Decision-making in EAPs:Purchaser & Client Perspectives Bernie McCann, PhD, CEAP EAPA Annual World Conference Session # 1020-1b-390 Baltimore, MD, USA October 20, 2012
Presentation Materials 1 page summary available in today’s session PowerPoint slide show is available online: www.linkedin.com/in/berniemccannphd or www.eapassn.org/onDemand Both summary & slide show are available by email; please provide business card or email request to firstname.lastname@example.org
Study Rationale EAPs have become an important component of contemporary behavioral healthcare for millions of working Americans and their families (>200 million per Oss, 2011). Although current treatments for substance use disorders and depression are considered highly successful, uptake rates are low. Reasons include ineffective diagnosis, stigma, and suboptimal behavioral health benefit coverage (SAMHSA, 2011). This study sought to better understand how various factors may impact EAPs as a gateway to behavioral health treatment.
Theory Organizational studies provides the overall theoretical basis for the study of work organizations, which can then be investigated by their actions, processes, and by the behavior of their members. Additionally, theoretical frameworks of Institutionalism, Resource Dependency and Organizational Ecology were utilized to provide insights about employers’ and enrollees’ demand for EAP features and services.
Defining Study TermsDemand: In economic terms, a desire to possess goods or servicesEA Purchaser: Parent work organization which contracts for EAPsEnrollees: Workers & dependents eligible for EAP servicesSession allowance: Number of EAP sessions offered to enrolleesWorkplace activities: On site orientations, presentations, trainings, etc.Significant: Statistically ‘accurate’ findings (i.e., p ≥ 0.05)Association: When found between factors, does not prove causation.Alcohol Use Disorders: Alcohol abuse or dependence in past yearMajor Depressive Episode: Episode of major depression in past year
Research Questions1. What factors may influence employers’ demand for various service features in an EAP contract?2. Do these same factors influence employers’ demand for EAP worksite activities?3. Do these same factors influence enrollees’ demand for EAP counseling services?
Research Domains Structural Factors* Organizational type (For profit vs. non-profit) Size of workforce Industry type (by NAICS sector codes) Age of program (Contract length in years) Behavioral Health Conditions** Industry prevalence of alcohol use disorders Industry prevalence of major depressive episodes EA Program Features* Number of EAP sessions available (2-12) Session configuration (Per incident or annual)Service delivery mode (In-person, telephone, or both) *EAP source data; **SAMSHA data
Factors in Demand for EAP Services Structural & Prevalence of Environmental Behavioral Health Factors Conditions Employer EAP Purchasing Decisions Demand for Enrollee Demand Worksite Activities for EAP services
Study Sample - 490 employer purchasers from a major US EAP/managed behavioral health provider in 12 mo. period Agriculture, Forestry, Fishing & Hunting 0.4% Mining 1.8% Utilities 1.0% Construction 1.6% Manufacturing 16.1% Wholesale Trade 2.0% Retail Trade 3.9% Transportation & Warehousing 2.2% Information 6.5% Finance & Insurance 8.0% Real Estate, Rental & Leasing 1.6% Professional, Scientific & Technical Services 12.7% Mgmt of Comp & Entr; Admin & Supp, Waste Mgmt & Remed Svcs 1.6% Educational Services 3.7% Health Care & Social Assistance 9.4% Arts, Entertainment & Recreation 0.6% Accommodations & Food Services 2.7% Other Services 1.8% Public Administration 22.2%
Study Sample – 490 Employers Employer Type Workforce Size 37.1% 64.3% 11%35.7% 23.7% 28.2%Non-profit For profit 1 to 99 100 to 499 500 to 999 1000 +
Study Sample – 490 Employers Session Allowance Age of Contract 19.5% 7.3% 42.4% 20.2% 28.8%2.2% 35.9% 19.5% 25.5% 2-3 sessions 4-5 sessions 1-3 years 4-6 years 6-8 sessions 10-12 sessions 7-9 years 10-15 years 16-29 years
Study Sample – 490 EmployersSession Configuration Service Delivery Type 0.6% 7.8% 8.3% 92.2% 91.1% Telephone only Both optionsAnnual Limit Per-incident/issue In-person only
Predictions: Employer Choices in EAPs Regulatory, social, and environmental pressures such as higher workplace safety risks, higher public accountability, extent of workforce behavioral health disorders will influence employers to provide a more generous EAP benefit. If true, these variables: Employer type, Workforce size, Industry, Length of EAP contract, and Worker prevalence rates of behavioral health conditions by industry will be associated with statistically significant differences in employer choices of EA program features.
