Worried about the rising the cost of your health care? If so, you may be searching for something—short of dropping coverage for mental health and substance abuse—that can help. The twofold answer may be right in front of you: your employee assistance plan (EAP) and managed care techniques.
John Kamilis, LCPC, clinical director of CuraLinc Healthcare (www.curalinc.com), suggests a gatekeeper approach for your EAP, much like the one you may already use with your health plan. The idea is to direct employees concerned about mental or substance issues to the EAP before they seek treatment through the health plan.
“The gatekeeper approach allows us to have an assessment by one of our trained clinicians, who are all licensed mental health professionals, to determine exactly what is going on with the person and determine a course of action that is appropriate. If it is something that we can deflect into the EAP, there is a cost savings for the company, because it is one less person who accesses its health benefits and one less claim filed. Visits with a primary care physician cost a lot more money than they do with a mental-health provider.”
Applying this kind of managed care technique can result in reduced pharmacy costs, too, Kamilis says. “Sometimes people are prescribed psychotropic medications that aren’t necessarily appropriate. And the literature suggests that a lot of times, these drugs are prescribed through a primary-care physician. Sometimes he or she won’t have the training or expertise to diagnose and treat mental health conditions and tend to look at mental health issues as symptomatic, treating the symptoms rather than finding out what is really going on. They may be ordering tests that aren’t necessary or prescribing medication that isn’t appropriate. All of that adds to the cost of the health benefits.”
Mindee Zis, a senior account executive with third-party administrator Allied Benefit Systems, has been recommending a gatekeeper approach to Allied’s clients for the last several months. “We’re endorsing a gatekeeper model, very similar to a precertification process, whereby a member that needs to seek mental health or substance abuse treatment must first go through the gatekeeper process. The member calls the gatekeeper who then sets up face-to-face sessions through the EAP. If the member needed longer term care than the EAP provides, their advocate (the clinician who first saw that member) would then approve their transition into the health plan. Roughly 60 to 70 percent of all cases can be resolved within five sessions, so most never go to the health plan. Therein lies the savings, because those five sessions are much less expensive than they would have been through the health plan.”