Evaluating quality in mental health carego.sequoia.com/rs/269-ETP-979/images/...Quality-in-Mental-Health-Care.pdf · Evaluating Quality in Mental ealth Care March 201 PAGE 4 broken

Evaluating quality in mental health careThe shortcomings of traditional EAPs and health plan networks and how to overcome them

A LY R A W H I T E PA P E R | M A R C H 2 0 1 9

Executive Summary

Employers are increasingly making mental health one of their top priorities. With anxiety and depression on the rise, 61 percent of employers say they will implement a company-wide behavioral health action plan by 2021, according to Willis Watson’s annual Best Practices in Health Care Employer Survey1.

It’s a sound business decision. A report2 issued by the National Alliance of

Healthcare Purchaser Coalitions (NAHPC) claims that every dollar spent on more

effective and easily accessible mental health coverage, potentially returns four.

Unfortunately, many traditional health plans, Employee Assistance Programs

(EAPs), and app-based solutions still aren’t addressing the fundamental issues

of accessibility and quality care. Meanwhile, employees are receiving care that

may be ineffective or even harmful, while employers foot the bill for inadequate

solutions.

With the cost of healthcare already so high, no one has an appetite for additional

wasted investments. The good news is that there are steps you can take to

evaluate the quality of your existing mental health benefits.

This report covers two important facets of the quality conversation:

The limitations of traditional networks and EAPs

The five key criteria to evaluate mental health solutions

Use this guide to help you consider alternatives that may more fully address the

challenges of quality and accessibility.

Poor mental health care has a high price for companies and employees.

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Evaluating Quality in Mental Health Care | March 2019 PAGE 3

The challenges of traditional networks and EAPs

In traditional networks, only 5 percent of providers are both offering therapies that have been proven effective and available to see new patients. It’s no wonder employees find these traditional programs difficult to use and employers have difficulty measuring their effectiveness.

Challenge #1: poor network adequacy — bigger isn’t necessarily better

Many traditional networks and EAPs create the illusion of access with their

large networks, but fail to vet providers for quality or availability. While many

employers consider a large network an indicator of guaranteed access, most

provider directories include clinicians who are not taking new patients, retired,

or even deceased. The reality is, 75 percent of in-network providers aren’t

accepting new patients. Of the remaining 25% who are available, even fewer

practice effective therapies proven to work.

Employers may review geo-access reports, which look at provider density across

urban, suburban, and rural geographies. However, this method for evaluating

access does little to assess the actual availability of those providers or whether

their expertise is a good fit for employees’ needs. Without rigorous and ongoing

management of provider availability, networks are more limited than they

appear, and on average, patients have to wait 21 days for their first appointment.

Looking for a metric to evaluate just how small these “big” networks actually

are? More than 50 percent of mental health and substance abuse claims come

from out-of-network providers. The issue is specific to mental health — more

than half of mental health providers practice outside of employee health

networks, compared to only three percent of primary care physicians.3 This

75% of in-network providers aren’t accepting new patients.


broken system creates a barrier for those seeking care and increases costs, as

many patients are forced to pay-out-of pocket and deal with the hassle of health

plan reimbursements. With the rising prevalence of mental health issues across all

ages and costs increasing, the matter is only getting worse.

Challenge #2: Treatments that are ineffective or harmful

When an individual seeking care finally gets an appointment, it may be with a

provider who is a poor match for their specific issues, or practicing treatments

that aren’t proven to reduce symptoms. Only 20 percent of therapies practiced

today have evidence that proves they help patients improve or recover. The

80% of therapies have never been proven to work

Proven methods

˚ Cognitive Behavioral Therapy

˚ Acceptance & Commitment Therapy

˚ Dialectical Behavioral Therapy

˚ Prolonged Exposure Therapy for Trauma

˚ Interpersonal Therapy for Depression

˚ Emotionally-Focused Therapy

˚ Exposure & Response Prevention

˚ And more…

Unproven methods

˚ Family Constellations Therapy

˚ Coherence Therapy

˚ Past Life Regression Therapy

˚ Focused-Orientation Therapy

˚ Imago Relationship Therapy

˚ Jungian Depth Analysis

˚ Regression Therapy

˚ Dream Work

˚ Shamanism

˚ Brainspotting

˚ Biogenetic Analysis

˚ Possibility Therapy

˚ Redecision Therapy

˚ Postmodern Therapy

˚ PsychoDrama

˚ Body Talk System

˚ Play Therapy

˚ Somatic Therapy

˚ Lifespan Integration Therapy

˚ Emotional Freedom Techniques

˚ Depth-Oriented Brief Therapy

˚ And more...

