Uti l i zati on and Cost of Behavi oral Heal t h

Servi ces: Empl oyee Charact eri st i cs and

Workpl ace Heal t h Promot i on
James V. Trudeau, PhD
Diane K. Deitz, PhD
Royer F. Cook, PhD
Abstract
The study sought to (1) model demographic and employment-related influences on behavioral
health care utilization and cost; (2) model behavioral health care utilization and cost influences on
general health care cost, j ob performance, and earnings; and (3) assess workplace-based health
promotion' s impact on these factors. Behavioral health care utilization was more common in em-
pl oyees who were female, over age 30, with below-median earnings, or with above-median general
(non-behavioral) health care costs. Among employees utilizing behavioral health care, related costs
were higher f or employees with below-median earnings. Employees utilizing behavioral health
care had higher general health care costs and received lower perf ormance ratings than other
employees. Health promotion participants were compared with a nonparticipant random sample
matched on gender, age, and pre-intervention behavioral health care utilization. Among employees
without pre-intervention behavioral health care, participants and nonparticipants did not differ in
post-intervention utilization. Among employees utilizing behavioral health care adjusting f or pre-
intervention costs, participants had higher short-term post-intervention behavioral health care costs
than nonparticipants.
Background and Significance
This article addresses behavioral health care utilization and costs among employees of an insur-
ance company in the southeastern Uni t ed States, including the related effects of a health promo-
tion/substance abuse prevention program. Three related objectives are addressed. First, demographic
and employment-related influences on behavioral health care utilization and costs are explored.
Second, the relationships between behavioral health care utilization and other outcomes such as
non-behavi oral health care costs, j ob performance, and earnings are assessed. Third, participants
in a health promotion/substance abuse prevention program are compared with nonparticipants with
respect to pre-intervention and post-intervention behavioral health care utilization and cost. This
article does not address clinical outcomes of behavioral health services.
Address correspondence to James V. Trudeau, PhD, is Senior Research Scientist, ISA Associates, 201 N Union Street,
Suite 330, Alexandria, VA 22314: e-mail: jtrudeau @isagroup.com.
Diane K. Deitz, PhD, is a Senior Research Scientist, ISA Associates.
Royer E Cook, PhD, is President, ISA Associates.
Journal of Behavioral Health Services & Research, 2002, 29(1), 61-74. 2002 National Council for Community Behavioral
Healthcare.
Employee Characteristics and Workplace Health Promotion TRUDEAU et aL 61
Behavioral health care and factors influencing its utilization and cost are of great and increasing
interest to many audiences, including empl oyers and the managed care industry. The American
Journal of Managed Care recently released a special issue entitled "Out comes of Best Practices in
Behavioral Healthcare." An article titled "New Directions in Alcohol and Drug Treatment under
Managed Care" noted that "in some payment systems, the costs of behavioral health care have risen
by 20% or 30% annually. Thus, although services for alcohol and drug abuse are a small proportion
of overall costs, they are often considered unnecessarily high and identified as services that can be
reduced.'q(p 58)
Several demographic characteristics have been significantly associated with medical costs at-
tributed to mental health services. 2 Occupational characteristics such as occupational grouping have
been associated with differences in depression ratings and global health i ndi ces) Similarly, a recent
study 4 investigating modifiable health risks and health care costs found psychological factors to be
associated with the highest expenditures.
Empl oyer interest in i mprovi ng worker heal t h- - and behavioral health---extends beyond concerns
over insurance costs. Most heavy drinkers and users of illicit drugs are working adults, 5 and it is
quite likely that substance abuse and mental illness have cost effects (often hidden) well beyond
those directly reflected in behavioral health claims. 6
Nearl y nine out of ten compani es have some form of health promotion, 7 and there is accumu-
lating evidence that such programs can be excellent mechani sms for increasing worker health and
productivity. 8 Studies 4,9 have shown that worksite health promot i on programs contribute significantly
to reductions in health care costs for those workers who participate in such programs. Moreover,
recent reviews 1,11 of multiple studies of the effectiveness of worksite health promot i on programs
and their i mpact on health care costs have concluded with cautious opt i mi sm about these programs.
Studies investigating the return on investment from health promot i on and wellness programs have
found that participation not only affects health status but also overall productivity and absenteeism
rates.l'12
Over the previous decade, researchers f r om I SA Associates have developed and tested substance
abuse prevention programs and materials for the workplace. 13 Participant compani es have come from
the manufacturing, 14 construction, 15 and insurance 16 industries. Import ant and encouraging effects
have been seen in participant self-reported attitudes and behaviors. In the last several years, the ISA
research t eam has extended this work into a managed care environment and has used health care
claims data to explicitly address behavioral health care utilization and associated costs.
In 1996 and 1997 ISA developed and tested a pr ogr am- - t he Connections pr ogr ams- - t hat com-
bined substance abuse prevention with health promot i on at the participating insurance company.
