Employee Assistance Research Foundation

Background Documents

Resources: Background Documents


About the Employee Assistance Research Foundation

Bernie McCann, PhD, CEAP

In Volume 23 of the Journal of Workplace Behavioral Health, Carl Tisone wrote: “It will come as no surprise to anyone working in the Employee Assistance field that we are facing a perplexing dilemma. This dilemma impedes our effectiveness as practitioners; and threatens our very existence as a profession. I am referring to the increasingly visible phenomenon of commoditization of EAPs…I call for support to create an independent EA research body bring professional legitimacy to our field though evidence-based research on the efficacy of EAPs.”(Tisone, 2008). Mr. Tisone’s remarks are reflective of his long, successful career as an external provider of EAPs, and his Call to Action was intended to speak to the future existence and vitality of the Employee Assistance movement.

Coincident with this Call to Action, a group of concerned individuals was meeting and planning the establishment of the Employee Assistance Research Foundation (EARF), a 501(c)(3) non-profit foundation dedicated to support academically rigorous research of the highest scientific quality. As chartered, this new foundation’s mission and goals include setting an EAP research agenda, providing a vehicle to make strategic research grants, and disseminating results of these research findings to EAP purchasers, practitioners, researchers, policy makers, and others.

Funded Research Progress – In March of 2011, with its governing board and structure firmly established, the Foundation made its initial two research grants to study the current state of the EAP field. One was awarded to ISW Limits, a spin- off of Leuven University in Belgium in partnership with Clinica CAPA and the Universidade Autónoma in Lisbon, Portugal for their proposal, EAPs in Continental Europe: State of the Art and Future Challenges. Principal Investigators Debora Vansteenwegen, PhD, and Manuel Sommer, PhD have authored a report entitled Eureka: An Employee Services Perception Study in Continental Europe, presented findings to professional conferences, and are currently at work on submission of their results to a peer-reviewed journal.

The second grant was awarded to the National Behavioral Consortium, a not for profit trade association of regional EAP and MBHO companies for its proposal, Comparative Metrics for the External EAP field. Employing an online survey methodology, Principal Investigator Stan Granberry PhD and colleagues collected extensive information from external EA providers with the local, regional, national and international contracts serving thousands of work organizations and millions of workers and their families, making it the largest and most wide-ranging study of the EAP provider universe to date. This unique and major study is the only contemporary profile of external EAP vendors. The study’s findings provide an unparalleled view of current characteristics of the contemporary EAP market, representing 82 EAP vendors and incorporating over 150 unique data points, providing a first ever comprehensive look at this major market EAP segment. This document marks the publication of the first peer-reviewed article funded through the grant-making efforts of the EARF.

Current Research Funding – In July 2013, the Foundation announced its most recent and largest research grant for a study proposed by the OMNI Institute in Denver, CO entitled The Impact of Employee Assistance Services on Workplace Outcomes. The Omni research team headed by Principal Investigator Melissa Richmond, PhD and Co-Investigator Randi Wood, CEAP will conduct a 14-month study of the Colorado State EAP. This rigorous study will use a quasi-experimental design to examine casual relationships between work-related outcomes and use of the EAP, and attempt to 1) quantify the impact of EA services on absenteeism, presenteeism, and workplace distress; 2) identify circumstances under which EA services are most effective; and 3) estimate cost-savings in reductions in absenteeism directly attributable to EAP. The State of Colorado employs over 83,000 workers in many different occupations with a wide variation in demographics, education levels, and training. The large and diverse worker population will enable the study’s findings to be generalizable to many worksites, and not limited to specific industry settings. Preliminary results of this research project are expected to be released towards the end of 2014.

Future Research Efforts – In an address to the 2007 EASNA conference, Paul Roman, PhD, co-author of the EAP Core Technology, rightly noted that the lack of hard data has severely weakened the EA profession, undermining its credibility and future survival. Much of the information available about the EAP industry and its effect on workplace productivity has significant limitations (Merrick et al, 2007). With a few exceptions, there is little experiential data regarding basic metrics and effectiveness, and in general the development and use of solid outcome measures and analytics in our field has progressed far too slowly (Sharar, Bjornson & Mackenzie, 2012). In the current economic environment, if EAPs only provide subjective assessments of their worth, the lower the pricing for (and the perceived value of) EA services will become. In the future, EAP value needs to be able to demonstrate that it meets the needs of employers and to quantify its impact and outcomes (Burke & Sharar, 2009). To paraphrase Dee Edington in his recent book, Zero Trends: Health as a Serious Economic Strategy, hopefully, the successful work organizations of the future will move beyond simply finding the best-priced benefit plans and insurance policies, to an informed view which allows purchasers to identify the best strategic value available in a benefit plan and insurance policy. It is this precise point the Foundation seeks to illuminate. It is the driving force of the EARF’s mission of funding and disseminating credible, empiric evidence of a solid foundation which underpins the program models, services and individual techniques we practice. The Employee Assistance field is at a juncture. As stakeholders, is vital we act now to preserve our past good efforts and ensure our continued market presence. For more information about the Employee Assistance Research Foundation, please visit our website, www.eapfoundation.org.

