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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
VIII. Appendix C: Employer Case Studies
B. Delta Air Lines
Company History / Profile
Delta Air Lines, Inc., operates scheduled air transportation for passengers, freight, and mail over an extensive worldwide route. The third largest U.S. airline in operating revenues and passenger miles flown, Delta has more passengers and more aircraft departures than any of its competitors. In addition to pilots and flight attendants, Delta's 70,000 employees include ticket agents, gate agents, aircraft mechanics, engineers, business executives, and a wide range of other staff.
Factors Influencing Company's Decision to Provide Comprehensive Benefits
The early 1990s was a difficult financial period for the entire airline industry. During the first half of the decade, Delta undertook cost-cutting measures to offset poor financial performance, including severe reductions in force (RIF's) that, according to the company's 1998 annual report, "threatened Delta's core values of high employee morale" (Mullin, 1998, p. 2). Declining morale ran counter to the ideal of the "Delta family," a philosophy centered on respect and teamwork among all Delta employees. To rekindle this attitude, the airline focused more intensively on its employees, implementing changes such as increasing employee salaries in January 1999. The company emphasizes that its employees provide the "centerpiece of success" and that they deserve to be compensated at the top of the industry (Mullin, 1998, p. 3).
The airline's financial hardships also affected its mental health benefits. During the first half of the decade, many employees who had never doubted their job security began to worry that they might be "downsized." An increased number of employees experienced depression and anxiety. As a result, Delta improved mental health coverage and instituted programs, such as the EAP, to provide additional employee support. Delta's employee-focused culture improved morale dramatically in fiscal 1998. An independent survey revealed that overall employee satisfaction jumped 20 percent from 1996 to 1998.
Mental Health Benefits
Description of Benefit Options
Only recently has Delta made the transition from fee-for-service health coverage to managed care. In 1995, in the wake of growing fee-for-service health care costs, Delta contracted with CIGNA HealthCare and several smaller insurance companies to provide managed care for employees. Delta remains self-insured, relying on these contractors to manage the health benefit plans.
Approximately three-quarters (53,000) of Delta's 70,000 employees are insured through the airline. Of these enrollees, 90 percent participate in plans run by CIGNA. This case study focuses on these nearly 48,000 Delta employees enrolled in the CIGNA plan who are covered through an HMO with a POS provision allowing for out-of-network care. The remaining 10 percent select coverage from either smaller fee-for-service plans or regional managed care insurers, such as Kaiser Permanente on the West Coast and United Healthcare in the eastern half of the country. Delta offers coverage to all full- and part-time employees, spouses, and dependents; the company is currently considering coverage for domestic partners. Employees can petition for coverage of a sibling or parent in their care (see Table 5).
Delta contracts through CIGNA with a third party, MCC Behavioral Care, Inc., to provide mental health benefits. CIGNA thus manages Delta's physical health benefits and serves as an intermediary between Delta and MCC for mental health care. Mental health care is about 10 percent of Delta's total health care budget.
In the past few years, at the behest of Delta, MCC has reduced its limitations on mental health coverage. The plan now considers psychiatrists and psychologists as primary care physicians. The result: unlimited outpatient access. Utilization restrictions apply only to physical and mental health specialist care. Employees do not need to contact the EAP or another gatekeeper to access the mental health benefit.
Delta covers employee premiums; coverage for a spouse costs an employee an additional $15 biweekly; coverage for a dependent child is available for $10 biweekly.
Medications are covered with a $10 copayment for both name-brand and generic drugs; no distinction is made between physical and mental health pharmaceuticals.
Employee Assistance Program
When Delta first entered the managed care market, it contracted with MCC for both the EAP and the mental health benefit. Delta soon grew dissatisfied with the external EAP arrangement and decided to manage its own EAP. Delta now contracts with MCC only for mental health coverage.
In the past few years, Delta's internal EAP has grown from a staff of three in the Atlanta office to 12 licensed social workers working throughout Delta's major geographic hubs. Currently, each counselor sees or speaks with approximately 30 employees and family members every week.
The EAP counselors frequently help employees and family members with anxiety, depression, and substance abuse problems. While no limits are placed on EAP visits, in most cases, counselors need about four visits to determine whether EAP intervention is sufficient or outside specialist care is warranted. When a patient experiences no improvement, expresses indications of self-harm or harm to others, or otherwise requires additional treatment, the EAP counselors refer the individual to providers in the managed care networks.
The EAP has reduced significant sources of tension for supervisors by enabling them to refer employees to professional counselors. The EAP staff also can intervene with supervisors to improve employee performance and productivity.
Benefit Management
CIGNA manages the entire health benefits plan, including mental health benefits through MCC and the pharmaceutical benefits plan. CIGNA's national presence allows Delta to maintain administrative simplicity and uniform health benefits across the country. The airline found that CIGNA was one of the few MCOs able to offer such widespread coverage. Delta does contract with other vendors in regions where the vendors have a strong presence.
