Comprehensive Mental Health Insurance Benefits:
Case Studies
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Mental Health Services
Office of Managed Care
III. Methodology
This report presents case studies and analyses of six employers and three MCOs that provide comprehensive mental health benefits. The key tasks in preparing the studies and analyses included
- identifying study participants;
- developing a survey instrument;
- conducting interviews;
- summarizing and analyzing findings; and
- collaborating with employers to ensure accuracy of results.
A literature review of major studies of comprehensive mental health and substance abuse insurance coverage provided the base for selecting participants and developing the survey instrument. This review included a case study synopsis for several employers that offer innovative behavioral health benefits and identified key topics for consideration in the report. The literature review also established a locus for discussion for an Advisory Panel (see Appendix A) convened to offer guidance. The panel, which included health care policy experts and representatives from the employer community and the insurance industry, provided advice concerning criteria for selecting case study subjects and identified types of information to be gathered.
Initially, a quantitative methodology was proposed to guide participant selection. Candidates were to be selected only if they met a minimum threshold of coverage, based on a review of publicly available data on specific benefits. The existing literature, however, revealed that available data would be insufficient as the sole criteria for selecting employers. Specifically, determining an appropriate threshold proved difficult because almost all employers met the benefit standard. Furthermore, existing data did not accurately represent differences in benefits and did not offer the opportunity to examine innovative practices. For example, the type of case management offered by employers who reported having "case management" varied dramatically, yet the data did not portray those variations. The panel eventually helped make the decision to select employers and MCOs through less quantitative measures.
Criteria Involved in Employer Selection
Employer identification was approached through the Delphi method, in which expert nominations and referrals guide the selection process. The panel recommended employers and identified additional experts from whom to select nominees. Key journals also were searched to locate other employers with innovative benefits plans.
The literature review and Advisory Panel discussion revealed the problems inherent in developing a specific definition of "generous" or "comprehensive" benefits. No consensus on the issue exists. Reliance solely on a certain threshold of comprehensiveness would prove limiting. Thus, "comprehensive benefits" were defined more broadly to include such elements as EAPs and access to and flexibility of behavioral health services. All selected employers
- provide benefits that extend beyond traditional benefit limits, such as 30 inpatient days and 20 outpatient visits per year;
- place high priority on behavioral health;
- provide a range of innovative and flexible benefits (e.g., multiple levels of care beyond inpatient and outpatient treatment) and integrate behavioral health benefits with the corporate culture or other company elements such as an EAP;
- encourage employees to use needed behavioral health care;
- represent a geographically diverse group; and
- operate in a variety of industry sectors.
Companies that met these characteristics were contacted to assess their level of interest in participating. When a set of companies had been identified as potential participants, the recruiting process involved several challenges posed by the employers:
- concern about confidentiality of employee and employer health care and cost information;
- fear of being stigmatized by investors, clients, competitors, and potential employees as a company with a high prevalence of behavioral health disorders in its employee population;
- questions about resources required to devote to participation; and
- concern that national publicity would hamper the ability to reduce behavioral health expenditures in the future.
The group of six employers is primarily the product of self-selection. These employers shared several common characteristics, such as
- national reputation for providing comprehensive and innovative health and non-health-related benefits;
- national lines of business;
- extensive scope of operations, with Fortune 500 rankings ranging from 26 to 160;
- large workforce, ranging from 3,500 to more than 100,000 employees; and
- with the exception of Company X,3 self-insured employer status.
After study participants were selected, interviews with employer representatives were conducted and information was synthesized into individual case studies. Although the project originally examined behavioral health benefits, for the most part employers focused on the unique aspects of their mental health benefits. With few exceptions,4 the employers have devoted more resources to developing innovative programs for mental health than for substance abuse. To capture these innovative, unique elements, this report concentrates on mental health benefits.
Participating employers use a variety of approaches--including HMOs, PPOs, and indemnity plans--to manage and deliver health benefits. The majority of participants contract with third-party administrators to manage benefits and provider networks. These contracted insurers, MCOs, and benefits administrators will be referred to as "insurers" or "vendors" throughout this report. The term "managed care organizations" refers to the two HMOs and one MBHO studied.
Criteria Involved in MCO Selection
The process of selecting MCOs differed substantially from employer selection.
First was a decision to focus the study on a staff model HMO and on a more open provider network such as a PPO. This strategy raised several issues, however, since most HMOs and PPOs offer a basic menu of services and do not provide innovative behavioral health care.
The few exceptions were predominantly staff model HMOs. Although a staff model HMO was originally intended to be part of the strategy, very few employees receive care through such an HMO. Thus, to examine a more typical arrangement, two MCOs that had experience integrating a staff and network model were included in the study. Further, many MCOs use behavioral health carve-outs to manage mental health and substance abuse treatment. This study, therefore, examines one MCO specializing in behavioral health care.
After the types of MCOs to select were identified, three participants were chosen, based on
- a favorable National Committee for Quality Assurance (NCQA) ratings;
- nationally recognized behavioral health programs; and
- geographical diversity.
3 This company has withdrawn its name from the study to avoid publicity during pending union negotiations. It participated fully throughout the process, provided researchers with all necessary information, and reviewed the case study. Other than the company name, no information has been altered. Some information concerning the company history and profile has been generalized to maintain confidentiality.
4 For example, Fannie Mae's HMOs offer more generous coverage for substance abuse than for mental health. Its Aetna HMO plan provides up to 30 inpatient and 20 outpatient visits for mental health but places limits of 60 days for both inpatient and outpatient substance abuse care. The company's Kaiser Permanente HMO also provides less restrictive substance abuse benefits.
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