FIGURE 1: UNPROVEN TREATMENTS ARE COMMONLY PRACTICED WITHIN TRADITIONAL NETWORKS


remaining 80 percent of therapies may be ineffective, or even iatrogenic,

meaning that they can actually cause psychological harm. Harmful therapies

include Conversion Therapy and Recovered-Memory Techniques.4

Challenge #3: High friction in the member experience

Attempting to get support from an EAP can be an exercise in futility for many

members. Sixty-seven percent of people never get care due to the many

barriers,5 highlighted in figure two on the following page. After being routed

through an 800-number, they are left to sort through a cumbersome directory of

providers with little support to understand what is the right care for their issues,

or help finding a therapist or coach who offers it. EAPs offer minimal online

content for self-care support, while what is offered is typically unengaging. This

friction, plus the high cost of care and stigma around mental health, results in

as few as one in seven receiving effective care. Sadly, people with anxiety or

depression wait an average of eight or more years before they get help.6

Challenge #4: Lack of insight into quality and results

Unfortunately, most EAPs don’t take a data-driven approach to evaluating

patient progress to ensure that people are actually getting better. Best practices

for quality care include capturing a baseline assessment for each patient and

gauging progress throughout treatment using standard clinical measures. It is

advisable not to rely on proprietary measures defined by an EAP, but instead to

look for standardized measures that have been validated for patient outcomes,

like the PHQ-9 (used for evaluating symptoms and severity of depression) and

GAD-7 (used for evaluating symptoms and severity of anxiety).

EAPs may track some form of engagement and use this as a measure of the

value of their service, but even then, how they calculate this metric may be more

noise than signal. An average of two percent engagement nationally is hardly

an impressive result, especially when you consider that almost 20 percent of

Americans suffer from a mental health issue in any given year. Some EAPs report

higher engagement rates, but often count non-meaningful touchpoints in their

Sadly, people with anxiety or depression wait an average of eight or more years before they get help.


numbers, such as calls into their call center or visits to an EAP-hosted booth at a

wellness event. Misleading numbers conceal how few people are, in fact, able to

access care.

Challenge #5: Limited coverage and types of care

Research shows that most people need between eight and 16 sessions to reliably

improve or recover from anxiety and depression. However, most EAPs only cover

three to five sessions before referring members back to their health plan. While

the health plan may offer more coverage, individuals face a myriad of challenges

that may prevent them from receiving effective care. Without adequate coverage

to help individuals improve, outcomes and quality suffer.

In addition, most EAPs don’t offer different types of care, such as self-care apps,

coaching, and therapy, suited to address the diverse needs of a workforce. They

typically offer a one-size-fits-all approach that doesn’t account for the variety of

issues and varying degrees of severity, requiring different treatments. Without the

appropriate type and level of care for each individual, it is difficult to demonstrate

reliable improvement and high rates of recovery.

EAPs engage an average of 2% of employees.

FIGURE 2:

Traditional EAPs - High friction and only 2% engagement

Lose motivation and give up




Call 800-number, sift through a directory

Wait 1+ months for an appointment

Receive poor

quality or wrong care

Quit or make little progress

Call a dozen providers, wait for

call-backs


How to evaluate the quality of your mental health solution

Understanding the intricacies of mental health treatments, provider networks, and benefit coverage is enough to overwhelm even the most seasoned benefits professionals, not to mention the members who are looking for support. Here we will break down the most important components to consider when evaluating the quality of your current solution or considering a new solution.

Do your networks do the following?

1. Include only treatments that are evidence-based

There are hundreds of therapies out there, but only a handful of them have

been proven to work. Known as evidence-based treatments, as defined by the

Society of Clinical Psychology,7 these proven methods have been researched

and tested in randomized controlled trials and repeatedly demonstrate results in

terms of helping people actually feel better. Common evidence-based therapies

(EBTs) include Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, and

Exposure and Response Prevention (ERP).

Ask your EAP if they exclusively offer providers who practice EBTs.

When your network offers only providers who practice evidence-based

treatments, your employees receive the most effective care to improve

functioning and recovery, as quickly as possible. The result is a healthier, more

productive workforce and, over time, lower health care costs overall.

If your EAP only offers a lengthy directory without personalized recommendations, it will be a frustrating experience that doesn’t result in effective care.


Check to see if your EAP supports individuals in finding providers

suited to their needs.

