July 18, 2023

Engineering Mental Health: Building a Strategy from the Ground Up

This Guide informs the development and execution of a comprehensive mental health strategy built on three pillars: 1) Organizational factors that impact employee mental health; 2) Initiatives to promote mental health; and 3) Benefits and programs to treat mental health conditions and substance use disorders.

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Employers play a crucial role in supporting employees and family members with mental health conditions and substance use disorders, as they’re often the primary source of coverage to treat these conditions, particularly in the U.S. Across the globe, coverage and availability of services varies widely by country, but in many cases, large employers provide coverage for mental health services above what is available in-country, especially in regions where the infrastructure for mental health services is very thin. In many cases, the recommendations below pertain to the U.S., but they can also inform what employers should provide to employees in all countries, including those where the health care financing system is different.

While mental health and substance use disorder benefits, including employee assistance programs (EAPs) and virtual solutions, have become table stakes in an employer’s mental health strategy, efforts like leave policies, workplace accommodations and targeted programs to help employees re-integrate into the workplace must also become the norm. As employers continue to invest in and refine benefits, programs and leave policies for employees with mental health conditions and substance use disorders, they must keep in mind and try to solve for the following challenges:

• Inadequate access to care across regions within and outside the U.S.;
• Uneven measurement of care quality and outcomes, as well as poor adherence to evidence-based treatment;
• A history of poor or no coverage of many treatments for substance use disorders, influenced by misunderstanding about their causes and available evidence-based treatments;
• Ongoing stigma within the health care system toward patients with mental health conditions and substance use disorders; even some mental health professionals may dismiss substance use disorders as a “behavior” rather than a condition in need of compassionate treatment;
• High cost of care, especially for people seeking treatment out-of-network, which is often where people can find mental health providers taking new patients; and
• Fragmented delivery, where mental health and substance use disorder programs and providers are unable to share data with primary care and other providers, is a problem particularly exacerbated when using a multitude of virtual solutions.

Supporting Those Living with Mental Health Conditions and Substance Use Disorders

Go “back to the basics” on mental health and substance use disorders:

As a first step in developing a mental health and substance use disorders benefits coverage strategy, certain foundational elements should be in place. Many, if not most, large employers already implement some aspects of the following foundational elements: providing robust access to comprehensive benefits across a spectrum of severity, focusing on integration of benefits and holding vendors accountable. Nonetheless, these elements are worth reviewing and provide a helpful lens through which to view the recommendations that follow.

Ideas for Action

Ensure that these elements are in place and fill gaps where necessary:

• Provide multiple and integrated avenues for plan members to access quality mental health care. This includes: 1) integrating EAPs, mental health and substance use disorder services into other settings of care (e.g., primary care, on-site clinics, surgical care) and 2) providing a robust network of mental health and substance use disorder providers through EAPs and health plan networks. Employers expect high-quality primary care providers (PCPs) to integrate mental health and substance use disorder capabilities into their practice, whether it’s offered in-office or through a close partnership that makes it easy for a PCP to make a referral to a mental health expert. Increasingly, this concept is being applied to other health services and sites of care beyond primary care. For example, someone receiving heart surgery will likely have several limitations after their procedure, which can lead to depression and anxiety, or hinder patients’ ability to do things like exercise that alleviate mental health symptoms.
• Continue holding EAPs accountable. The provision of EAPs is nearly universal: 98% of employers offer some type of EAP in at least some countries, including 38% of employers that offer newer EAP models.¹ These newer models offer mental health care across a continuum of needs and severity, including substance use disorders, through a combination of self and virtual care with providers in a curated network. As employers implement these newer models or manage their relationship with more traditional models, they must continue to push programs to continuously innovate and integrate into the employers’ broader health benefits.
• Cover services that treat the full array of mental health conditions and substance use disorders. There are a significant number of mental health conditions and substance use disorders that require support, making it necessary for employers to evaluate potential gaps in coverage. Employers should pay particular attention to pharmacy services for mental health and substance use disorders, as formulary changes and prior authorization rules that change throughout the year can unexpectedly make coverage hard to find.Another problem is that some evidence-based treatments are not covered in many plans. Note: Outside the U.S., this recommendation, along with the one below, may be difficult for multinational employers to implement because providing coverage doesn’t ensure that the care can be or is provided; some countries prohibit the provision of some types of care that is common in others, or may simply not have sufficient providers.
• Cover medical and pharmacy services across the spectrum of severity for any given condition. Employees may experience varying degrees of severity, thus necessitating several levels of care, ranging from basic coaching all the way to care at an inpatient residential facility.