Methods: Employer Choices in EAP FeaturesStudy methods were designed to test 1) the null hypothesis (nodifferences) and, 2) determine differences among employers for: 1) choice of EAP session allowances (3 - 12 sessions) 2) choice of EAP session configuration (sessions per incident/issue vs. annual session limit) 3) choice of EAP service delivery (telephone only, in-person only, or both) Methodologies: t-tests, ANOVA, Chi-square, Post-hoc & Regression
Findings: Employer Choices in EAP Features EAP feature ANOVA Chi-Square RegressionNon-profitemployer (vs. for Session allowance +profit) = Moregenerous EAP Session configuration + ̶ +benefit Service delivery N/S + ̶ EAP feature ANOVA Post hoc RegressionLarge workforce(vs. medium vs. Session allowance +small) = Moregenerous EAP Session configuration + ̶ +benefit Service delivery + ̶ + + = As predicted; ̶ = Against predicted; N/S = Not significant
Discussion: Employer Choices by Org Type & Workforce Size Findings indicate that differences in employer decisions regarding EAP features were positively associated with organizational type and workforce size, this suggests these choices may be based on organizational resource dependency considerations. The prediction that non-profit and larger employers offer a more generous EAP benefit was largely confirmed, although evidence regarding employer choice of service delivery option was mixed.
Findings: Employer choices by Age of EAP contract Post hoc, EAP feature ANOVA Chi-Square RegressionOlder EAPcontract (vs.younger) Session allowance += More Session configuration + + ̶generousEAP benefit Service delivery + + ̶ + = As predicted; ̶ = Against predicted
Discussion: Employer choices by Age of EAP contract As predicted, EAP contracts of longer ages (10 years +) were associated with a more higher allowance of EAP sessions chosen by employer purchasers. Contrary to predictions, results were mixed for session configuration and service delivery type, as programs of 1-9 vs. 10 years were more likely to have both per-incident and multiple delivery options. Any thoughts..?
Findings: Employer choices by Industry Risk 5 High safety Post hoc, EAP feature ANOVA Chi-Square Regression risk and 3 high public accountability Session allowance + industries (vs. 11 low risk) = More generous Session configuration + +/- ̶ EAP benefit Service delivery type N/SHigh safety risk = Mining, Utilities, Construction, Transportation & ManufacturingHigh public accountability = Government, Education, Healthcare + = As predicted; ̶ = Against predicted; N/S = Not significant
Discussion: Industry Type & Risk Overall, differences in employer decisions for session allowance were positively associated with industry sectors (data not shown); indicating this EAP feature may be subject to industry-specific employer needs. Similarly, for employer decisions of high risk/accountability vs. low risk industries, employers with higher risks were positively associated as offering a greater number of EAP sessions. Results of employers’ choice of session configuration by industry type and high vs. low risk industries were mixed, thus some influence of structural and environmental factors on employer choices is likely present, but not conclusively.