This project assessed the effects of integrating substance abuse prevention materials into standard
workplace health promot i on offerings, such as stress management , nutrition, and fitness. The original
Connections study is briefly summari zed below because the current study builds on this earlier work,
assessing the i mpact of the program on health care utilization and cost.
The original Connections study used a pretest-posttest experimental design in which empl oyees
who volunteered to participate in a health promot i on program (stress management or healthy eating)
were randoml y assigned to a health promot i on only condition (the control group) or to a condition that
included bot h health promot i on and substance abuse prevention (the experimental group). Classes
and materials were identical across conditions except that in the experimental groups the participants
also received specially developed substance abuse prevention messages and materials tailored to the
specific health promot i on topic. A total of 424 empl oyees participated in the classes, which were
held during lunch over a course of several weeks.
Pre-/post-intervention survey results indicated that the stress management and healthy eating
programs were highly effective in reducing stress and i mprovi ng eating practices, respectively. Ap-
proxi mat el y 1 month after the program, participants in the stress management program reported
significant i mprovement s on all four measures of stress levels, and participants in the healthy eating
62 The Journal of Behavioral Health Services & Research 29:1 February 2002
program reported significant i mprovement s on all five measures of eating/weight management prac-
tices. Moreover, 10 months after completion of the program virtually all the i mprovement s were
maintained.
The inclusion of substance abuse prevention materials resulted in i mprovement s in attitudes and
practices with respect to the use of alcohol and other drugs. Participants in the stress management
program who received the substance abuse prevention materials reported decreased use of alcohol
and drugs to relieve stress. Participants in the healthy eating program who received the substance
abuse prevention materials reported increases in the degree to which they perceived alcohol and
drugs as harmful to their health. On bot h of these measures, i mprovement s by the experimental
group were significantly greater than those by the control group. An unexpected finding was that
stress management participants reported a significant decrease in alcohol consumpt i on and illicit
drug use- - whet her or not they were exposed to the substance abuse prevention materials.
Me t h o d s a n d Da t a
For the current study, the insurance company' s managed care organization (MCO) provi ded health
care claims data for all covered empl oyees from January 1996 through March 1998. Key elements
of the claims database included diagnosis codes from the International Classification of Diseases,
9th Revision (ICD-9 codes), location of service, cost of service, and date of service. Cost of service
was defined as a combination of what the MCO and the insured empl oyee pai d to the health care
provider (ie, physician or hospital).
Behavioral health diagnoses included mental health diagnoses (psychoses, neuroses, adjustment
reactions, depressive disorders, schizophrenic disorders, etc) and substance abuse-rel at ed diagnoses
(drug dependence and non-dependent abuse of drugs). By selecting certain codes in the diagno-
sis (ICD-9) fields, behavioral health care claims could be identified. 17 (A compl et e listing of the
diagnosis codes used to categorize these claims is available from the authors on request.) Cl ai ms
were identified as behavioral health claims i f they had one or more specified codes in the primary,
secondary, or tertiary ICD-9 fields. (A cl ai m may have up to three ICD-9 codes to allow the provider
to indicate co-occurring or contributing conditions in addition to the mai n diagnosis.) A cl ai m does
not necessarily correspond to a visit or event, as more than one claim can result f r om a visit. To min-
imize this limitation, analyses focused on a dichotomous measure of utilization (having a behavioral
health care cl ai m or not) and costs, rather than on cl ai m counts. Further, these analyses speak onl y
to health care for which claims were submitted to the MCO and do not capture utilization and costs
for which no cl ai m was submitted.
Information on demographic and empl oyment -rel at ed factors was drawn from a data file pro-
vided by the insurance company' s human resources (HR) department. To safeguard confidentiality,
a procedure was developed to link claims data and HR data using a t ransformed portion of the
Social Security number. Demographi c variables included age, gender, race/ethnicity, and marital
status. Empl oyment -rel at ed factors included quarterly earnings, exemption status (whether exempt
from the Federal Fair Labor Standards Act requiring overtime pay [executive, administrative, and
professional empl oyees are exempt]), maj or occupational group, and performance ratings.
To increase the interpretability of analyses, each variable was simplified as much as possible.
Gender (male, n = 456; female, n = 1,354) and exemption status (exempt, n = 678; non-exempt,
n = 1,101) each have onl y two categories and were not change~. Race/ethnicity was simplified to
white (n = 1, 436) and nonwhite (n = 349); marital status was simplified to married (n = 1,121)
and unmarried (n = 665). Major occupational group was simplified to three groups: (1) professional,
technical, sales, and related occupations (n = 284); (2) executive, administrative, and manageri al
(n : 220); and (3) administrative support, clerical, and precision production (n = 1,269). The re-
maining variables were split into two groups at as close to the median as possible given the distribu-
tions. Age was split into younger and older (18-29, n = 874, and 30+, n = 936); quarterly earnings
Employee Characteristics and Workplace Health Promotion TRUDEAU et al. 63
were split into high and low (above $6,020, n = 903, or below $6,020, n = 876); and pertbrmance
ratings were split into high and low (above 3.00 or 3.00 and below). Because many employees re-
ceived ratings of 3.0 (on a scale of 1 to 5), the intended "median split" did not result in two groups of
equal size; rather, 63% of employees received performance ratings of 3.00 and below (n = 995; the
low performance rating group) and 37% received performance ratings above 3.00 (n = 588; the high
performance rating group). Not all variables were available for all subjects. Also, HR data typically
reflected marital status at time of hire and were not routinely updated. Consequently, this variable
may be inaccurate for some employees whose marital status has since changed.