For additional information, see: Redesigning the EAP: Employer FAQs for Getting Started and Global Employee Assistance Programs: Evaluating EAP Effectiveness.

Press mental health and substance use disorder vendors for quality and outcomes data beyond basic utilization and assessment trends:

Quality measurement in mental health and substance use disorders has historically lagged physical health metrics due to stigma and privacy considerations that make data harder to obtain. Still, employers should press their vendors and providers to provide more than utilization rates and PHQ-9 scores, as these may not indicate whether services are benefiting members. Multinational employers should keep in mind that some data may be easier to obtain within the U.S. than in other countries.

Ideas for Action

Ask current and prospective mental health and substance use disorder vendors and providers if and how they are measuring and reporting the following:

• Percent of in-network providers integrating measurement-based care into their practices.
• Improvement on and resolution of mental health condition and substance use disorder challenges that necessitated treatment.
• Time to treatment.
• Provider quality, including adherence to evidence-based protocols.
• Therapeutic alliance (i.e., a cooperative working relationship between client and therapist).
• Patient-reported outcomes like satisfaction with care.
• Outcomes like emergency room utilization, hospital readmissions and pharmaceutical utilization associated with mental health conditions and substance use disorders.
• Impact of treatment on total cost of care. For example, as mental health and substance use disorder costs increase, are overall costs decreasing as comorbid conditions are alleviated or avoided?
• Access to providers who are concordant with patients across multiple demographics, including gender identity, sexual orientation, race and ethnicity (see below for additional information).
• Other metrics that may show effectiveness of treatment. For example, one school-based mental health vendor is exploring tracking the impact of utilization of their services on student/patient truancy, grade point average or other academic outcomes correlated with overall mental health. Other vendors have begun to assess provider quality using proprietary technology that measures the speech patterns of patients and providers in their sessions, which gives them insight into the impact of providers’ approaches on their patients above the intermittent feedback available through surveys like the PHQ-9 or GAD-7.

Push health plan partners to increase in-network mental health and substance use disorder specialists and hold them accountable for time to care:

About one- third of mental health providers do not participate in health plan networks, compared to about 10% of other specialty and primary care providers.² Inadequate networks of mental health and substance use disorder specialists have led to long appointment wait times, care “deserts,” and high costs for patients who seek care outside the network.

According to one survey in the U.S., four of the top six reasons that people gave for an unmet mental health care need were related in some way to network adequacy.³ The reasons given included not being able to afford care, not knowing where to get treatment, not having time and health insurance not paying enough for services. The average wait time for behavioral health services is 48 days, which can take longer for certain specialties.⁴ This is particularly concerning, given that by the time someone has decided to seek care, they may be experiencing symptoms that need to be addressed expediently.

Ideas for Action

Areas where health plan partners may need to be pushed to increase access include:

• Assessing the adequacy of health plan networks of mental health and substance use disorder services by comparing the percentage of care that is out-of-network across markets and conducting patient surveys to understand the time between when they decided to seek services and when they were able to get them.
• Increasing in-network reimbursement rates to attract more providers. Direct spending on mental health care is a small fraction of overall health care costs, but unmet mental health needs significantly increase the total cost of care for those patients.
• Focusing high-performance networks on primary and specialty care that integrate mental health and substance use disorder services.
• Providing robust telehealth services (if employers don’t have a separate vendor already providing these services, such as through newer EAP models) that can expand access geographically.