Past Year Alcohol Use Disorders by Industry, Annual % Agriculture, Forestry, Fishing & Hunting 9.4% Mining 15.2% Utilities 8.6% Construction 15.0% Manufacturing 9.1% Wholesale Trade 12.4% Retail Trade 9.6% Transportation & Warehousing 8.2% Information 5.9% Finance & Insurance 9.8% Real Estate & Rental & Leasing 10.4% Professional, Scientific & Technical Services 9.0% Mgmt of Comp & Entp; Admin & Sup, Waste Mgmt & Remed Svcs 12.0% Educational Services 5.0% Health Care & Social Assistance 5.8% Arts, Entertainment & Recreation 12.3% Accommodations & Food Services 15.7% Other Services 7.8% Public Administration 6.1% Total, all industries 9.5%
Past Year Major Depressive Episode by Industry, Annual % Agriculture, Forestry, Fishing & Hunting 6.2% Mining 4.4% Utilities 2.5% Construction 5.2% Manufacturing 6.1% Wholesale Trade 4.9% Retail Trade 8.2% Transportation & Warehousing 5.9% Information 8.7% Finance & Insurance 8.2% Real Estate & Rental & Leasing 6.8% Professional, Scientific & Technical Services 6.7% Mgmt of Comp & Entp; Admin & Sup, Waste Mgmt & Remed Svcs 9.6% Educational Services 7.6% Health Care & Social Assistance 9.4% Arts, Entertainment & Recreation 8.6% Accommodations & Food Services 9.6% Other Services 7.5% Public Administration 7.0% Total, all industries 7.4%
Findings: Employer choices by Behavioral Health Conditions Post hoc,High (vs. low) EAP feature ANOVA Regression Chi-Squareindustry workerprevalence rate Session allowance N/S ̶of AUDs = Moregenerous EAP Session configuration + ̶benefit Service delivery N/S Post hoc,High (vs. low) EAP feature ANOVA Chi-Square Regressionindustry workerprevalence rate Session allowance + N/Sof MDEs = Moregenerous EAP Session configuration N/Sbenefit Service delivery N/S + = As predicted; - = Against predicted; N/S = Not significant
Discussion: Employer choices by Behavioral Health Conditions Alcohol use disorders (AUD) – Results indicate higher industry rates of AUDs are associated with a tendency to offer a per incident sessions, however regression (OLS) results of session allowance indicate that for every increase of 1 in the AUD prevalence rate, the number of EAP sessions drops by .073. Any thoughts..? Major depressive episodes (MDE) – Results of employer decisions regarding session allowance and industry rates of MDEs are mixed, indicating slight evidence for the prediction that purchasers in these industries may choose a higher number of sessions.
Employer Demand for EAP Worksite Activities Of the 490 employers in the sample, Demand for Worksite 286 reported EAP worksite activities. Activities Again using same six variables, e.g., • Organizational type • Workforce size • Industry type 41.7% 58.3% • Length of EAP contract • Behavioral health conditions We now ask: Are there differences in demand for EAP worksite activities among employers? YES NO
Findings: Demand for Worksite Activities Odds ratios for significant variables (all others N/S; n = 286) For Profit Ref: Non-profit (p= .01*) Wkforce1-99 Ref: Wkforce1000+ (p= <.0005***)Wkforce100-999 Prog Age3-9 Ref: Prog age10+ (p= .009**) Manufacturing Ref: Government (p= .01*) 0 0.2 0.4 0.6 0.8 1
Discussion: Demand for EAP Worksite Activity As predicted, non-profit employers’ demand for EAP worksite activities was nearly double that of for profits’. Also as predicted, employers with longer EAP contracts showed greater demand for EAP worksite activities. Contrary to predictions, larger (1000+) employers’ demand for worksite activities was substantially greater than smaller (1-99) and medium-sized (99-999) workforces. Any thoughts..? Non-significant findings regarding high risk vs. low risk industries and for behavioral health conditions preclude any conclusions about these factors.
Predictions: Enrollee Demand for EAP Clinical Services Enrollees in non-profits, smaller workforces, with EAPs of longer contract length, and higher prevalence rates of behavioral health conditions will demonstrate higher demand for EAP clinical services. For industries with higher risks for workplace safety and more public accountability - this effect will “trickle down” through the workplace environment and demonstrate higher enrollee demand for EAP clinical services.
Study Sample: Enrollees The total number of eligible employees represented in the sample was 687,958 with median of 139 employees per employer. The total number of eligible members (employees, spouses and dependents) represented in the sample was 961,122 with a median of 178 members per employer EAP benefit population. The following equations were used to create measures for employee and member demand: Aggregated number of employee EAP clinical authorizations/employer Aggregated number of employees/employer Aggregated number of member EAP clinical authorizations/employer Aggregated number of members/employer
Methods: Enrollee Demand for EAP Clinical Services To determine differences among aggregated employer enrollee population for EAP clinical authorizations (Number of authorizations/Employer enrollee population), I used the same six variables, e.g., • Organizational type • Workforce size • Industry type • Length of EAP contract • Behavioral health conditions Methodologies: t-tests, ANOVA, Post-hoc & Regression (OLS)
Findings: Demand for EA Clinical Services Non-profit workforce Enrollee group ANOVA Regression (vs. for profit) = More demand for EA Employees + + clinical services Members + +Smaller workforce Enrollee group ANOVA Post hoc Regression(vs. med. vs. larger) =More demand for EA Employees + + +clinical services Members + + +Older (vs. younger) Enrollee group ANOVA Post hoc Regressionprogram = Moredemand for EA Employees + + ̶clinical services Members + + ̶ + = As predicted; - = Against predicted
Discussion: Enrollee Demand for EA Clinical Services by Employer Type, Workforce Size, and EAP Contract Length As predicted, greater demand for EAP clinical services was positively associated with enrollees in non-profit workforces, small and mid-size workforces than in larger-sized workforces. Contrary to prediction, greater enrollee demand was present in workforces with shorter EAP contract rather than longer contract lengths. Any thoughts..?