In addressing the first objective of this study, these demographic, personal, and employment-
related variables were used in two-part modeling to assess factors influencing utilization and cost
of behavioral health services. First, logistic regression was used to identify factors influencing the
likelihood of utilizing behavioral health services (ie, having one or more behavioral health services
claims during the study period). Second, for employees with behavioral health services claims, linear
regression was used to identify factors influencing the cost of those claims. An average monthly cost
based on each employee' s plan enrollment during the study period was calculated. This average
monthly cost was transformed using natural log transformation to bring the error distribution closer
to normal and thus more amenable to ordinary least squares (OLS) linear regression.
Under the study' s second objective, analyses were conducted to assess the relationship of utilization
of behavioral health services to general health care costs and employee performance ratings, adjusting
for the influence of demographic and other employment-related variables previously described. The
third objective of this study addressed the impact of the Connect i ons health promotion program on
health care, particularly behavioral health care, utilization, and cost. Participants in the Connect i ons
program with available health care data (total sample size of 309) are collectively referred to as
"participants." A sample of 309 employees who did not participate in the earlier study is referred to
as the "nonparticipant matched sample." This latter group includes a random sample of employees
that is proportionate to the participant group in gender, age group, and the occurrence of a behavioral
health-related medical claim in the pre-intervention period (January 1996 to December 1996).
The matched sample of nonparticipants more closely resembled the health promotion participants
than did nonparticipants in general, making differences in behavioral health claims less likely to be
the result of confounding variables such as age, gender, or preexisting behavioral health problems.
It should be noted that the Connect i ons participants included in these analyses were not a random
sample of worksite employees, as they had volunteered for the health promotion/substance abuse
prevention program offered at the worksite in 1996 and 1997. The nonparticipant matched sample
also did not represent the workforce, as it was selected to resemble the participant group in gender,
age, and occurrence of a behavioral health-related claim. Given these circumstances, findings do not
necessarily apply to worksite employees in general.
Resul ts
In order to place the following discussion of behavioral health care claims into a broader context,
Table 1 lists the number and costs of all medical claims filed by worksite employees during the
study period (January 1996 through March 1998). Claims are classified into general categories or
subgroupings following the chapters used in standard ICD-9 coding.17 Each claim was classified into
a single category based on the primary ICD-9 code; secondary and tertiary ICD-9 codes were not
used to make this classification into category. ICD-9 categories are listed in Table 1 by descending
cost for "all claims." Overall, the mental disorders category ranked 13th for both the number of
claims and the costs associated with those claims.
Data for visits involving behavioral health are summarized in the two right-hand columns of
Table 1. Claims were categorized into ICD-9 category using only the primary ICD-9 diagnosis,
64 The Journal of Behavioral Health Services & Research 29:1 February 2002
Tabl e 1
Costs and number of claims for all claims and behavioral health-related claims
(January 1996--March 1998)
Be ha v i o r a l
Al l c l ai ms he a l t h c l ai ms
Li abl e Li abl e
I CD- 9 a mo u n t No. o f a mo u n t No . o f
c ha pt e r De s c r i pt i on ( $) c l ai ms ( $) c l ai ms
11 Complications of pregnancy and childbirth 947, 406 3,630 2,564 10
10 Genitourinary system diseases 524,256 6,157 257 13
13 Musculoskeletal and connective tissue 450,802 55,663 1,178 41
diseases
V codes Factors influencing health status/health
services contact 448,877 10,180 347 13
16 Symptoms, signs, and ill-defined conditions 411,126 6,732 1,242 29
2 Neoplasms 332,107 2,945 1,600 1
8 Respiratory system diseases 282,161 4,508 1,452 51
9 Digestive system diseases 281,522 1,986 4,976 45
7 Circulatory system diseases 248,161 2, 166 3, 114 34
17 Injury and poisoning 235,758 3,353 550 12
6 Nervous system and sense organ diseases 123,484 1,602 195 6
3 Endocrine, nutritional, metabolic, and
immunity disorders 110,717 2,997 667 24
5 Mental disorders 94,359 1,495 94,359 1,495
12 Skin and subcutaneous tissue diseases 70,073 1,476 406 10
1 Infectious and parasitic diseases 53,006 1,031 90 6
4 Blood and blood-forming organ diseases 21,277 303 0 0
14 Congenital anomalies 14,693 91 60 1
E codes External causes of injury and poisoning 1,728 21 0 0
15 Conditions originating in perinatal period 1,470 40 0 0
Total 4,652,983 106,376 113,057 1,791
but were identified as belonging in the behavioral health claims category (two right-hand columns)
using primary, secondary, or tertiary diagnoses. The primary diagnosis category of mental disorders
contained the vast majority of behavioral health claims, accounting for 1,495 of 1,791 behavioral
health claims, or $94,359 of $113,057 in liable costs. An additional 296 behavioral health care claims
and $18,698 in liable costs were captured by expanding the definition of behavioral health conditions
to include secondary and tertiary diagnoses as well as primary. These additional claims axe dispersed
across various primary diagnosis categories. Using this expanded definition, behavioral health claims
accounted for 2.4% of health care costs among these employees for this timeframe.
