Costs

1
Costs Interventions Depressive Disorders in
the Workplace

• Daniel J. Conti, PhD
• VP / EAP Director

2

• 6th Largest U.S. Bank Holding Company
• Largest Visa Card issuer
• Over 1,800 banking centers
• 75,000 employees
• 6/1/2004 Merged with JPMorganChase

3

• 3rd Largest U.S. Bank Holding Company
• Over 3,000 banking centers
• 1.2 trillion assets under supervision
• 2nd largest credit card issuer in U.S.
• 170,000 employees
• 140,000 U.S.

• 6th Largest U.S. Bank Holding Company
• Largest Visa Card issuer
• Over 1,800 banking centers
• 75,000 employees
• 6/1/2004 Merged with JPMorganChase

4
Observing the Costs of Depression and Other M.H.
Problems in the Workplace

• Medical plan
• Pharmacy plan
• Presenteeism / productivity
• Short-term disability (STD)

5
Depression Medical Plan Costs

• After significant study in the 1980s 1990s,
  now almost impossible to track by employers
• Most larger companies have employees enrolled in
  a variety of plans with different benefits
• The near exclusivity of MH carve-outs to MCOs
• Mercer/Foster Higgins Survey (1997) MH SA
  costs had dropped to 3 of employers total
  medical plan outlays in 1997, compared to 10 in
  1988.

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Pharmacy Plan Costs Antidepressants
7
Work Limitations Selected Medical Conditions
Source Burton, Pransky, Conti, et al.
JOEM.200446S38-S45.
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Work Limitations Health Risk Factors
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Psychiatric Disability Costs Rising...

• Early 90s Psych Disability Rates Double
• UNUM life Insurance Corp. (1996)
• Health Insurance Association of America (1995)
• Global Burden of Disease (1996)
• 1990 Depression is 4th leading cause of
  worldwide disability
• By 2020 Depression will rank 2nd

10
Psychiatric Disability Costs Rising...

• Social Security Advisory Board (2001)
• Mental impairment has become the largest single
  reason for SSDI awards
• Grew from 11 in 1980 to 22 in 1999
• State agency administrators examiners report
  more than half or more of the cases they process
  involve issues relating to mental impairment

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Psychiatric Disability Costs Rising...
Source U.S. Commission on Civil Rights, 2000
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First Chicago NBDJPMC Psych STDPrimary
Diagnostic Categories

• 1989
• 7th leading cause of an STD event
• 4th in total STD days
• 1997
• 3rd leading cause of an STD event
• 2nd in total STD days

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First Chicago NBDJPMC Psych STDPrimary
Diagnostic Categories

• 2000 - 2002
• 2nd leading cause of an STD event
• 2nd in total STD days
• Longest average duration
• 2003 2005
• 3rd leading cause of an STD event
• 2nd in total STD days
• Longest average duration

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Psych STD 1985-2005
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Psych STD Events
per 1,000 Ees, 1985-2005
16
Avg. Growth Rates of STD Events, 1985-2005
17
Combined Med-Surg STD Events
Psych STD Events
10.4
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2005 Psych STD Dx Categories
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Interventions

• Screening
• Psych STD management
• Disease management
• Education

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Screening for Depression

• JPMC Health Risk Assessment
• Contains Depression, Anxiety CD screening
  questions
• Contains questions on disease treatment
  identification
• Contains productivity questionnaire

21
Screening for Depression

• JPMC Health Risk Assessment
• About 24 of respondents score positive for
  follow-up message
• 14 of respondents report history of Dxd
  depression

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Depressions Association With Other Health Costs

• 2002 HRA and STD, med pharm plan costs
• Ee with Hx of Dxd depression
• STD cost 571
• Medical pharmacy costs 4,188
• Ee without Hx of Dxd depression
• STD cost 287
• Medical pharmacy costs 1,896

23
Employers Are Beginning to Notice Psych
Disability

• 2005 Watson Wyatts Staying at Work Survey
• 56 The continuous rise in employees MH claims
  is a top concern
• 75 MH issues continue to be the leading cause
  of STD claims

24
Psych STD Return to Work Issues

• W. M. Mercer (1998) survey
• RTW is more difficult following psych disability
  than after physical disability (53)
• Most common problem in RTW following psych
  disability employee reluctance to return (74)
• 2005 Watson Wyatts Staying at Work Survey
• Only 1/3rd of companies report RTW processes
  specific to MH claims

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JPMCs Approach to Managing Psychiatric
Disabilities

• Front end assessment intervention with MH
  professionals
• Require employees be in active mental health
  treatment
• Establish dialogue with behavioral health plans
  providers concerning expectations and monitoring
• Immediate expectation for return to work plan as
  part of treatment
• Aggressively separate true disability from
  workplace issues
• Integrate with EAP
• Carve-in behavioral health to all disability

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Need to Screen for Comorbid Depressive Disorders
in Med-Surg STD Cases

