Employee assistance programs (EAPs) are relics. They were created decades ago when people were concerned about alcoholism in the workplace. We still care about this issue, but they are relics because employers fund this per-employee-per-month (pepm) benefit largely out of habit. Employers also fund robust insurance plans today, unlike what existed when EAPs started. Why do EAPs exist?
EAPs were a vanguard healthcare movement when it started. Vanguards are at the forefront of new developments or ideas. The EAP is well positioned to be there again. Employers can get better value for these vestigial benefits by digitizing them and moving their home base. They belong in the primary care setting with other early intervention programs. This is where behavioral healthcare should be.
From relic to relevance
The need to help people before they become dysfunctional from myriad behavioral issues is as relevant today as when EAPs first started. Yet the historical reality is that the benefit is little used. Those visiting a therapist use about one session on average. We could easily make these preventive services largely virtual. This would cut costs. Money could then be spent on broader engagement with digital services.
The clinical research conducted by each company providing digital behavioral services tells a happy tale. The clinical outcomes for these services are comparable to in-person psychotherapy. Making the benefit digital (possibly with an in-person, ancillary component) does not diminish its value. The value grows substantially every year as more people receive clinically effective services.
The essence of the EAP benefit is identifying problems before they advance to clinical conditions. The EAP visit does not require a diagnosis by the therapist to ensure payment. Also, everyone living in the employee’s household can use the benefit. EAPs understand context, including how family systems and workplace environments impact us. Digital services can explore that context as well.
Funding has already started
Introducing new benefits into bloated healthcare budgets is extremely challenging, however strong their case. It is easier to reallocate existing funding. It is easier yet when combined with cost reductions. It is quite possible that EAP dollars can be shifted to largely digital resources with some savings to be realized. This business case is strong.
EAP leaders are not motivated to make such a change. They undoubtedly resent terms like relic. Reducing the size of their provider network is not a welcome task. Yet the rationale for this opposition is grounded mostly in tradition. Their mission is just as valuable today, but the means of achieving it can change with potentially better results. Their business case for doing nothing is weak.
Employers pay for EAPs by covered population rather than by service volume. Given the historically low rates of utilization, this benefit was destined for change at some point. In fact, EAP rate negotiations were often an exercise in distraction. Employers got enhancements to basic EAPs each year with new “concierge services” like work-life balance and financial counseling. These services can also be digitized.
From assistance to wellbeing
Traditional EAPs measure the assistance highlighted in their name by the number of services provided. Strangely, those utilization rates have never really justified the program by either the size or the nature of what was counted. There has never been a routine practice of measuring outcomes, and so the purchaser has been left to assume the services go to some good purpose.
Outpatient behavioral healthcare services have not measured clinical outcomes either, but they have presumably been resolving the diagnosis attached to the service. Nonetheless, patient self-report measures should have been in place long ago for monitoring the outcomes from all types of care. As for the uniquely non-diagnostic EAP services, the appropriate measure for this work is wellbeing.
This is not a vague or faddish measure of contentment. It is a clinical measure of emotional resilience. It is what employers care most about for their employees. The goal for EAPs should be to increase the wellbeing of a covered population. The days of addressing hidden cases of alcoholism in the workplace are long gone. A multitude of hidden problems exist. We need resilience to cope with all of them.
Adoption by primary care
Physicians in primary care, or those serving as medical directors for large employers, will not immediately resonate with discussions of wellbeing. Their preferred terms are disease prevention and health promotion. Yet each term reflects strength and resilience. EAPs serve to prevent the emergence of disabling conditions like depression and addiction, or at least to reduce their dysfunctional impact.
Physicians today are mindful of the need for interventions focused on health, not just illness. There is a keen awareness that our medical systems have failed to embrace this focus. This is well suited to the EAP. Since health behaviors are a significant driver of health status, expertise in behavior change is essential to the mission of health promotion.
When your task calls for preventing a negative occurrence, a better course is switching to a positive goal. This is where wellbeing appears. We have good measures of wellbeing. We can track our progress in preventing illness by increasing the level of wellbeing in populations. Digital resources for this abound today, and they will proliferate as healthcare professionals appreciate their value.
Digital resources need broad promotion to ensure utilization. Yet people want assurances that any resource is reputable. It helps to know that an independent third-party backs the resources or services that are promoted. Many are suspicious that employer offerings might be self-serving. Endorsement by a health plan is similarly suspect. Few people describe them as trusted, unbiased entities.
The PCP has strong credibility on health issues, and promotion of digital self-care tools by doctors and their staff would be welcome. Of course, PCPs have no experience promoting digital resources for general health, behavioral health, or EAP. Marketing campaigns would need to leverage their credibility. PCPs must embrace this as an important expansion of their focus on prevention and health promotion.
Marketing can begin once the EAP name is replaced with one related to health and wellbeing. Digital self-care resources are a good starting point for behavioral services in primary care. Yet questions exist. How will employers view this change? Will PCPs see the value? How do we leverage digital vendors? Behavioral health leaders can address these practical concerns. My next article offers some direction.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.