Obj e c t i ve 1: Be havi or al he a l t h servi ces as o ut put s
The first objective addressed the extent to which personal, demographic, and employment factors
were related to the utilization and cost of behavioral health services. In the first part of the two-part
modeling, logistic regression analysis showed that gender, age, earnings, and having general (ie,
excluding behavioral) health care costs above the median were all significantly related to having a
Employee Characteristics and Workplace Health Promotion TRUDEAU et aL 65
Figure 1
Percentage of empl oyees with behavioral health care claims by gender, age, earnings, and
nonbehavioral health care (non-BH) costs (January 1996-March 1998)
Female
Male
Age 30+
Age 18-29
Lower Earnings
Higher Earnings
Higher Non-BH Costs
Lower Non-BH Costs ~ 11%
I I i I i I I i I
0 % 20/0 4 % 60/0 8 % 1 0 % 1 2 % 1 4 % 1 6 " / o 1 8 % 2 0 %
Percentage of each group with behavioral health care utilization
behavioral health claim or not (as a dichotomous outcome). After adjusting for the other factors,
females were about 2.3 times as likely as males to have a behavioral health cl ai m (log odds ratio =
2.3; p = .001). (In logistic regression, a log odds ratio reflects the likelihood of the group of in-
terest having the outcome relative to the likelihood of the reference group having the outcome;
a log odds ratio of 1.0 would indicate that the groups were equally likely to have the outcome. )
Empl oyees ages 30+ were about 1.5 times as likely as younger empl oyees to have a behavioral
health cl ai m ( p = .01). Empl oyees with earnings below the median were about 1.4 times as likely
to have a behavioral health claim as empl oyees with earnings above the median (p = .02). Em-
ployees with general health care costs above the median were about 1.5 times as likely to have a
behavioral health cl ai m as those with general costs below the median ( p = .006). Figure 1 shows
the raw percentage in each of these groups having a behavioral health cl ai m (not adjusted for other
variables).
Despite these group differences, the model including these four predictors accounts for (or ex-
plains) only a small portion of the variability in the out come of having a behavioral health cl ai m or
not. In linear regression, the proportion of variance accounted for is reflected in the R 2 statistic. In
logistic regression there is no exactly comparabl e statistic, but the Nagelkerke R 2 statistic offers a
way of quantifying the proportion of variance explained in the model. The Nagelkerke R 2 for the
current model is 5%; the remaining 95% of the variance is not explained by the combination of
variables in the model,
In the second part of the two-part modeling, linear regression was performed on the log transfor-
med average monthly cost of behavioral health claims for empl oyees with such claims, The use
66 The Journal of Behavioral Health Services & Res~eareh 29:! Febma~ 2002
of mont hl y averages made the analysis more precise but the resultant model s were comparabl e
whether monthly averages or overall totals were used. Stepwise selection was used, with p = .05
entry criterion and p = . 10 removal criterion.
Only one factor was significantly related to cost of behavioral health claims. Among empl oyees
with behavioral health claims, those with earnings below the medi an had higher average mont hl y costs
for behavioral health claims than those with earnings above the median. With empl oyees with above-
medi an earnings coded 1 and those with bel ow-medi an earnings coded 0, the regression coefficient
(B) was - . 463, ( p = .001). Regression coefficients reflect the change in the log t ransformed average
mont hl y costs per unit change in the predictor, adjusting for any other predictors in the model. Here,
the negative coefficient indicates that the group coded 1 (the above-medi an earnings group) had
lower costs than the group coded 0 (the bel ow-medi an earnings group). In terms of actual (non-
transformed) costs, the average monthly cost of behavioral health claims for empl oyees with such
claims was $26.88 for empl oyees with bel ow-medi an earnings versus $7.93 for those with above-
median earnings. (The respective average total behavioral health care costs for the study period
were $467 and $158.) However, the model (which includes only the earnings group predictor)
accounted for only about 5% of the variance in t ransformed average monthly behavioral health
costs.
No other variables were significantly related to average monthly costs of behavioral health claims.
As described above, empl oyees who were female, age 30+, had bel ow-medi an earnings, or had
general costs above the median were more likely to have utilized behavioral health care than their
counterparts. In this analysis of behavioral health care costs, conditioned on havi ng one or more
behavioral health care claims, these groups did not differ from their counterparts.