• Depressive Disorders are a Common Comorbid
  Condition with Med-Surg Disability
• 1995 study Complex cases produce longest STD
  durations
• 2x Longer durations than average Med-Surg case
• 37 Longer durations than average MH case

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Impact of EAP Management on Psych STD

• Outcomes
• Overall duration to FT RTW (1989-2005) Little
  change

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Psych STD Average Durations to Full-Time RTW
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Impact of EAP Management on Psych STD

• Outcomes
• Overall duration to FT RTW (1989-2003) Little
  change
• Began an aggressive PT RTW program in 2002.
• 2003 data
• 24 of cases returned on a PT RTW basis
• Avg duration to PT RTW 39 STD days (compared to
  overall, 43 STD days)
• Avg duration of PT 15 workdays
• Overall 12-mo. recidivism 9 (compared to 17 in
  1989-1992)

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The Capacity for Disease Management via
Integrated M.H. Disability Management

• Integrated, internal STD management process
  allows enhanced follow-up support after return
  to work
• Need for medication compliance support

31
Medication Persistency Analysis SSRIs in
Pharmacy Plan, 2003 2004
32
MPR
Sum of days in an analysis period Length of
the analysis period (in days)

Pt. 1
Pt. 2
Dec.
Jan.
Feb.
March
May
April
MPR for Pt. 1 120 days / 180 days 0.67 MPR
for Pt. 2 90 days / 180 days 0.5
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Antidepressant Adherence Study
34
Antidepressant Adherence Study
A retrospective observational analysis with an
identification period, six-month index period and
one-year follow-up period.
Design
35
Design
Identification Period index date is the first
antidepressant fill for each subject any time in
this period
Jun 29, 2000
Jan 1, 2004
Jan 1, 2000
Dec 31, 2004
Pre-Index Period (180 days before index date)
Follow-up Period (365 days following index date)
36
Antidepressant Adherence Study
A retrospective observational analysis with an
identification period, six-month index period and
one-year follow-up period.
Design
Data Source

• De-identified employee data files were used to
  locate study subjects. The following data files
  were linked
• Personnel files (2000-2004)
• Pharmacy claims records from a single pharmacy
  benefit management organization (2000-2004)
• Employees short-term disability (STD) claims
  (2000-2004).

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Antidepressant Adherence Study
Population
Inclusion criteria subjects prescribed an
antidepressant (SNRIs or SSRIs only) during the
identification period. Subjects currently
employed and receiving continuous pharmacy
benefit coverage during the pre-index and
follow-up periods who are 18 or older.
Exclusion criteria subjects with an
antidepressant pharmacy claim in the pre-index
period (180 days). Subjects with a prescription
fill of an antipsychotic medication in the
pre-index and follow-up period.
38
HEDIS Treatment Adherence Criteria

• Acute Phase (114 days)
• Individuals need to fill a sufficient number of
  prescriptions to provide medication for at least
  84 days (12 weeks)
• Medication gaps due to washout in changing
  medication or gaps to refill medication can total
  a maximum of 30 days during the 114-day period
• Continuation Phase (231 days)
• Individuals need to fill a sufficient number of
  prescriptions to provide medication for at least
  180 days
• Medication gaps due to washout or refills can
  total a maximum of 51 days during the 231-day
  period

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Antidepressants Included

• SSRI Antidepressants
• Citalopram
• Escitalopram
• Fluoxetine
• Fluvoxamine
• Paroxetine
• Sertraline
• SNRI Antidepressants
• Venlafaxine

• Miscellaneous Antidepressants
• Bupropion
• Mirtzapine
• Nefazodone
• Trazodone

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Study Sample Selection
Pharmacy subscribers
of employees in personnel
of pharmacy subscribers
of pharmacy subscribers
final study population
N4456 subjects were excluded due to use of
antipsychotic in pre- or post-index (N298), use
of other antidepressants in pre-index (N371),
pre-index period less than 180 days (N2120),
post-index period less than 365 days (N1320), or
employment terminated during post-index (N347).
41
Characteristics by Acute Phase Adherence
42
STD Absences by Acute Phase Adherence
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Characteristics by Continuation Phase Adherence
44
STD Absences by Continuation Phase Adherence
45
Employees Filing any STD Claim during Post-index
period by Treatment Adherence Status
46
Conclusions

• Patients who adhere to either acute treatment
  regimen or continuation treatment regimen are
  30-40 less likely to file an STD claim within
  one year of starting treatments
• Assuming an average cost of salary and benefits
  of 200 per day, the annual cost to a corporation
  of 70,000 employees for lost short term
  disability productivity related to non-adherence
  with anti-depressant medications could
  potentially be 1,044,000.

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Workplace Education Re Depression

• Positive outcomes
• Awareness materials
• EAP WorkLife internet
• Printed materials in Occ Health offices
• HRA reports
• Managerial training
• Workplace seminars on mental hygiene topics

• Neutral to negative outcomes
• Workplace seminars focused on identification of
  disorder