Reduce financial barriers to care where appropriate:

Because of the shortages of in-network providers in many markets, patients are about five times more likely to access care out-of-network for mental health services than they are for physical health.⁵ This drives up costs for patients, which can serve as a barrier to care that disproportionately impacts lower-income individuals.⁵ Given that financial stress can contribute to mental health conditions and substance use disorders, employers should continue to look for ways to reduce the cost burden of seeking care.

Ideas for Action

Employers can reduce financial barriers to mental health and substance use disorder care through the following:

• Covering no- or low-cost mental health services through telehealth programs. The vast majority (77%) of employers do this for virtual counseling in 2023.⁶
• Covering out-of-network providers at in-network rates, something that 32% of large employers are doing in 2023.⁶
• Offering low-cost mental health care from on-site or near-site providers, which 32% are also doing in 2023.⁶
• Working with health plan partners to expand networks for mental health services. A handful of employers have created such networks of mental health providers in major markets to increase access to in-network providers covered by the medical plan.⁶
• Covering mental health or substance use disorder medications at low or no cost. In 2023, 16% of large employers are doing this for mental health medications.⁶
• Reducing cost sharing for mental health and substance use providers in high-performance networks (HPNs) and COEs. In 2023, 14% of employers are doing this for HPNs.⁶ Similarly, in 2023, 34% of large employers have COEs in place for substance use disorder and 32% have them for mental health conditions.³⁷
• Addressing fraud, waste and abuse in mental health and substance use disorder treatment in partnership with health plan and other vendor partners. As mentioned later in this section, people who have challenging diagnoses related to mental health and substance use disorder can be taken advantage of by bad actors who may provide inappropriate and unnecessary services and testing, driving up costs and failing to help people in need.

Push vendor partners to offer mental health and substance use disorder services that are culturally competent and in the primary language of the patient:

The need for culturally competent health care services spans conditions and specialties, including for mental health conditions and substance use disorders. Consider this: Black people in the U.S. often receive poorer quality mental health treatment and lack access to culturally competent care.^7,8 Furthermore, LGBTQ+ individuals report stigma and discrimination when accessing mental health care, leading them to delay or forego treatment altogether.⁹

Culturally competent care is important because it addresses many of the barriers to care that marginalized populations experience while seeking and getting treatment. This is why the American Psychological Association considers cultural competence as a core competency of mental health treatment overall.¹⁰ Mental health treatment that is sensitive to differences between cultures and how it impacts mental health and adapts clinical interventions to best serve an individual based on their background increases the likelihood that they identify as needing mental health services, seek care and stick with treatment over time.¹¹ For example, research shows that when Black patients receive care from Black doctors, they report greater satisfaction and quality of care, and new data suggest that Black people live longer in counties with more Black doctors.^12,13

Ideas for Action

Employers can promote culturally competent care for all people by:

• Requiring vendors to include diverse providers in their networks, as well as maintaining provider directories to allow employees and their families to identify clinicians more easily.
• Asking current and prospective vendors about whether they train providers on cultural competency.
• Asking vendors to include questions about cultural competence in patient surveys, such as whether their provider understood and respected them throughout the course of care.

Assess the connection between employee leave programs and mental health and substance use disorder benefits:

Employers have numerous considerations when designing leave for mental health conditions and substance use disorders. For employees seeking leave for these conditions, the need for an accelerated approval process is higher than for other types of leave, which may be planned or less pressing. Additionally, many mental health and substance use disorder providers do not consider approving the clinical necessity of leave as a part of their job responsibilities and may claim that they cannot share clinical information because of privacy requirements, which can lead to delays in access.

