11). Employees who receive antidepressant treatment have fewer disability days (12). Efforts to improve care are cost-effective (13). The evidence is there. The treatment is there. But too few persons receive needed and effective care.

This fundamental question was the focus of an APA board of trustees retreat led by APA past-president Daniel B. Borenstein, M.D., in June 2000, which sought to further the work of Rodrigo A. Munoz, M.D., during his presidency. To answer the question of what can be done and to devise improvement strategies, APA then launched its business and industry initiative. The aim of this initiative is to make the business case for mental health care. A committee chaired by Norman A. Clemens, M.D., and comprising selected APA members, including other members of the board of trustees, was constituted last year. The APA Office of Healthcare Systems and Financing staffs the committee.

APA must make every effort to bring the facts to business leaders. Only by presenting persuasive evidence, rendered through ongoing working relationships and alliances, can we correct a legacy of erroneous cost concerns, denial, and stigma.

Corporate America purchases 50 percent of the health care in this country—more than government, which purchases around 40 percent. The APA business initiative has sought to reach corporate decision makers and demonstrate that mental health care is a good investment. Many corporations use managed care companies to administer their mental health benefits and services. By going directly to corporate leaders we are, in effect, going upstream from managed care to the employers who purchase health care and can ultimately control what care is available for employees and their dependents.

The APA approach to business leaders is a traditional business case. Corporate chief executives and their senior management want to know what they are getting for their money. In isolation, the social benefit that medical care provides is not enough to convince them that medical care in general and psychiatric care in particular warrant allocation of more resources than business leaders currently think they should provide. We have to demonstrate, with data, what care is provided and the results of that care. Most important, the results that business leaders are interested in are only indirectly related to clinical improvement. Business leaders want to know what good their business will derive from the investment they are making in mental health care.

Psychiatrists and other clinicians can appreciate the vital role that work serves in the homeostasis of human psychology. We know, as illustrated above, that people in the workplace who have a mental illness are not being adequately served. The APA business initiative contends that providing high-quality care to employees will yield a medical good, a social good, and an economic good. But we have to prove it.

The committee on business relations and APA staff began this initiative by meeting with senior corporate officials from a large number of Fortune 500 companies. We wanted to hear what they had to say and to fashion our plans collaboratively. The road to parity for the care of persons with mental and substance use disorders is best walked in alliance with the major purchasers of health care.

In the spring of 2001 we were invited to the Employee Assistance Roundtable, a group of about 80 directors of employee assistance programs from major corporations around the country. We heard about their problems in gaining access to high-quality psychiatric care, and together we began to develop plans. Managed care services were highly problematic to them, which presented APA with a remarkable opportunity to work with corporate leaders to improve on the shortcomings of managed care. In June 2001 APA cohosted with the Carter Center in Atlanta a highly successful invitational conference, "The Business Case for Mental Health Care." About 100 corporate and government leaders, researchers, benefit consultants, and APA leaders attended. We were much honored to have former First Lady Rosalynn Carter present and involved throughout the conference. After the conference Mrs. Carter asked APA to cohost her annual conference on mental health in November 2002. Other initiatives are also under way; as a result of the meeting, participants want to join us in making the business case for mental health.

We are planning projects with specific exemplar corporations in which high-quality psychiatric care will be provided. These projects will be consistent with APA practice guidelines and quality indicators, and employees will have adequate access to psychiatrists for appropriate and integrated care—that is, care that combines pharmacotherapy with psychotherapy. We have established a working group of corporate health leaders to devise a model of key measures of functioning, coupled with human stories of pathos, prejudice, and hope that will be compelling to corporate chiefs and their financial advisers. We are pursuing research opportunities and seeking funding from foundations, government, and industry that will focus on productivity and health. We are examining how APA's district branches can assist local businesses in achieving access to psychiatric care for their employees. More ideas are under consideration, but only selected projects can be undertaken at this time because of limited resources. As critical as this initiative is to APA, it competes with many other important projects. For that reason, and because of the complexity and resources needed over many years, we are pursuing funding from multiple sources outside the APA budget to support this initiative.

The mental health of American employees and the nation's productivity are inextricably bound. The provision of high-quality mental health care, including substance abuse services, to employees and their dependents is instrumental to employee functioning. Demonstrating the medical and social benefits of psychiatric care is a compelling argument, but it is not sufficient. We must also show that a dollar spent on mental health care returns more than that dollar to the purchaser of care—the employer. Here is where we will need to substantiate our case with business metrics of absenteeism, productivity, turnover, disability, medical cost offset, and the like. When we can consistently show that high-quality mental health care results in clinical improvement, enhanced social and occupational functioning, and increased corporate profits, we will have the power to persuade those who have so much control over the services that our patients need. Only then will full parity and access to high-quality care become possible.

Dr. Sederer is director of the division of clinical services of the American Psychiatric Association, 1400 K Street, N.W., Washington, D.C., 20005 (e-mail, [email protected]). He is also associate clinical professor of psychiatry at Harvard Medical School in Cambridge, Massachusetts. Dr. Clemens is clinical professor of psychiatry at Case Western Reserve Medical School in Cleveland, Ohio. Steven S. Sharfstein, M.D., is editor of this column.