Health and productivity management: should EAPs focus primarily on providing short-term counseling or improving productivity? The two missions are not mutually exclusive and can, in fact, complement each other.

A new value model is emerging for employers that provide health benefits to their employees but increasingly are growing concerned about the value they are receiving to offset the rapidly rising cost of providing these benefits. This model, known as health and productivity management, integrates data from the domains of health promotion, disease prevention, care management, occupational health, disability management, and organizational dynamics. Health and productivity management offers a way to put a real bottom line under efforts in each of these areas.

In the mid-1990s, the Institute for Health and Productivity Management laid the basis for health and productivity management by assigning research teams to each of these domains. The research teams discovered that while the direct medical costs of mental health issues can be very large, the "indirect" costs of lost productivity are much greater. Because employers traditionally have viewed healthcare costs and labor costs independently of each other, they have failed to make the connection between health and productivity

EAP providers, meanwhile, often have conceptualized their products in their marketing campaigns as both short-term treatment programs and tools for improving employee productivity, but typically they have operationalized them as one or the other. While good examples of onsite assessment-and-referral programs managed and staffed by EA professionals still exist, the vast majority of EAPs are outsourced, externally managed, offsite services whose primary mission is short-term counseling.

Employers today, however, are beginning to recognize that they do not have to choose between brief treatment and productivity improvement when they can have an EAP that offers both. IHPM is working with leading EA professionals to move employer-based healthcare from a medical model to a workplace model in order to realize the greater value--in the feral of less unnecessary absence from work and less "presenteeism," or lost performance while at work to be derived from indirect cost savings. At the same time, many EAPs are collaborating with other workplace initiatives to emphasize health promotion and wellness and prevent disease in the first place, all of which can produce savings in avoidable direct medical expenditures. Thus, EAPs can help generate both direct and indirect savings.

DEPRESSION AND STRESS

The most obvious direct cost of ill health is money spent on medical services. To the extent EAPs intercept health problems before they become more serious, they help slow the rise of direct health care spending. Less obvious, and thus harder to quantify and influence, are the indirect costs associated with absenteeism and presenteeism.

Now, using psychometrically designed survey tools, it is possible to identify and "count" the cost of lost productivity, which is conservatively estimated to be at least twice and perhaps three times as large as the direct medical cost of treating illness. For some conditions, such as depression and substance abuse, the cost of lost productivity may be high enough to provide a return on investment that will pay for the EAP several times over.

Depression is, in fact, the "epidemic" of the modern workplace. In a survey conducted by IHPM in 2002, the leading reported health-related cause of productivity loss in the workplace was mental illness, primarily depression. The survey also revealed that while musculoskeletal problems remain the largest health issue in the traditional "physical" workplace, mental health issues claim that distinction in the modern "psychological" workplace, which is occupied mostly by knowledge workers who produce and exchange ideas and information rather than things.

Knowledge work produces high levels of stress in part because instantaneous communication has erased the physical boundaries of the workplace and also because global competition keeps increasing productivity expectations. High stress Levels, sustained over time, contribute to illnesses of all kinds but especially affect mental health Research shows that workers who are stressed and depressed consume 250 percent more medical services than the average employee.

For years, depression lived in the corporate closet. Like other mental health problems, depression was so stigmatized that it was rarely identified and even more rarely treated. Now it has come out of the closet (at least partially), although it remains burdened with a certain degree of stigma and is still largely under-diagnosed and under-treated. The National Institute for Mental Health has found, for example, that only half of patients who present with depression to their primary care physician are appropriately diagnosed, and of these only one in five receives proper treatment. The inability of the healthcare system to identify and treat depression is the principal reason depressed patients consume medical care at twice the average rate

EAPs are ideally constituted to identify depression in its early stages and head off the costs associated with it because they are highly accessible to employees and are stalled by mental health professionals, who are far more likely to refer depressed patients to the proper resources for diagnosis and treatment. This becomes a win-win tot employers because early diagnosis and treatment reduce direct medical costs by substituting more cost-effective therapies for hospitalizations and because significant savings also can be realized by reducing short-term disability claims and related absences from the workplace Additionally, savings accrue from restoring functionality and reducing the productivity loss attributable to presenteeism, which we can now measure with validated self-report surveys.

Research being conducted with employers by Ron Kessler at Harvard Medical School and Debra Lerner at the Health Institute of the New England Medical Center is starting to reveal the true size of lost productivity costs stemming from depression. This research will make the productivity "target" for EAPs more important than ever, but hitting the target will require that EAPs increase their effectiveness

IMPROVING EAP PERFORMANCE

To a considerable extent, the effectiveness of an EAP depends upon the mission it sets tot itself and the model it uses to fulfill that mission. Worksite model programs using onsite counselors are highly effective in identifying depressed employees and those with drug and alcohol problems because they prioritize the role of the supervisor in referring low functioning employees. In contrast, network model programs are a very effective means of providing readily accessible, no-cost, short-term counseling. EAPs that are totally offsite programs attract only a small number of supervisory referrals, however, thus missing a large number of depressed employees and substance abusers, who are reluctant to reach out for help.

Regardless of which model they use, EAPs today must provide ongoing case management and continuity of care if they are to produce successful long-term outcomes that save medical costs and increase productivity. A number of leading companies utilize a "hybrid" EAP that combines elements of the worksite and network models, using on-site counselors as well as an outside network. Companies such as Abbott Laboratories, Boeing, Chevron/Texaco, International Truck and Engine, Pfizer, Pacific Gas & Electric, and Pitney Bowes are showing the way to realizing much greater value from their EAPs through the recapture of productivity that is lost on the job. Widespread adoption of this model could generate big gains in performance from the growing ranks of knowledge workers who are particularly vulnerable to depression.

Sean Sullivan is a co-founder, president, and chief executive officer of the Institute for Health and Productivity Management (IHPM), which works with purchasers and providers of health care to create greater value for employers as measured by improved employee health and performance. He can be reached at [phone] or at [e-mail]. Ken Collins is president of Kenneth Collins and Associates, a behavioral healthcare consulting firm in Orinda, Calif. He can be reached at [phone] or at KennethRCollins@comcast net.