Therapies are evidence-based only for a specific problem area, so individuals

seeking care need further support to find and choose a provider who has

expertise suited to their needs. For example, Exposure and Response Prevention

is the gold standard treatment for someone with Obsessive Compulsive

Disorder (OCD), but is not recommended for someone with a primary psychotic

disorder. If your EAP only offers a lengthy directory without personalized

recommendations, it will be a frustrating experience that doesn’t result in

effective care.

2. Verify your network adequacy and quality

While many EAPs and health plans tout a large network, it’s worth exploring how

they recruit, qualify, and train providers to maintain quality and availability on an

ongoing basis.

EBTs for…

Depression

˚ Behavioral Activation

˚ Cognitive Behavioral Therapy

˚ Problem-Solving Therapy

˚ Self-Management Therapy

PTSD

˚ Prolonged Exposure

˚ Cognitive Processing Therapy

˚ Seeking Safety

˚ Present Centered Therapy

FIGURE 3: EXAMPLES OF EVIDENCE-BASED TREATMENTS


FIGURE 4: WHAT IS AN EVIDENCE-BASED TREATMENT?

1. Fewer than 25 sessions - Evidence-based treatments are often

short-term, and research shows that the results are long-lasting.

2. Goal-setting - Providers focus treatment sessions on specific

patient goals and continually track progress towards those

goals.

3. Progress measurement - Tracking patients’ progress via

thoroughly researched clinical measures allows providers

to tailor their approach to ensure efficacy. Standardized

measurement tools include PHQ-9 and GAD-7.

4. Skill development - When people are stuck, they sometimes

need new strategies rather than insight or catharsis. Effective

treatments teach practical skills to better manage thoughts,

emotions, and behaviors.

5. Skill practice between sessions - Treatment usually involves

assignments to help patients practice new skills. The more they

practice, the faster they progress.

The most effective methods share some common characteristics8

Key questions to ask:

How does your EAP ensure that providers are accepting new patients?

Look for an EAP that has processes in place to assess provider availability

on an ongoing basis. Also, verify that your network includes providers who

are located near where your employees live and work and have expertise

that matches their needs. To ensure the best member experience, the

EAP should offer bi-weekly verification or real-time updates synced with

providers’ calendars and the option to book appointments online.

Modern solutions will use smart data-driven tools to rapidly identify, qualify, and onboard high-quality providers who are right for your workforce.


Does your EAP curate and expand their network based on your needs?

Consider a mental health solution that uses technology and data to build and

maintain their network. Modern solutions will use smart data-driven tools to

rapidly identify, qualify, and onboard high-quality providers who are a good

fit for your workforce. This curated network should account for where your

employees live and work, who they are, and the types of issues they’re dealing

with. To effectively address their needs, your network should have the right

mix of providers, including therapists and coaches specializing in children,

couples, parents, Millennials, diverse and sensitive populations, substance abuse,

suicidality, and self-harm. In the age of personalization, your employees expect

and deserve care that is tailored to them; technology enables this at scale.

What incentives does your EAP offer to attract the highest quality clinicians?

With so few providers participating in traditional networks, find out how your EAP

is attracting the best evidence-based providers. Look for EAPs that simplify the

business of having a private practice. This might include steady client referrals

whose needs match their expertise; APA-accredited continuing education

training; and tools for managing invoicing, scheduling, and more.

Does your EAP include providers who only practice

evidence-based therapies?

Evidence-based treatments are an important foundational component to

ensuring high quality care. Consider how deeply your EAP adopts an evidence-

based approach to care. How do they recruit providers and assess their practice

approach on an ongoing basis?

3. Use technology to improve the member experience

Look for smart technology that overcomes stigma and barriers

Does your EAP or mental health solution offer the convenience and simplicity of

modern web and mobile applications as a core part of the member experience?

You can order groceries, delivered to your home, from an app and get music

recommendations perfectly suited to your taste. You should expect the same

modern approach to mental health care.

Data-driven technology can intelligently match employees to the right type of care for their needs.


Online tools that streamline the member experience help to overcome stigma

and other barriers to care. Online platforms can collect data from individuals

— symptoms, severity, and preferences — and intelligently match them to the

right care — from self-care apps and digital lessons to one-on-one work with a

mental health coach or therapist. Tools can also offer convenient instant online

booking to make the process more approachable and private.

Include care navigation and guidance tools for personalized care

Are personalized care recommendations a key component of your mental

health solution? Data-driven technology can help employees navigate the

complexities of mental health care and intelligently match them with the right

type of care. Having an elite network of available providers is an important

foundation, but it is still not enough to ensure optimal outcomes. Different

evidence-based treatments are designed for different problem areas. For

example, Cognitive Behavioral Therapy (CBT)is a good fit for relieving

symptoms of anxiety and depression and Motivational Interviewing (MI) is

designed to help people suffering from substance use disorders. A one-size-

fits-all approach or leaving employees to navigate the complexity alone will

result in subpar care or no care at all.