Obj e c t i v e 2: Be h a v i o r a l he a l t h s e r v i c e s as i nput s
The second objective addressed the relationship of behavioral health care to other out comes,
including general health care costs, performance, and earnings. Analyses were conducted to as s e s s
the relationship of each of these outcomes with the demographi c and empl oyment -rel at ed factors
described above as well as a variable indicating whether or not each empl oyee had a behavioral
health claim, referred to as behavioral health claim status.
Effects related to general (non-behavioral) health care costs were assessed by applying linear
regression modeling to the natural log transform of average monthly non-behavioral health care
costs. Three factors were identified as significantly related to general (non-behavioral) health care
cost: gender, marital status, and behavioral health cl ai m status (which echoed the earlier finding
that empl oyees with non-behavioral health care costs above the medi an were more likely to have
behavioral health care claims than those with non-behavioral health care costs below the median).
The regression coefficients (B) for the model explaining non-behavioral health care costs were as
follows: gender (females coded 1), B = 0.790; marital status (married coded I), B = 0.307; and
behavioral health care claim status (with a cl ai m coded 1), B = 0.386 (all p values < .001).
While these three factors were the best predictors of general health care costs identified in this
study, they explained only a small part of those costs. With these three variables in the model, the
model accounted for 6. 1% of the variability in general (non-behavioral) health care costs. Thi s study
included quite a few variables that seemed to hold great promi se as predictors of health care costs,
so this limited predictive power may indicate that much of the variability in health care costs cannot
be easily accounted for.
Because the transformed variables are not easily interpreted, the original overall totals are presented
in Figure 2. Empl oyees with behavioral health care claims averaged $3,038 in non-behavioral health
care costs during the study period (January 1996 through March t998), al most 50% hi gher than
the average non-behavioral health care cost of empl oyees without behavioral health care claims
($2,134). General health care costs for females ($2,456) were al most 50% higher than those for
Employee Characteristics and Workplace Health Promotion TRUDEAU et al. 67
Fi g ur e 2
Average cost of nonbehavioral health care by marital status, gender, and behavioral health care
(BH) utilization status (January 1996-March 1998)
Unmarried (n= 591)
Married (n=980)
Male (n=453)
Female (n= 1,352)
Without BH Claim (n=1,540)
With BH Claim (n=265)
I i I I i
$0 $500 $1,000 $1,500 $2,000 $2,500 $3,000 $3,500
Average total cost of nonbehavioral health care
mal es ($1,702), and costs for married empl oyees ($2,521) were al most 50% higher than those for
unmarried empl oyees ($1,730).
Turning to j ob performance, empl oyees with behavioral health claims were less likely to re-
ceive high performance ratings than were empl oyees without behavioral health claims. As Table 2
shows, of empl oyees with behavioral health claims, only 31% received high performance ratings;
of empl oyees without behavioral health claims, 38% received high performance ratings. Chi-square
analysis showed that this pattern would be unlikely i f there were no difference in the population
( X 2 = 5.55, df = 1, p = .02).
In addition, among empl oyees with one or more behavioral health claims, actual performance rat-
ings were negatively correlated with the average mont hl y cost of behavioral health claims
(r = - . 13; p = .04). The above cross-tabulation treated performance rating as a dichotomous mea-
sure (high or low). In contrast, this correlational analysis uses performance rating as a continuous
measure and is (by definition) limited to empl oyees with behavioral health claims.
Performance ratings also were related to many of the demographi c and empl oyment -rel at ed vari-
ables included in this study. (The earnings variable was not included as a potential predictor.) In
Tabl e 2
Performance ratings and behavioral health claim status
Low ratings High ratings Total
With behavioral
health cl ai m 171
Without behavioral
health cl ai m 824
Total 995
69% 77 31% 248 100%
62% 511 38% 1,335 100%
63% 588 37% 1,583 100%
68 17ze Journal of Behavioral Health Services & Research 29:1 February 2002
stepwise linear regression analysis, the following variables were identified as significantly predict-
ing performance rating: white (B = . 18); major occupation group of executive, administrative, and
managerial (B = . 15); exempt status (B = .09); behavioral health claim (B = - . 12); and age 30-t-
(B = .06). Of greatest interest is the finding that the influence of having a behavioral health claim
remained significant (p = .001) above and beyond the influence of these other predictors. Table 2
shows that employees with behavioral health claims were less likely than employees without such
claims to receive high performance ratings. The present linear regression analysis showed further
that employees with behavioral health claims received lower performance ratings even after adjust-
ing for the influence of race, age, exempt status, and major occupation group. Logistic regression
modeling of these predictors on performance rating g r o u p - - l o w versus hi gh- - showed comparable
results. With the other predictors in the model, employees without behavioral health claims were
almost 1.5 times as likely as employees with such claims to receive high performance ratings (log
odds ratio = 1.42; p = .03).