References

Burke, J. & Sharar, D. (2009) Do ‘Free’ EAPs Offer Discernible Value? Journal of Employee Assistance. 39(3):6-9

Edington, D. (2013) Zero Trends: Health as a Serious Economic Strategy. Ann Arbor, MI: Health Management Research Center.

Merrick, E., Horgan, C., Volpe-Vartanian, J. & McCann, B. (2007) Revisiting EAPs & Workplace Substance Abuse: Key Issues and a Research Agenda. Psychiatric Services. 58(10):1262-1265.

Sharar, D., Bjornson, T. & Mackenzie, A. (2012) The State of EAP: Observations from the Trenches. Journal of Employee Assistance .42(1):20-23.

Tisone, C. (2008) Employee Assistance Research Foundation: A Call to Action. Journal of Workplace Behavioral Health 23(3):205-213.

Bernie McCann is a Development Consultant with the Employee Assistance Research Foundation and an independent consultant and researcher in the area of workplace behavioral health. He may be reached at mccannbag@gmail.com.

Observations from the Trenches on the State of the EAP Field

David A. Sharar, Ph.D., Tom Bjornson & Alex Mackenzie, MFT, CEAP

            We intend to provide a glimpse of what is currently going on in the field of EAP. First the bad news: our field is currently in peril for two reasons: 1) slowness in demonstrating how EAP adds value to the organizations we serve; and 2) the flawed process through which EAP services are contracted. Now, the good news: as a field we are in a position to address both of these problems.

Even the best information available about the EAP industry has significant limitations. With a few exceptions (most notably Open Minds and Dr. Tom Amaral), there is little data regarding characteristics and basic metrics. We lack operational definitions for the terms we use: “What is a ‘true’ annualized utilization rate?” “What percentage of EAP cases are work/life or financial/legal versus short-term counseling?” “What percentages of cases are by phone or online versus face-to-face counseling with a clinician?” “What is the average number of sessions in a typical EAP case?” These and other questions will hopefully be addressed by the national “Benchmarking in EAP” study underway by Dr. Stan Granberry of the National Behavioral Consortium, and sponsored by the Employee Assistance Research Foundation.

According to Open Minds’ 2011 Market Industry Report, the ten largest firms control about 78% of the EAP market. Not much has changed since Open Minds’ previous report in 2002, which indicated that the top six firms covered roughly 70% of the cumulative share. The 2011 report noted a remarkable increase in so-called integrated models, meaning EAPs are now routinely bundled with Work-Life or Managed Behavioral Health as a “one-stop shop” program for purchasers. EAP “only” enrollment stood at 55.1 million; down 12.3%. Meanwhile, integrated programs jumped 285% from roughly 80.2 million in 2002 to 309 million in 2011. This number, however, lacks validity, as there are only about 309 million people in the U.S.

Acting like a successful business: strategy and innovation – In terms of a business product life cycle, it’s time for service innovation in the EAP field. But innovation doesn’t have to mean ripping out the core, as many businesses in the mature life cycle do, but it can mean redefining, adding or integrating features, and repackaging. Many EAP firms are working on just these sorts of strategies. But is this good?

Beyond bundling with Work/Life and Managed Behavioral Health Care, providers are developing proprietary “breakthrough” (but easily copied) products that complement or are attached to an EAP. Some of these new EAP-type products seem akin to the past housing boom’s financial inventions, like floating rates, reverse amortization, and sub-prime loans. In their own way, some EA firms are like mortgage banks were “in the day,” slicing up EA services and gluing them back together into new, re-structured, integrated products such as Life Coaching, Life Management, and so on.