Findings: Enrollee Demand for Clinical Services by Industry Type and Risk Enrollee group ANOVA Post hoc Demand for EAP clinical services by industry type Employees + + Members + + Post hoc,High risk (vs. low Enrollee group ANOVA Chi-Square Regressionrisk) industries =More demand for Employees + + +clinical services Members + + +
Discussion: Enrollee EAP Clinical Service Demand by Industry Type ANOVA and Post-hoc tests reveal significant differences in rates of enrollee demand for EAP sessions in eight industries with high workplace safety and public accountability risk vs. those eleven with lower risk. As predicted, enrollee demand for EAP sessions increased in workplaces in industries with either a high risk for workplace safety or high risk of public accountability vs. enrollees in those with lower risks.High safety risk = Mining, Utilities, Construction, Transportation & Manufacturing High public accountability = Government, Education, Healthcare
Findings: Enrollee Demand for Clinical Services by Behavioral Health ConditionHigh (vs. low) Enrollee group ANOVA Post hoc RegressionIndustry AUDprevalence rate Employees + + ̶ Members + + ̶ Enrollee group ANOVA Post hoc RegressionHigh (vs. low)Industry MDE Employees N/Sprevalence rate Members N/S + = As predicted; - = Against predicted; N/S = Not significant
Discussion: Enrollee Demand for Clinical Services by Behavioral Health Condition Alcohol use disorders (AUD) – Rates of enrollee demand for EAP sessions showed significant findings of differences between employers industries above the 9.0 median AUD prevalence rate vs. those below median. However, regression results are negative, indicating as industry AUD prevalence rates rise, enrollee demand authorization rates for EAP clinical services fall; specifically, -.063 for employees and -.071 for members with each 1 point rise in AUD rate. Major depressive episodes (MDE) – Tests for differences in enrollee demand between employers in industries above the 7.5 median MDE prevalence rate vs. vs. those below median were not significant, as were regression results, thus no conclusions can be drawn for this condition.
EAP Practice Implications One clear finding is that significant and predictable differences exist among employers regarding: 1) choices about the nature of EAP benefits offered to enrollees; 2) in demand for EAP-provided worksite activities; and, 3) that significant and predictable differences exist in enrollee demand for EAP clinical services. These findings advise that the employer market for EAPs is quite diverse, and that a bona-fide organizational analysis combined with purchaser/client education regarding any findings is a good practice when proposing an EAP for a particular work organization. Cautions in applying “cookie cutter” approaches to providing EAP services for diverse work populations. Potential risks may be low/poor utilization rates by enrollees, and a subsequent premature cancellation or disinterest in EA services by a work organization.
Behavioral Healthcare Policy Implications Findings suggest that the diversity of purchasers in the marketplace is reflected in differing choices of EAP service features and enrollee demand for EAP counseling. Thus, these influences should be considered when benefits consultants, human resource staff and MBHOs design and implement behavioral health care coverage. A primary motivation for including prevalence rates of alcohol use disorders and depression as dependent variables is the well- documented need for increasing identification of and access to treatment for these conditions. While the results for these two variables were less than conclusive -- it appears the variance in prevalence rates among enrollee populations is worthy of consideration when designing and implementing behavioral health care coverage.
Study Limitations1. Cross Sectional Research Design2. Data Issues • Convenience Sample Population (not randomized) • Ecological Fallacy of NSDUH Prevalence Rates • Regression to the Mean3. Effect of Unexamined Variables – Any thoughts…?4. Combined Effect of Contextual Factors
Questions or Comments..?Thank you for your attention