Include app-based messaging, digital exercises, and self-care resources

Does your EAP offer self-guided tools, resources, and one-to-one messaging

with providers between sessions? Some EAPs have online content, but most

is not evidence-based or particularly engaging. Quality self-care options are

important for enhancing skill development between sessions with a provider

and those who prefer to tap into support anytime, anywhere.

4. Measure quality using data

How does your EAP demonstrate value? If it’s more of a black box than a

beacon of clarity, explore whether it is tracking and measuring the right criteria

to help you understand quality of care. Defining the right metrics is important to

shed light on engagement, satisfaction, and outcomes. Assess these measures

for your EAP on a quarterly basis to ensure it's living up to its promise.

To effectively address their needs, your network should have the right mix of providers, including therapists and coaches specializing in children, couples, parents, Millennials, diverse and sensitive populations, etc.


Theme Metrics

Engagement ˚ % employees engaged (sign-ups)

˚ % engaged who get into care

˚ Average time to first appointment

Satisfaction ˚ % satisfaction with member experience

˚ % satisfaction with provider

Outcomes ˚ % improved or recovered (clinical)

˚ % stress reduction (subclinical)

Population Insights

˚ % engaged in different care programs (therapy, coaching, self-care apps)

˚ % by primary need (stress, anxiety, depression, etc.)

˚ % by modality (in-person, video, onsite, self-care)

˚ % breakdown by demographics (age, gender)

FIGURE 5: RECOMMENDED MEASURES OF QUALITY

5. Offer comprehensive care for every need

Lastly, make sure your EAP or mental health solution is addressing the diverse

spectrum of needs across your entire employee population by offering different

types of care with an integrated approach. There are three different facets to

consider:

Modalities

Give employees different ways to receive care — in person at a provider’s office,

via a live video call from a convenient location of their choice, or through a self-

guided app. Also consider the option of bringing a mental health provider onsite

at your office for added convenience.

Give employees different ways to receive care — in-person at a provider’s office, via a live video call from a convenient location of their choice, or through a self-guided app.


Types of care

Offer care options that are tailored to different levels of severity. For those

with mild symptoms of stress or relationship issues, mental health coaching

is a great option. For those with moderate symptoms, a blended care

approach that offers sessions with a provider plus online exercises and digital

content may be a good fit. For those with more severe symptoms, in-person

therapy will be most effective. Also, ensure that these different care options

are integrated for seamless transitions in the event that an individual starts

down one care path and needs to be transitioned to more intensive care. It’s

important to meet people where they are, help them find and access the right

care, quickly and easily, and make the entire experience seamless.

Care coverage

Most EAPs only offer a few sessions, which often isn’t enough to make any

significant improvement. Consider an EAP that offers enough coverage, at least

16 sessions, so that your employees have the care and support they need to

improve and recover. Research indicates that 16 sessions of evidence-based

treatment is often enough to help individuals develop new coping skills that

have lasting results.

Summary — five dimensions of quality

As you look for solutions to support your employees' mental health, manage

costs, and increase productivity, there are five key dimensions to evaluate:

1. Evidence-Based Treatments

2. Curated, Data-Driven Network

3. Clinically Valid and Standardized Measures

4. Tech-Enabled Member Experience

5. In-Person and Virtual Care Options

Consider an EAP that offers enough coverage, at least 16 sessions, so that your employees have the care and support they need to improve and recover.


Each dimension is equally important to delivering measurable clinical outcomes

for employees in need. Quality solutions will offer proven methods through a

variety of channels suited to each individual. It will measure the effectiveness of

care at every stage of the care journey. It will use modern technology to enable

convenience and smarter, more data-driven care. And lastly, technology will

not ever completely replace the need for face-to-face work with an in-person

provider.

Your employees deserve the best care and with these five quality dimensions

in mind, you can take a quality-driven approach to evaluating mental health

solutions on the market today.