From a market perspective, Dr. Tom Amaral of EAP Technology Systems attempted to define the different segments and numbers of EA providers by analyzing data from his firm’s proprietary warehouse. Although not yet published his findings, he presented the “Seven Market Segments of the EAP Industry” at the World EAP Conference in Tampa in 2010. These estimates appear to be the best effort to date to define the total number of EAPs by market segment. Amaral conservatively estimates a minimum of 1,600 providers of EA services in the U.S. – 900 more than Open Minds identified in their recent report. One conclusion that could be drawn is that little is really known about the state of contemporary EAP in the US. The apparent growth in EAPs has not been accompanied by a rigorous examination of the similarities and differences of the various vendors and models.

Table 1

Number   of Employee Assistance Programs in Each Market Segment

Market Segment

Number   in Segment

Provide   Internal Services

Provide   External Services

Fortune   1000 EAPs

150-250

150-250

Government   EAPs

250-360

250-350

10-20

University   EAPs

175-250

175-250

10-20

National   EAPs

30-40

30-40

Local/Regional   EAPs

400-600

400-600

Health   Care EAPs

500-750

450-700

375-600

Union   Programs

100-250

100-250

100-250

Total

1605-2490

1125-1800

925-1530

Source: Amaral, T. (2010) The Seven Market Segments of EAPs.

Presentation at the EAPA 2010 Annual World Conference. Tampa FL. October 7, 2010

Perhaps another conclusion we can draw from Open Minds and Amaral’s work is the vast majority of American workers have access to an EAP (or EAP-“like” service), and the field is saturated with a variety of EA providers. The goal for many of them is to gain more market share by capturing more covered employees already covered by a different provider – competing fiercely to have the total employee pie re-distributed.

If the status quo remains – It seems safe to infer that even with uncertain numbers, EAP is fundamentally changing and is likely dissipating as a specialized field or a “stand-alone” program. But there is a more fundamental issue – the field’s reluctance to demonstrate its value concretely and quantitatively, leading to our ultimate demise if we don’t break out of our “price-driven box.”

As a field, we haven’t figured out how to differentiate on the basis of real performance – or how to find purchasers who are willing to pay fair prices for true value. We simply do not operate in a rational capital market that channels higher rates to those who most significantly deliver results. Ironically, the profession whose stock and trade involves listening has not done a good job of listening to our constituents about what is important to them, so that we may deliver it. Instead, we’ve believed the worst – that what they care about most is price.

The new breed: differentiating and developing based on analytics and outcomes – The trend toward EAP as a commodity is partly our own fault. In general, the development and use of solid outcome measures and analytics in our field has progressed far too slowly. However, a few EA firms have quietly shifted the battle and relied on their strengths – delivering highly responsive, results-oriented services and then communicating to the purchaser the added value being delivered. How did they do it? They aligned value and price and thoughtfully communicated the value being provided. They created a system for reliably gathering and analyzing data for each component of their EA service, and the impact of results on key business drivers such as productivity and containing health care costs. The key was to document and precisely quantify their activities and outcomes, which led to tangible value appreciated by the purchaser. This type of supporting data leads to a more real, enduring partnership with the purchaser about sustaining rates – or at least a discussion about why a cheaper or “free” EA service actually causes the client organization to lose value.

Every EA firm calculates simple descriptive statistics about client demographics, utilization, and program activities. However, this “new breed” is moving beyond simple calculations as their primary form of reporting. They are also doing things like measuring the workplace effects of EA intervention using credible before/after measurement designs, and pooling EA data with data from employers and external vendors, such as absenteeism records, health risk assessments, and others. In other words, they are differentiating themselves by harnessing better data and using statistical processing to help purchasers get real facts. More tangible results are what wins accounts, not low price or inflated utilization numbers. What matters most is rigorous evidence on what you and the client agree upon as great results – be it improved work performance, less presenteeism or absenteeism, etc.

The price-competitive environment in EAP – to be blunt – does not reward and retain the best providers, nor does it maximize the value provided to business. Strategically speaking, the key is to simultaneously sort out “early adopter” purchasers by understanding how to distinguish valuable “service” from those who just want a “commodity” at the lowest price possible.

Shifting focus: a mission for success – Every EA firm needs to make money, but making money isn’t our mission, but rather an outgrowth of being “the best we can be at what we do.” The critical question for EAP providers is not, “How much money do we make once expenses are subtracted from revenues?” but, “How effectively can the organization make an impact, or obtain results that matter to the client organization?” The time has come to put at least as much energy into measuring workplace outcomes as we do in measuring our financial status. Performance should be assessed relative to our purpose.

