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Employers Can Transform Healthcare with Key Funding Changes
Employers have major influence over the direction of American healthcare. Roughly half of us with health insurance get coverage through employers, and so their power is substantial. Their funding decisions have a domino effect. Employers should consider letting the dominos fall by consolidating some employee health benefits as a step to changing where and how behavioral care is delivered.
Three specific benefit plans are not meeting their goals and need reconfiguration. First, employee assistance (EAP) benefits no longer work as a first layer of behavioral services prior to accessing today’s rich, parity-compliant insurance benefits. EAP once made sense in juxtaposition to behavioral health insurance, conceived variously as an entry point, replacement, or diversion from insurance use.
Disease management (DM) benefits are similarly past their prime. Even putting aside the low use of these virtual services, DM’s core nursing model (education with goal-setting) is inadequate. Nurses are minimally trained to help people change health behaviors underlying conditions like diabetes and heart disease. Behavior change is hard. A better model is to offer brief, in-person services with a therapist.
If wellness means more than keeping healthy people healthy, then wellness programs must address how to change unhealthy behavior. While some might benefit from working with specialists like dieticians, many people are unwell despite fully understanding healthy lifestyle practices. Once again, therapists are behavior change experts who probe psychosocial factors that are not obvious or easy to change.
Consolidate Where and How
EAP, DM, and wellness programs struggle because the setting of service is ill-conceived. While some large employers have worksite EAP counselors, most hire networks of clinicians working in private offices. This is a barrier to access for many. Virtual services are helpful but not ideal. It would be a radical departure (and great convenience) to provide access to EAP-like services at the PCP’s office.
If the preferred behavior change specialist for DM is a therapist, then having therapists available in primary care would be optimal. PCPs can be connected as skilled clinicians address impediments to healthy behavior. This also applies to wellness services. The primary care setting should function as first line care for emerging behavioral issues of every type, with referrals available for severe problems.
How would this work practically? Because employers already budget these funds, the big change is a new vendor for administrative functions. These poorly used benefit dollars would be aggregated and funneled to therapists working in primary care. We already see a shift of therapists into this setting, but it is impeded by fee-for-service funding. The vendor must track utilization, outcomes, and satisfaction.
This approach has flexibility because discretionary employee benefits have fewer regulations and restrictions than insurance benefits. Employers can collaborate with behavioral and primary care providers on establishing local solutions. It is “win-win” as payers get more for their money, and employees get better access to behavioral care, including for health conditions poorly addressed today.
Building Momentum for Change
Health policy experts seem aligned in supporting behavioral integration into primary care. Yet this guarantees little about the future of healthcare. In our country, healthcare is a familiar political battleground, and entrenched interests are powerful since roughly 20% of our GDP is tied to it. The reform ideas outlined here may be too bold for some, but employers pay the bills and can decide.
Governmental agencies like the Centers for Medicare & Medicaid Services drive many innovations in healthcare, but their control has limits. For example, many reform proposals today assume value-based funding will ultimately replace fee-for-service healthcare, but this transition is largely occurring in publicly funded contracts. Consolidating employee benefits as described here could build the momentum for change in the commercial sector.
Forces are aligned for this proposed reconfiguration. Employers are loathe to eliminate existing employee benefits, and yet they are well aware of the limitations of EAP, DM, and wellness services. The strategy here continues to fund employee benefits, but it shifts the location and nature of those services. These would be brief, in-person services, with ancillary digital resources, without visit limits.
Employers excel at this type of collaboration since they know all the major stakeholders. It will be easiest for employers with geographically concentrated groups of employees. Behavioral clinicians should be invited to offer system design ideas. Many will want to access new funding with brief, primary care interventions. However, this transition should not be over-engineered.
The spirit of this reform is to put the right clinicians in place, and then listen and learn. Standardized programs for specific problems should be avoided, especially in the beginning. Let patients be delighted to find their PCP office now staffed by clinicians with unique listening skills, ready and able to focus (unlike nurses or dieticians) on the personal drivers of behavior change. Change is hard, but achievable.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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