The relationship among these predictors and performance ratings is not strong, however, with
the significance enhanced by a large sample size (1,378 for this analysis). The first predictor to
enter the model, white/nonwhite, improved R 2 by just .03; the second predictor, major occupation
group of executive, administrative, and managerial, improved R 2 by an additional .02. Exempt status,
behavioral health utilization, and age group each improved R 2 by less than .01. The R 2 for the final
model with these five predictors was .07, indicating that the model may be of limited practical value
for predicting performance ratings even though it is statistically significant. Performance ratings
may be determined by many factors, only a few of which were included in this study, leaving a large
element of unexplained variability. Nonetheless, it is noteworthy that having a behavioral health
claim was significantly related to performance rating after the influence of the other predictors (race,
occupation group, exempt status, and age group) was accounted for. Other potential predictors such
as gender were not. In any event, only a small proportion of the variability in performance ratings
was accounted for by variables in this study.
Obj e c t i ve 3: I mpac t o f t he Connections he al t h p r o mo t i o n p r o g r a m o n be havi or al he a l t h
s ervi ces ut i l i z at i on a n d c os t
This section describes findings for health care utilization and costs for three groups of employees:
the Connect i ons program participants, a matched sample of nonparticipants, and the larger group
of all nonparticipants (which included those in the matched sample). Analyses assessing the impact
of the Connect i ons program on health care claims focused on change from the pre-intervention to
post-intervention periods. As in earlier analyses of demographic and employment-related factors
affecting health care claims, these were two-tiered analyses. First, how likely were employees in the
respective groups to have a behavioral health claim? Then, for individuals with such claims, how did
the cost of those claims differ?
Table 3 shows the number of employees having a behavioral health claim in the pre- and post-
intervention periods in the participant group and the nonparticipant matched sample group. In the
first part of the two-part approach, logistic regression was used to assess the influence of partic-
ipation status and pre-intervention behavioral health claim status on the likelihood of having a
post-intervention claim. Not surprisingly, employees with a pre-intervention behavioral health claim
were much more likely to have a post-intervention behavioral health claim (58% did) than were
employees without a pre-intervention behavioral health claim (only 8% did; log odds ratio 14.90,
p -- .0001). Participants and nonparticipants did not significantly differ in their overall likelihood
of having a post-intervention claim ( p ---= .44). Of greater interest, the interaction of pre-intervention
claim status and participant status was nearly significant ( p = .08). This was mostly due to the fact
that among people with pre-intervention behavioral health claims, participants were more likely
than nonparticipants to also have post-intervention behavioral health claims (68% versus 47%). Of
Employee Characteristics and Workplace Health Promotion TRUDEAU et al. 69
Tabl e 3
Behavioral health cl ai m status by participation status and intervention period (pre-intervention:
1/1/96-12/31/96; post-intervention: 1/1/97-3/31/98)
Post-intervention
behavioral health claim
Pre-intervention
behavioral health claim Yes No Total
Participants
Nonparticipant
matched sample
Total
Yes 26 68% 12 32% 38 100%
No 22 8% 249 92% 271 100%
Total 48 16% 261 84% 309 100%
Yes 18 47% 20 53% 38 100%
No 24 9% 247 91% 271 100%
Total 42 14% 267 86% 309 100%
Yes 44 58% 32 42% 76 100%
No 46 8% 496 92% 542 100%
Total 90 15% 528 85% 618 100%
particular interest is the question of whether the intervention led empl oyees without pre-intervention
behavioral health claims to have such claims after the intervention. Among empl oyees without pre-
intervention behavioral health claims, participants and nonparticipants did not significantly differ in
their likelihood of having post-intervention behavioral health claims (8% versus 9%, log odds .907,
not significant), suggesting that the intervention did not lead to greater help-seeking behavior among
empl oyees who had not previously received behavioral health services.
Analyses discussed above showed that the likelihood of having a behavioral health claim was
higher for empl oyees who were female, age 30+, with earnings below the median, or with general
(non-behavioral) health care costs above the median. Additional logistic regression analyses were
performed to assess whether any of these variables influenced the interaction of pre-intervention
behavioral health claim status and intervention group; that is, each of these variables was added as
a third interaction term. None of these t hree-way interactions was significant.
In the second part of the two-part approach, the next analyses addressed the cost of behavioral
health claims, focusing on empl oyees in the participant and nonparticipant mat ched sample groups
who had one or more behavioral health claims in the pre-intervention or post-intervention periods.
People who had a behavioral health cl ai m in either period were included in the analysis, with a
cost of zero for any period in which they had no claim. Behavioral health costs in each period
were natural log transformed, first adding one to each cost so that persons with zero cost in either
period would not be excluded from the analysis. OLS linear regression was conducted using the
transformed post-intervention cost, with participant status and transformed pre-intervention cost as
predictor variables; that is, the analysis adjusted for pre-intervention cost and assessed the influence
of participation status on post-intervention cost.