In his Business Week best seller, “Good to Great”, author and researcher Jim Collins indicates that in business, money is both an input (a resource to achieve results), and an output (a measure of success). In organizations with a health or social purposes (including for-profits), money is primarily an input, and not a measure of greatness. The urgent goal, as a field, is to hold ourselves as accountable for improved progress in outputs (e.g. improved work performance) as we do in finding ways to make money with capitation rates as low as $11.00 PEPY. The latter should no longer be viewed as a successful output.

The broken procurement process – Consider the companies that offer a gratis EAP service with the purchase of an insurance product – when of course the EA services are not really free but buried in other charges. What these companies do to the field is muddy the true cost-benefit equation and make it more difficult for purchasers to determine the true value of an EA service. When something is free for any length of time, the perceived value gradually erodes. Put another way, if something previously cost money and now does not, buyers logically tend to correlate that with a decline in quality or value. Inevitably, that perception becomes reality as suppliers water down products and services in order to survive. Ultimately, client organizations come to feel entitled to receiving EAP services for free.

In addition, the procurement process itself is broken. Many EA firms regularly slog through a Request for Proposals (RFPs), a hodge-podge of previously used RFPs that are long on rhetoric, but short on separating mediocre from superior providers. These RFPs are full of mandatory questions about areas unrelated to actual performance or quality. Many EA firms discover their proposal is just one of many that allow purchasers to satisfy internal bidding requirements, or worse, the unsuspecting bidder is part of an intelligence gathering exercise and has squandered their resources for an opportunity that never materialized. In other words, competitive bids are often used by purchasers to drive down the existing vendor’s price, and never any intent of changing vendors. The RFP process is merely a mechanism to keep the current vendor in line or to bag a new idea. Consultants, brokers, and even employers will admit that many RFP responses are not helpful in determining where purchasers get the best value.

Summary

While we are known for listening, we must apply that skill to market research to discover our purchasers’ needs and values so we can deliver them. For our field to be sustainable, we must define our mission in service-oriented terms, and demonstrate how we deliver measurable results. The value proposition that got us started – that a “win-win” exists between individual and organizational health and productivity – is still valid, but we must be more innovative in order to respond to the increasingly dynamic business environment of our corporate clients. To avoid being devalued to the point where there is no viable EAP business, we need to stop treating ourselves, our services, and our clients as commodities. Only by using these basic business approaches and seeing our client relationships as partnerships – rather than through a vendor-customer transaction-based businesses – can we break out of this cycle.

Dave Sharar is the Managing Director of Chestnut Global Partners and a researcher with Chestnut’s Research Institute in Bloomington, IL, where he focuses on workplace behavioral health. He may be reached at dsharar@chestnut.org. Tom Bjornson is Chairman of Claremont Behavioral Services and an early EA pioneer. He can be reached at tbjoronson@claremont.com. Alex Mackenzie is Senior Account Manager and Management Consultant with Claremont. Contact him at amackenzie@claremonteap.com.

Preparing for the Challenges of the Employee Assistance Research Foundation: A Response to Carl Tisone’s Call to Action

John C. Pompe & David A. Sharar

Much fanfare surrounded the inaugural meeting of the Employee Assistance Research Foundation at the 2007 World EAPA Conference in San Diego this past October. The naming of Dr. Paul Roman, Distinguished Professor of Sociology, University of Athens–Georgia, as senior advisor to the EARF Board and a pledge of matching financial support from the Carl Tisone Family Foundation formalized the presence of this organization within the professional world of Employee Assistance Programs. The event was a true milestone for the EAP field, and Tisone deserves our recognition for organizing this initiative. Now that the standing ovations have quieted and we have all returned to our varied rolls in doing work loosely defined as EAP, the infant EARF is charged with a not-so-simple question, ‘‘Now what?’’

Carl Tisone issued a paper, Employee Assistance Research Foundation: A Call to Action (2008), which laid the foundation for the EARF and created the gauntlet that was thrown down by Dr. Roman at the World Conference. The voices of Roman, Tisone, Paul Heck, DuPont’s Worldwide Director of EAP, Dale Masi, President of Masi Research Consultants, and a collective who’s who of the EAP industry attending the conference resonated with many. Although celebration is in order, Tisone’s call to action should be viewed as a wake-up call. While we have been busy doing our good work, the world of EAP has moved, without guidance, from under our feet and in the wrong direction.