Dimensions of Quality What to Avoid What to Look For

Evidence-Based Treatments ˚ Treatments that are ineffective or harmful ˚ Only evidence-based treatments and providers

who practice them

Curated, Data-Driven Network ˚ Large network of providers with unverified quality

or availability ˚ Highly-curated network of available providers based on members’ needs and location

Clinically Valid and Standardized Measures

˚ Engagement metrics that don’t include whether or how quickly people access care

˚ No outcomes measures or non-standardized clinical measures

˚ Engagement metrics such as % of sign-ups, % in care, and average time to first appointment

˚ Standardized outcomes measures, such as PHQ-9 or GAD-7, that quantify % improved and % recovered

Tech-Enabled Member Experience

˚ Cumbersome directory of providers

˚ Little personalization or guidance to the right care

˚ Online portal that intelligently matches individuals to the right care, based on patient data (symptoms, severity, preferences) and provider data (treatments, expertise, availability)

Comprehensive Solution

˚ Point solutions that address a narrow set of issues or a small population

˚ One or few modalities (i.e., only self-care, in-person care, or virtual care)

˚ Tightfisted session limits that may not provide enough care for improvement or recovery

˚ Personalized recommendations for available providers

˚ Care for a diverse spectrum of clinical needs: therapy, coaching, self-care options

˚ Many modalities: virtual and in-person care

˚ Session coverage driven by the amount of care needed for clinical improvement (16-25 sessions)

FIGURE 7: FIVE DIMENSIONS OF QUALITY AT A GLANCE

References1. Willis Towers Watson 23rd Annual Best Practice in Health Care Employer Survey. (2019, January 3). Re-

trieved January 9, 2019, from https://www.willistowerswatson.com/-/media/WTW/PDF/Insights/2018/10/wtw-23rd-annual-best-practices-in-health-care-employer-survey-executive-summary.pdf

2. Achieving Value In Mental Health Support: A Deep Dive Powered by eValue8. (2018, August). Retrieved January 9, 2019, from http://higherlogicdownload.s3.amazonaws.com/NAHPC/3d988744-80e1-414b-8881-aa2c98621788/UploadedImages/Achieving_Value_in_Mental_Health_Support_Report_Final_9_12_2018.pdf

3. Achieving Value In Mental Health Support: A Deep Dive Powered by eValue8. (2018, August). Retrieved January 9, 2019, from http://higherlogicdownload.s3.amazonaws.com/NAHPC/3d988744-80e1-414b-8881-aa2c98621788/UploadedImages/Achieving_Value_in_Mental_Health_Support_Report_Final_9_12_2018.pdf

4. Lilienfeld, S. (2007). Psychological Treatments That Cause Harm. Perspectives on Psychological Science, 1(2), 53-70. Retrieved January 8, 2019.

5. Layard, R., & Clark, D. M. (2015). Thrive: The Power of Psychological Therapy. Chapter 4, Page 54. London: Penguin Books.

6. Layard, R., & Clark, D. M. (2015). Thrive: The Power of Psychological Therapy. Chapter 4, Page 54. London: Penguin Books.

7. Tolin, D. (2010). Is Cognitive-Behavioral Therapy More Effective Than Other Therapies? A Meta-Analytic Review. Clinical Psychology Review, 30(6), 710-720. Retrieved January 9, 2019.

8. O’Donohue, W., Buchanan, J. A., & Jane, J. E. (2000). Characteristics of Empirically Supported Treatments. The Journal of Psychotherapy Practice and Research, 9(2), 69-74. Retrieved January 7, 2019.

About LyraLyra reimagines the EAP to provide companies and employees with personalized,

effective mental health care that works. Serving more than 500,000 members nationwide,

Lyra brings together technology and an elite provider network to improve access, quality,

and outcomes for your employees.

7x engagement | 3x faster access | 3x better outcomes

˚ Frictionless member experience

Our online platform helps members find care

in just a few clicks. They can sign up and book

appointments instantly, choose to meet virtually

or in-person, and tap into digital tools to build

new skills.

˚ Elite providers and proven treatments

Lyra only works with the most qualified and

effective providers. Our therapists and coaches

use only evidence-based methods proven to

help people feel better.

˚ Personalized care for every member

Lyra uses technology to intelligently match

individuals with the right providers and

treatments based on their symptoms, severity,

and preferences.

˚ Gain insight into effectiveness

Get visibility into member utilization, satisfaction,

recovery and improvement rates, and mental

health needs of your workforce.

Support for issues that are simple, complex, routine, or unexpected.

˚ Therapy

˚ Coaching

˚ Self-Care Apps

˚ Critical Incident Support

˚ Work-Life Services

˚ 24/7 Member Support

Ready to reimagine your EAP? Get in touch with us.

Featured Customers

Ready to reimagine your EAP? Get in touch with us.

[email protected] | www.lyrahealth.com

Documents

Evaluating quality in mental health carego.sequoia.com/rs/269-ETP-979/images/...Quality-in-Mental-Health-Care.pdf · Evaluating Quality in Mental ealth Care March 201 PAGE 4 broken