There was a significant effect of participation status (B = 0.794, p = .05). Adjusting for pre-
intervention behavioral health costs, participants had higher post-intervention behavioral health costs
than the nonparticipant matched sample. Figure 3 shows the raw (non-transformed) pre-intervention
and post-intervention average behavioral health costs for each group. The nonparticipant matched
sampl e group showed a substantial decrease in behavioral health costs from pre- to post-intervention,
the interpretation of which was not obvious. Therefore, comparisons also were made between the
participant group and the all nonparticipants group. The latter group showed virtually no change
713 The Journal of Behavioral Health Services & Research 29:1 February 2002
Figure 3
Mean cost of behavioral health care claims for empl oyees with behavioral health care cl ai ms by
participant status (pre-intervention: January 1996--December 1996; post-intervention: January
1997-March 1998)
Mean Liable
mount
per Person
(in Dollars)
300
250
200
150
100
5 0 ,
Pre-lntervention Post-Intervention
~. Participants
(n=60)
~ A- - Nonparticipants
matched sample
(n=62)
- " D " All
Nonparticipants
(n=212)
between periods, perhaps serving as a better compari son group in this instance. This linear regression
(which again adjusted for pre-intervention cost) showed a significant influence of group (participant
versus all nonparticipants) on transformed post-intervention cost (B = 0.592, p = .05), as had the
participant/nonparticipant matched sampl e analysis.
There were no significant differences between Connections program participants and nonpartici-
pants in terms of pre-/post-intervention i mprovement s in performance ratings, which is not surprising
given the intervention and the brief t i meframe of the outcome data.
Discussion
This study identified several empl oyee characteristics that were significantly associated with be-
havioral health care utilization and cost. Empl oyees who were female, ages 30+, or wi t h bel ow-
median earnings were more likely to have a behavioral health cl ai m than their counterparts. Thi s
finding serves as a reminder that a broad range of empl oyees may benefit from programs addressing
substance abuse and mental health issues. Another (not necessarily competing) interpretation of these
findings is that these individuals may not have greater behavioral health probl ems but are si mpl y
more likely than their counterparts to access behavioral health services; this interpretation suggests
that greater outreach efforts should be directed at the counterparts. In any event, this finding should
not be seen as disparaging those who utilize behavioral health services or as i mpl yi ng that they are
necessarily more in need of such services than their counterparts.
Among empl oyees with behavioral health claims, the cost of behavioral health care was found
to be associated only with lower earnings; no other empl oyment factor or empl oyee characteristic
was significantly associated with behavioral health care costs. The question arises as to whether
empl oyees with higher earnings actually have lower behavioral health care costs, or whether they
Employee Characteristics and Workplace Health Promotion TRUDEAU et al. 71
axe simply more able to afford not submitting claims for services i f they choose not to. This study
cannot speak to this issue. In any event, this study' s two-part analytic approach had greater suc-
cess identifying factors predictive of whether or not employees utilized behavioral health services
(in the first part) and less success explaining differences in costs once such services were ob-
tained (in the second part). Perhaps the predictable component of behavioral health care costs
is implicitly accounted for in the first part of the approach with the remaining cost variability
comprising much unpredictable vari abi l i t y--or at least unpredicted by variables included in this
study.
This study' s findings also provided support for the view that behavioral health problems and other
health problems can be interrelated: Employees with behavioral health claims were more likely
to have higher general health care costs than those without a behavioral health claim. This is not
a surprising finding given that many medical and psychological conditions co-occur. This finding
suggests that preventing substance abuse or mental health problems may have the collateral benefit
of reducing overall health care costs.
However, it was clear that behavioral health care costs were not among the leading categories of
health care costs. For this workforce during this study period, behavioral health care claims accounted
for a relatively small (although at $113,057, not insignificant) proportion of total health care costs:
behavioral health claims accounted for 2.4% of all costs; within behavioral health claims, substance
abuse claims accounted for only 4.2% of costs. However, these health care claims costs attributed
to behavioral health do not reflect other costs, such as those associated with losses in productivity,
emotional strain, and time off the job. The claims figures also reflect only the costs of treatment
received within the MCO health plan. In an ongoing related study, a number of employees reported
seeking care for an alcohol- or drug-related problem that was not filed with the MCO. It should
be understood that behavioral health claims are an imperfect and partial indicator of the actual
prevalence of related disorders in the workforce.
This study also found that substance abuse and mental health problems were related to a key
employee outcome beyond medical claims: Employees with behavioral health claims were less likely
to receive high performance ratings than were employees without such claims. This difference (31%
versus 38%, respectively) was not enormous but it was large enough to be of interest to companies
interested in improving performance. Moreover, this relationship persisted after controlling for the
influence of demographic (race, age) and employment-related variables (exemption status, major
occupational grouping). With the other predictors in the model, employees without behavioral health
claims were still almost 1.5 times as likely to receive high performance ratings as were employees
with such claims.
It must be acknowledged that behavioral health utilization accounted for only a very small part of
the variability in performance ratings (about 1%, with other predictors in the model). By the same
token, however, it should be noted that variability in performance ratings was not well explained
by any of the predictors in this study, which included many important demographic and work-
related characteristics of employees. The five leading predictors (race, major occupation group,
exempt status, behavioral health utilization, and age group) collectively accounted for just 7% of the
variability in performance ratings.