Is Research a Cure For What Ails Us? – Few will disagree with Tisone’s indictment in his paper that there is an absence of significant empirical evidence showing that EAP, in any of its shapes and sizes, offers measurable business-relevant value. To clarify, this is not to suggest that EAP offers no value. Rather, the implication is that we can’t prove that it does. The gold standard of research, the randomized controlled study, is nonexistent in the contemporary EAP world. We also know from other research in the behavioral sciences that merely publishing and disseminating empirical research may not lead to major changes in practice.

Working with or inside company medical departments, we are surrounded by physicians whose professional existence is more grounded in evidence-based practices. Although our colleagues in the field of medicine do not completely dismiss our labors, in their eyes what we bring to the table lacks empirical evidence. If the practice of psychology is a soft science, then the practice of EAP is floating in a sea of watery Jell-O.

Let us play devil’s advocate. Is that level of scrutiny necessary? Does EAP really need to be held to the same standard of proof as medical science? At the San Diego EAPA Conference, Heck (2007) commented that to cement EAPs’ legitimacy and, as a result, secure the future of internal or highly integrated external programs and break the commodity trap. EAPs need to be viewed as legitimate business entities in the same manner as accounting, human resources, and legal departments. When was the last time that attorneys, accountants, or HR professionals were required to run a randomized control trial of their daily activities to justify their existence and command respect as a ‘field?’ It’s not likely that they ever have. The fact is that businesses could not run without these functions – and that is the evidence of their value. EAPs, however, cannot make that claim. Outsourcing and budget cutbacks threaten the status quo of these corporate entities just as the EAP has been threatened. These corporate service entities will not disappear; although the integrity of their work continues to be challenged through many of the same pressures EAPs have experienced. Paul Heck’s analogy, though instructive, falters because EAPs don’t hold that same immediate business impact as an accounting or legal department. Unlike accounting and legal, EAP is not recognized as a ‘discipline’ and does not have its own unique academic training, license to practice, and highly developed body of knowledge. Therefore, the future of EAP faces a much greater peril.

How EAPs Are Currently Defined – The truth is EAPs are rooted in medicine, as is the entire field of mental health. The issue of EAPs’ proper place in the world of work versus the world of health can be debated. However, even the Thundering 100 were trying to help employees recover from an illness. Successful recovery resulted in value that was seen and experienced by smartly using the workplace as leverage to motivate, and occasionally coerce, resistant employees into receiving treatment and returning to full productivity.

In his paper, Tisone (2008) channels some brilliant corporate jargon in his description of EAPs’ mission as “the application of our core competencies to the improvement of organizational productivity through the enhancement of individual well-being”. He boils this down further by quoting two of the Thundering 100: ‘‘focus on job performance and the rest will take care of itself”. If it were only that simple in the climate faced by today’s contemporary EAP.

On another day we may pontificate on observations of why the EAP field, which rests on the training, education, and efforts of mental health care professionals, has worked so hard to separate itself from the world of health. But make no mistake; in spite of our often inflated sense of purpose and importance, most purchasers do not view EAP as an HR consultant or a work performance management tool.

Recent research (Sharar, 2007) shows that contemporary EAPs, and their use of affiliate networks, have significant overlap with services provided through the employer’s outpatient behavioral health benefit. The content of EAP intervention, as practiced by network affiliates, has drifted from Roman and Blum’s original core technology. There has been significant leakage from routine general practice counseling into EAP, or the degree to which EAP clients simply receive brief treatment in the EAP setting. Some employers, but certainly not all, may be paying two premiums for a similar or identical service. A few savvy purchasers with highly integrated programs have and will connect the dots to see the broad business-relevant value of EAP. However, most purchasers view EAP as a type of employee counseling benefit designed to lessen the burden of employees’ mental health, substance abuse, and behavior problems on their ability to operate a business.

Therein lies the good news. We know how to address these personal and medical problems. There is even empirical evidence demonstrating that we know how to treat illnesses such as substance abuse and depression with tools that we are trained and licensed to use. Depression is now one of the leading causes of disability and performance decline worldwide, and employers are seeking solutions.