Ideas for Action

Employers can remove barriers to leave for mental health conditions and substance use disorders by doing the following:

• Providing a grace period for people taking leave for mental health conditions and substance use disorder to help them take leave immediately, rather than requiring clinical approval beforehand.
• Pushing organizations that provide mental health services, including EAP vendors, to require their providers to fill out clinical paperwork for leave approval in a reasonable amount of time. One employer has created its own form that requires less clinical information, but still includes a sign off from a provider before an employee can take leave for mental health conditions and substance use disorders.
• Communicating the availability of leave benefits for mental health conditions and substance use disorders. One employer says that the main barrier to employees benefiting from mental health and substance use disorder leave is a simple lack of knowledge. Manager communication about the ability to take this kind of leave can reduce stigma or concerns that taking leave for mental health conditions and substance use disorders will threaten their employment.
• Considering how mental health conditions and substance use disorders associated with other life events may necessitate leave; for example, 29% of employers offer leave for people after a miscarriage, a significant life event that without support can lead to downstream mental health conditions.¹⁵

For more information, see: Time Away: A Valuable Well-being Asset.

Creating a Minimum Global Standard for Mental Health and Substance Use Disorder Benefits

Ideas for Action

There are several steps employers can take to align benefit design with appropriate treatment:

• Auditing mental health benefits and programs with the assistance of clinical experts to confirm alignment of evidence. For employers with locations outside the U.S., a first step will be auditing what treatment is actually available before looking at alignment with the evidence. In the U.S., this process should include auditing health plan partners to ensure that they are appropriately processing claims for mental health and substance use disorder treatment that are covered under federal mental health parity law.
• Working with the health plan to ensure that in-network providers of mental health services deliver evidence-based therapies (EBTs) appropriate for the condition of the patient. EBTs are a baseline measurement of appropriateness in mental health services, but research suggests that a majority of providers in the U.S. do not deliver these treatments.²⁰
• Ensuring that communications to employees about mental health programs and benefits focus on directing them to evidence-based care.
• Implementing COEs that align with the best outcomes and adherence to clinical guidelines for mental health and substance use disorders. In 2023, 32% of employers currently have COEs in place for mental health, and 34% do so for substance use disorders.⁶
• Covering medications to treat substance use disorders, such as methadone or buprenorphine. Make sure that HPNs or COE facilities for substance use disorders provide these medications.

For more information, see Substance Use Disorder: An Employer’s Strategy Resource.

Assess the mental health and substance use disorder services offered by current partners (e.g., health plans and networks, mental health vendors, on-site clinics) for potential redundancies and seek opportunities to improve the employee experience:

With the marked expansion of mental health benefits and programs in recent years, particularly for virtual health solutions, there are more options than ever for people to obtain services for mental health and even substance use disorders. However, this may also mean that employees may be confused about where and how to seek mental health care. Furthermore, a large number of benefits can also mean that there is a greater chance of duplication, leading to increased costs for the organization. While providing multiple access points can be an important part of an employer’s mental health strategy, it should be intentional and thoughtfully designed with the employee experience in mind.

Ideas for Action

Employers can assess the employee experience with benefits and programs by:

• Documenting all the vendor partners, service providers and clinicians that offer mental health and substance use disorder services, including what they offer and to whom, highlighting any potential areas of redundancy, as well as potential gaps.
• Listing all the ways that employees and their families can access available mental health and substance use disorder benefits and programs (e.g., through health plan, advocacy/navigator, EAP, engagement or well-being platforms), as well as points of integration between services, documenting areas of strength and opportunities for further enhancement.
• Examining the employee experience in accessing mental health and substance use disorder benefits when they need them, such as through interviews, focus groups and/or journey mapping. When combined with the actions above, this may assist employers in understanding opportunities to fill in potential gaps, identify points of duplication, strengthen communication and enhance integration.
• Assessing any new potential vendor contracts with an eye to duplication of services, evidence of effectiveness and ability to integrate with other benefits and services. Requests for proposals should assess the willingness and capabilities of mental health and substance use disorder vendors to share data and cross-refer.