Nonetheless, companies will doubtless remain interested in predicting and improving performance
ratings. Two of the predictors identified in this study (race, age group) are immutable, and two (major
occupation group, exempt status) are inherently linked to the type of position and thus cannot be
influenced as long as that position is of interest. The remaining factor, utilization of behavioral health
services, is the factor that may be most amenable to influence. It is likely not the utilization per se
that is linked to performance, but rather the underlying causes and symptoms. This study suggests
that i f employees can access programs to promote positive behavioral health, including prevention
and early intervention, companies may realize an indirect benefit of improved per f or mance- even
i f much of the wxiability in performance ratings remains unaccounted for.
72 The Journal of Behavioral Health Services & Research 29:1 February 2002
Similarly, findings that the likelihood of behavioral health utilization is associated with certain
demographic and work-related characteristics, or that empl oyees with behavioral health utilization
had higher general health care costs, will be of interest to some audiences, even i f the identified
factors explain only a small part of the variability in these outcomes.
Analysis of claims data from the pre- and post-intervention t i meframes of the Connections program
indicated that the cost of behavioral heal t h-rel at ed services increased in the participant sampl e after
the intervention. An earlier study had shown that participants in the stress management program
reported decreased use of alcohol and other drugs to relieve stress and participants in the healthy
eating program reported increases in the degree to which they perceived alcohol or other drugs
as harmful to their health. Program effects of this sort may have increased participant willingness
to utilize behavioral health services. Alternatively, since program participants volunteered for the
Connections health promot i on program, it may be that the increased cost of behavioral health services
reflected generalized help-seeking behavior. For example, empl oyees for whom substance abuse or
mental health issues were of concern at that t i me may have been more likely to volunteer for the
program and increasingly utilize behavioral health services. These findings are similar to those found
in a study of the effect of use of empl oyee assistance programs (EAPs) on health care utilization,
which found that going to an EAP substantially increased bot h the probability of a behavioral health
cl ai m and the number of claims in the same quarter as the EAP contact.18 Furthermore, the increased
probability of a behavioral health cl ai m was maintained for 11 quarters after the EAP contact, and
increased costs were maintained for six quarters after the contact.
It is important to note that analyses reported in this article dealt with relationship, not causality.
They do not indicate with certainty that having a condition leading to utilization of behavioral health
services caus es - - or even contributes to lower performance ratings (much less lower performance
per se, as ratings are not a pure measure of performance). There are likely one or more unidentified
factors affecting both the behavioral health-related condition and performance ratings (or earnings).
Moreover, there is at best a weak relationship between behavioral health services utilization and lower
performance ratings, and even i f the relationship is causal, the effect is very slight. Nonetheless, these
findings of a relationship between behavioral health utilization and performance ratings offer some
support to the bel i ef that behavioral health may be linked to work-related outcomes. Subsequent
research is needed to better assess change over a longer period of t i me and to address causation.
The ongoing research project of which this study is a component includes collection of data on the
entire insurance company worksite for a mi ni mum of 4 years to allow better assessment of program
effects. This project will include more in-depth analysis of the differences between inpatient and
outpatient services, average length of stay for inpatient events, and the cost of those services. A key
advantage of the ongoing study is the linking of health care claims, HR data, and self-report health
behavi or questionnaires, which will greatly i mprove analysis of the relationships among personal
health risk factors, self-reported depression and anxiety, and the utilization of services for mental or
substance abuse-related problems.
Impl i cati ons for Behavi oral Heal th Services
This study' s findings hold several implications for behavioral health services. First, the findings
suggest that a broad range of empl oyees may benefit from programs preventing or addressing sub-
stance abuse and mental health services. Second, empl oyees with behavioral health probl ems also
may suffer f r om poorer overall health and have work difficulties (as evidenced by higher general
health care costs and lower performance ratings than other empl oyees), suggesting that successful
resolution of behavioral health issues may have additional, broader benefits to empl oyers as well as
employees. Third, the finding that participants in the Connections health promot i on program showed
increased behavioral health care costs following the intervention suggests that health promot i on ini-
tiatives can increase participant willingness to utilize behavioral health services, an important step in
Employee Characteristics and Workplace Health Promotion TRUDEAU et al. 73
addressing and preventing many behavioral health problems. Overall, this study' s fi ndi ngs support
the vi ew that behavioral heal th probl ems and behavioral health servi ces deserve a l evel of attention
be yond that indicated by the direct cost of these services. Workplace programs that promote health
and behavi oral health, i ncl udi ng preventi on and early intervention, may benefit not onl y empl oyees
but al so empl oyers by hel pi ng t o i mprove performance and l i mi t future behavioral heal th care costs.
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Er r a t um
In the November 2001 i ssue o f the J ournal of Behavioral Health Services & Research
(Vol. 28, No. 4) , the third sent ence o f the Appreci ati on to Revi ewers contai ned an i naccu-
rate word. The correct wordi ng i s as fol l ows: "Al though the transition was not seaml ess, we
are grateful to the authors and reviewers for their pati ence during this transition period."
74 The Journal of Behavioral Health Services & Research 29:1 February 2002