Although the world of EAP has been oversold by the cheapest bidder, and EAP professionals have worked hard not to be viewed as mental health professionals, we may have missed the boat in terms of developing a research base and demonstrating value that is relevant to EAP stakeholders and purchasers. To illustrate, we have spent the last few years tackling a couple of important issues that are relevant but seen as ancillary to EAP. Both are highly visible and cost employers real dollars. The first is the impact of mental health conditions, primary and comorbid, on health care costs and productivity. The second is the skyrocketing problem of short-and long-term disability due to mental health conditions.

We have spent considerable time and effort looking into these issues, including services offered by industries such as managed behavioral healthcare, health promotion, wellness, disease and disability management. All of these industries have proposed solutions to address the problem of mental health in the context of the workplace, albeit with varying levels of supporting data. Some service sectors, such as disease management or care management for depression, are investing resources in randomized controlled trials to demonstrate their impact on business-relevant metrics. Here’s the irony: companies large and small are spending top dollar for these products, especially when compared to the low capitated price of an EAP. What does this mean for EAPs? As the EAP profession flounders to find its identity and invests little in developing evidence-based prac­tices, these other industries walked right in and adopted the identity we have been futilely searching for yet are so unwilling to accept.

Now, back to the good news. As we read and reread Tisone’s (2008) compelling Call to Action, we are struck by references to we and what. The ‘we’ refers to the nebulous EAP industry – those who sell EAPs, manage accounts, work in call centers, develop work-life resources, see EAP clients in private practices, hold offices in union halls, conduct training, and operate internal EAPs. What is all of the various things we promise to do for EAP purchasers. Carl Tisone and the mission of the EARF are spot on. The we and the what of EAP are still too vague and still too undervalued. Only through the development of a body of empirical research can clear proof be demonstrated of the value of what we do. In addition, out of that evidence will come greater respect for our work, an end to marginalization and commoditization, and a transformation of the world of EAP.

Redefining EAPs by Making the Business Case – With a majority of North American work organizations purchasing EAPs and growing global enthusiasm for this product, why do EAPs and their services remain misunderstood, marginalized, and underfunded? Why are even the most revered and respected internal programs in top Fortune companies being threatened by low-bidding vendors and HR outsourcing?

There is clearly a paucity of empirical research supporting contemporary EAP products and practices. Research in EAP is dominated by proprietary vendor program evaluations that do not subscribe to high levels of rigor commonly seen in federally-funded research studies. In spite of the lack of sound empirical outcomes, the EAP field has been able to avoid scrutiny of its lack of evidence. This is true as EAPs, in some form, remain as a fundamental but tiny part of an employer’s benefit packages. Yet as an industry we have slowly and quietly been victimized by our own lack of a business case.

While health care costs continue to show yearly double-digit increases, EAPs – both internal and external – continue the fight to merely stay solvent. Internal programs are eliminated in favor of capitated affiliate model programs. Even successful EAP vendors operate on thin-to-no profit margins, ration services, and occasionally spin utilization reports merely to retain customers and persuade them that EAP activity is robust. Some are even making money by peddling the a ‘free’ EAP embedded as a ‘giveaway’ within an insurance product.

There are many published studies looking at EAP-type services. Most are either fraught with methodological problems or focus narrowly on EAP process evaluations, single-case studies, and measures of client satisfaction. Is a high level of exploration and scientific rigor really necessary for EAPs? Although the industry is struggling, it is not disappearing. After all, aren’t EAPs still being purchased? We contend that the lack of an evidence base and business-relevant metrics have directly led to the erosion of the business and practice of EAP. As a result, the tradition, integrity, and even the true value of EAP weaken under the weight of larger forces, such as EAPs’ integration into managed behavioral health and human resource outsourcing. The power of sound science in a health-related industry can be demonstrated in the simple example of diabetes. Diabetes has a huge health-related and financial impact. Research on treatments and chronic disease management is being widely conducted. As a result, health promotion and disease management is quickly emerging as a stand-alone industry and a health maintenance organization add-on that is being sold to address many chronic conditions.

Importantly, a relative small body of sound empirical studies pub­lished in reputable scientific journals has made the connection between improved diabetes control and business-relevant measures, such as health care costs, absenteeism, disability and retention, and thus fueled an entire industry (CDC Diabetes Cost-Effectiveness Group, 2002; Testa & Simonson, 1998; Wagner et al., 2001). For example, studies conducted by Health Partners (Gilmer, O’Connor, Manning, & Rush, 1997) have demonstrated that when diabetics with no significant comorbid illnesses reduce their HbA1c measure by one point (through treatment compliance and a healthy lifestyle) their total health care costs can be reduced by up to $1205 per year.