Although CIGNA manages the benefits, Delta plays an active role in ensuring quality of care. In 1994, it established a Health Services Department to oversee the benefits packages and the EAP. Employee complaints go directly to this department. CIGNA usually responds quickly to accommodate the airline. For example, if a significant number of employees believe that a drug should be included on the formulary, Delta requests that CIGNA add the drug to the list; CIGNA usually complies.
Furthermore, two CIGNA employees have their offices in the Delta Health Services Department, enabling CIGNA to manage complaints directly from Delta's offices. CIGNA also has created a special toll-free phone number for Delta employees.
Key Program Components / Best Practices
Delta places great value on its employees' overall wellness; the airline believes this corporate culture contributes to the average employee retention of approximately 17 years. Key components of Delta's mental health benefit and EAP reflect this dedication.
- Delta works to ensure employee satisfaction in managed care.
When the company moved from fee-for-service to managed care, some employees no longer could see their providers of choice. The company eased the transition by expanding its network and by allowing employees to change providers at will.
The company frequently discusses employee insurance policy problems with CIGNA to effect change and to advocate on behalf of individual employees. Thus, Delta works to prevent exclusions from its pharmaceutical formulary and seeks the input of both physicians and employees in designing it. As a result, the insurance covers most prescription medications. For mental health, the formulary includes many types of antipsychotics and antidepressants.
- Localized EAP improves ability to respond directly to specific employee problems.
In addition to a confidential telephone hotline, Delta's EAP provides a range of employee counseling services. Because the EAP counselors in each area are local Delta employees, they know the corporate culture, the types of jobs, and the characteristics of individuals employed in a certain area. The EAP staff thus can respond to problems on a personal basis and are familiar with challenges specific to Delta employees.
- Benefit design addresses challenges specific to the company's employees.
Because Delta faces industry- and population-specific challenges (such as mental health care for pilots), the airline has designed its mental health benefit to best address these issues. Federal Aviation Administration (FAA) guidelines restrict pilots from flying if they are taking certain prescription medicines, including antidepressants and antipsychotics. The FAA fears not only that the drugs may not work correctly, but also that such medications may make pilots drowsy or have other physiological or psychological effects. As a result, many pilots fear the FAA may ground them if they see a psychiatrist or call the EAP. Although the FAA allows pilots to seek counseling, such concerns create a severe obstacle to appropriate treatment. Moreover, pilots experience high rates of substance abuse and co-occurring depression. Delta's EAP is working to address this industry-wide problem by educating employees that EAP use is confidential and encouraging them to seek assistance.
Employee Satisfaction / Performance Data
Delta continues to monitor CIGNA's performance, conducting surveys of employee satisfaction with CIGNA and with the benefits plan in general. Although Delta has focused primarily on employee satisfaction, the airline plans to analyze cost and utilization data in the near future. Delta also is assessing the effect of adequate mental health treatment on employee physical health since it believes that mental health care may both reduce physical health problems and increase productivity.
The new EAP is the focus of several evaluations, including both a feedback survey of employees who have used the service and an assessment of psychiatrist and pharmaceutical utilization.
Lessons Learned and Challenges Remaining
With only 4 years of managed care experience, the challenges facing Delta in seeking to provide a cost-effective, generous mental health benefit plan are in their earliest stages.
Lessons Learned
- Employers must recognize that mental illnesses and subclinical problems do exist in the workforce. Companies can realize significant benefits by supporting programs and health care plans that provide comprehensive diagnosis and treatment for such illnesses.
- Employers should consider the specific needs of their employees carefully when purchasing benefits. Because standard HMO plans limit the administrative costs inherent in individualization, employers must be persistent to obtain the benefits they desire for their employees. For example, FAA regulations require airline pilots with substance abuse problems to receive inpatient treatment to fly again. As a result, Delta had to be certain that CIGNA would cover such treatment.
Challenges Remaining
- Delta is working to improve employee knowledge of and access to its EAP. Employees worry that revealing a problem to an EAP counselor may hurt their employment or may result in decreased benefits. Furthermore, the stigma associated with seeking mental health treatment persists.
- As the EAP and managed care plans have developed, Delta has begun to study their impact. The company needs to improve its data gathering and monitoring systems. It must evaluate the effects of mental health care on productivity, absenteeism, and disability.
- Delta faces several possible challenges resulting from changes in both the health care field and the corporate climate. Increasing regulatory and financial pressures in the managed care industry may force CIGNA to eliminate its on-site presence and preferred treatment of Delta or to reduce overall administrative staffing levels. Delta's corporate climate continues to change; new leadership may place less emphasis on comprehensive mental health coverage.
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