Child and adolescent mental health issues were brought sharply into the spotlight during the COVID-19 pandemic and remain an important area of concern for societies across the globe. For plan members who are 18 and under to be best supported by employers, they need: 1) benefits that address a spectrum of mental health conditions, 2) caregiving resources and policies that enable parents to focus on their children’s mental health and 3) a company culture that encourages parents to use these benefits. Even before the COVID-19 pandemic, Generation Z was much more likely to characterize their mental health as poor (27%) compared to millennials (15%) and Gen Xers (13%.).²⁴

Ideas for Action

Employers can support child and adolescent mental health through the following actions:

• Making mental health support programs available to kids under 18 where possible. There are legal, logistical and privacy reasons that explain why not all vendors offer services to children and adolescents, but many are expanding services as the need becomes increasingly clear.
• Communicating frequently about the availability of child and adolescent mental health and benefits. This can be done in conjunction with other mental health communications. For example, if you are communicating about the availability of a new caregiver benefit, you can include references to other benefits you have for dependents who may have mental health challenges.
• Working with health plan vendors and virtual mental health providers to ensure that their networks have an adequate number of specialists trained to care for people under 18.
• Covering applied behavioral therapy (ABA) and other services that are associated with adolescent mental health. These services are often mandated by state law that do not affect self-insured employers for the most part.

Many of the challenges for the mental health of young adults aged 18-25 mirror those experienced by adolescents. This age cohort, born between 1998 and 2005, experiences elevated rates of anxiety, depression and suicide compared to their older peers.²⁵ In 2023, this group also experienced unique stressors as they entered young adulthood. First, their high school, college and early careers were disrupted by a global pandemic, challenging their social relationships, stunting them in workplaces, losing friends and loved ones to COVID-19. Second, since 1998, there have been over 380 school shootings in the U.S., directly exposing more than 350,000 school children to gun violence in a setting that should be a safe learning space.²⁶ And third, this age cohort was one of the first to grow up with ubiquitous social media, creating new avenues for exposure to bullying, digital addiction and physical separation.²⁷

Ideas for Action

Employers can support child and adolescent mental health through the following actions:

• Consider the ideas for action mentioned above related to suicide prevention.
• Normalize conversations in the workplace about mental health. Young adults want to be able to talk about mental health in the workplace, especially in light of the fact that 75% of Gen Zers report leaving a job for mental health reasons.²⁸ See the section in Pillar 2 for ideas on normalizing discussions about mental health.
• Create opportunities for social connection for workers early in their career. A global pandemic forced many in this age cohort to avoid formative in-person social interaction that can lead to friendship, mentorship and engagement with their work. The increased prevalence of remote work for this group, particularly for white- collar workers, requires employers to think differently about creating connections between employees across age spectrums.
• Ensure that your health plan vendor networks include coverage for mental health providers nationally; many college-aged individuals live separately from their parents but remain on their benefit plan. Local solutions and network approaches may not serve this group well. This group requires a different approach for communications of the mental health services available to them because they often do not live with their parents but remain dependents on the plan.
• Ask your mental health vendors how they are providing age-appropriate services for young adults. Given the challenges mentioned above that have disproportionately impacted this cohort as they transitioned into adulthood, there may be different types of expertise or backgrounds of mental health providers that could benefit them.

Suicide and the mental health of children, adolescents and young adults are topics that significantly impact employers’ current and future workforce. Gen Z has much higher reported levels of poor mental health, and younger populations are more likely to attempt and die by suicide. To be an employer of choice in 2023 and beyond for younger workers, a deep commitment to supporting the mental health of the workforce is necessary.

For more information, listen to: Forget What You Think You Know About Gen Z and What’s Behind the Youth Mental Health Crisis?.

Conclusion

The time is now to transform the groundswell of support for mental health into a comprehensive employer strategy that addresses the mental health of all employees. A comprehensive strategy will weave together efforts to: 1) systematically improve organizational factors that may impact employee mental health, 2) promote positive mental health among the workforce and 3) provide robust benefits to treat mental health conditions and substance use disorders. Importantly, employer efforts to develop a comprehensive strategy should be ongoing to account for the fact that the organization and the workforce is always evolving. Routine assessment of the strategy and its alignment with employee needs will be critical as employers continue to forge a path to better mental health.

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