It is most noteworthy that these studies demonstrate value for the clinical consumer, potential return on investment for the employer-purchaser and help make the business case for products sold by a thriving industry. What if an EAP could demonstrate in an article published in the Journal of Occupational and Environmental Medicine that a select few of its services resulted in a 50% improvement in depression symptoms, reduced absenteeism by 9 days per year per employee-client, and a reduction in total health care claims by $800 per year per client? How might such a study influence EAP sales presentations? How many more companies would invest in EAPs? How would capitated rates or EAP vendor profit margins change?

We desperately need to establish a new standard of EAP science. Although the academic and financial infrastructure does not yet exist to accomplish this, the EARF provides an excellent first step. The EAP field is in need of scientific rigor that demonstrates evidence-based practices and outcomes that are both clinically- and business-relevant. We are not suggesting that EAP vendors should stop conducting studies of process measures that aid in quality management and evaluation. However, the industry needs independent, multisite randomized control studies that demonstrate the impact of what we do. In traditional EAP terms, we must prove value for the employee-client and employer-client.

There are several challenges inherent to the mission of the EARF. Securing funding for research is always an obstacle. Another challenge, which is a subtle yet likely major factor related to the dearth of research, is that the field has not traditionally been heavily populated with research professionals. Most often, EAP professionals are clinically minded or entrepreneurial and do not come from training programs that are heavily focused on research methods. As a result, we tend to focus on doing what we do rather than on expanding the knowledge base. We fail to invest in our own profession, then lament the state of EAP. The EARF seems intent to address these issues. Through matching grants and fundraising, necessary funding streams can hopefully be established. In our experience, institutions such as the Substance Abuse and Mental Health Services Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention are natural allies to support fund corporate and workplace-focused empiric studies. In addition, when attached to the names of large corporations, academic institutions are often eager to commit resources to partner on corporate research initiatives.

Squarely Facing the Challenges Ahead – Fundamental in developing any research initiative is to 1) define a research question, 2) operationally define the construct to be studied, and 3) determine the methods available to study the question. However, there are two core reasons why these fundamentals are the largest challenges facing the research initiative and could possibly undermine the mission of the EARF.

First, breaking the world of EAP into separate components to study effectiveness fundamentally challenges the validity of products, jobs, and professional work that make up an entire industry. The EAP industry, which now mostly comprises large vendor corporations rather than practitioners or internal EAP professionals, will be challenged by the mere discussion of independent research. We imagine there may only be marginal support from large EAP vendor corporations for research potentially demonstrating that pieces of their product show no financial benefit for purchasers. The fear is that the EAP field/ industry will be unwilling to face an honest and candid look in the mirror. In addition, the results of such research may even been hidden from purchasers when they reflect unfavorably on product offerings.

Second, in spite of the EAP Core Technology, there is no consistent and well-defined operational definition of an EAP. Instead, we have a large array of products and practices that fall under the rubric of EAP. Therefore, rather than immediately setting out on a path to research the [cost] effectiveness of EAP, we need to step back, break the practice of EAP into its fundamental components, and operationally define the individual activities that make up the EAP practice. There is continued uncertainty regarding the active and specific ingredients that separate EAP as a unique model. Once we can articulate the exact recipe for EAP, we can begin asking research questions of those EAP constructs.

It is expected that some, if not many, of the constructs that make up EAP will not show well under the scrutiny of well-controlled research. This will challenge our profession and our industry. As discussed, this level of rigor will be necessary for EAP to move to a higher level of professional credibility and reap longer-term financial benefits. The long-term results will reveal a list of ‘active ingredients’ that make up an EAP. These active ingredients will be those that clearly show positive outcomes through evidence-based practices. Again, we must be prepared to challenge what we hold as our unique definition of what is and isn’t an EAP. It is possible that components of what we view as EAP will show no improvements on the measures we view as important, such as clinical improvement, improved absenteeism, reduced accidents, or decreased health care costs. We then need to face the decision to change our practice and our products, or not. However, a demonstration of partial or limited benefits does not mean that we must stop doing some of the things fundamental to EAP practice. One glance at a tube of toothpaste shows that only one of the 15 ingredients are active. The remaining 14 are still relatively important to the overall quality of the product.

A reasonable analogy to conducting EAP research would be for the medical community to study the benefits of hospitalization. The concept of hospitalization is vast, vague, and contains many com­ponents. Depending on an individual’s vantage point, what encom­passes a hospitalization will vary greatly. Taken as a whole, it would be impossible to make any comments on the benefits of hos­pitalization primarily because of the many discriminate parts and a lack of an operational definition. However, broken down, the benefits of all the things that encompass a stay in the hospital can be evaluated. For example, there is the efficacy of the medical care provided. Certainly, the medi­cal community works tirelessly to develop evidence-based medical guidelines for the hundreds of conditions that may warrant an in-patient stay. What about all the other activities that drive costs and manpower? Does an unlimited supply of ice chips and clear liquids served by a nurse help a patient recover any faster? What about a private room or a television hanging from the wall? Is there evidence in favor of frequent visits by a nurse to the hospital bedside or the value of allocating real estate resources to an in-house gift shop? These questions seem tangential, but they reflect the ingredients of hospitalization.

In spite of the obvious lack of impact on the ultimate outcome of a hospital stay, hospitalization still involves many non-value-added activities. Hospital administrators likely debate and study the cost–benefit of these nice-to-haves. But there should be only limited, isolated professional debate on the active ingredients or the evidence base leading to a patient’s improved health as a result of a hospital stay. In many ways the practice of EAP is no different. EAP involves a multitude of ingredients provided by professionals of many disciplines. Our contention is that, like toothpaste or a stay in the hospital, there are likely many active and other ingredients that make up EAP services. Can we demonstrate how a client’s personal prob­lem affects job performance? Perhaps case management and follow-up leads to improved business-relevant measures. Perhaps referrals for childcare, pet sitting, or short-term couples counseling do not. The fact is, we just don’t know. EAPs may choose to engage in work that is a non-value-add to the purchaser but pleases the employee-client. Or, perhaps the future of EAPs will involve a mere fraction of the services currently offered because we will get better at doing what we know works; and we will stop doing what doesn’t.

A Time for Change – History has shown that purchasers will not force the EAP industry to demonstrate value through scientific rigor. No one is going to force us to self-evaluate to the degree suggested in this article. However, if we choose not to, the value of EAP will be out of our control and left to the variability and whim of the economy and the pur­chaser. It is our responsibility to learn what works and what doesn’t and to then, in an unbiased and objective fashion, disseminate this new knowledge to the field and the purchaser. It will be at that point, and only at that point, where the perceived and true financial value of EAP will grow and no longer stagnate. It will be at that point where EAP will be a practice, a product, and a profession that we can provide with unwavering confidence.

References

CDC Diabetes Cost-Effectiveness Group. (2002). Cost-effectiveness of intensive glycemic control, intensified hypertension control, and serum cholesterol level reduction for type 2 diabetes. Journal of the American Medical Association, 28(19), 2542–2551.

Gilmer, T.P., O’Connor, P.J., Manning, W.G., & Rush, W.A. (1997). The cost to health plans of poor glycemic control. Diabetes Care, 20, 1847–1853.

Heck, P. (2007, October). Presentation at the inaugural meeting of the Employee Assistance Research Foundation, EAPA Conference, San Diego, CA.

Testa, M.A. & Simonson, D. C. (1998). Health economic benefits and quality of life during improved glycemic control in patients with type 2 diabetes mellitus: A randomized, controlled, double-blind trial. Journal of the American Medical Association, 280(17), 1490–1496.

Tisone, C.R. (2008). Employee Assistance Research Foundation: A call to action. Journal of Workplace Behavioral Health, 23, 201–211.

Sharar, D. (2007, October). Do EAP affiliates adhere to EAP concepts? An exami­nation of EAP affiliate fidelity to EAP theory and practice. Presentation at the EAPA Conference Dissertation Research Forum, San Diego, CA.

Wagner, E.H., Sandhu, N., Newton, K.M., McCulloch, D.K., Ramsey, S.D., & Grothaus, L.C. (2001). Effect of improved glycemic control on health care costs and utilization. Journal of the American Medical Association, 285(2), 182–189.

John C. Pompe, PsyD, SPHR, is the Manager of Behavioral Health for Caterpillar Inc. David A. Sharar, PhD, is the managing director of Chestnut Global Partners, the international EAP and workplace services arm of Chestnut Health Systems, and a research scientist with Chestnut’s Research Lighthouse Institute. dsharar@chestnut.org