The 2020 Global Medical Trends survey identified diabetes as an illness that had attracted a smaller level of attention from health care providers than its capacity to cause significant cost escalation might suggest. We called it a “sleeper condition” as rates are quietly but steadily increasing.
This report would like to sound a similar alarm call about the mounting crisis in mental health conditions and in funding for their treatment.
The scale of this crisis is such that it has received in-depth attention from the World Health Organization (WHO), which led to a 2013 – 2020 action plan for participating states. This plan calls for the wider dissemination of four objectives. These extend from the strengthening of leadership in line with the understanding of human rights, increased provision for mental health disorders, prevention programs tied into reduced suicide rates, and improved monitoring and reporting.
What makes the subject more difficult is that unlike diabetes, many mental health conditions can be hard to define, for all that they have the potential to cause significant harm. An untreated mental health condition can jeopardize the life of the sufferer; cause significant harm to society, as addiction can be part of a comorbidity; and, in the case of conditions such as stress, result in ongoing health conditions, which can be expensive.
For clarity we are using the term “mental health” to refer to more than definable mental health disorders — using it more broadly than “behavioral health” alone. Rather, Willis Towers Watson views the state of good mental health to be one of successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and an ability to adapt to change and cope with challenges. It should not be confused with emotional wellbeing that relates specifically to social/emotional competencies, such as the ability to empathize or regulate emotions.
Some statistics
Both a wider statistical basis to the concerns about mental health and a series of more specific figures of direct interest to employers are revealed in the survey:
- Mental health disorders are common in the workforce globally; around three in 10 employees suffer from severe stress, anxiety or depression.1
- Over 300 million people of all ages suffer from depression globally.
- One in four people is affected by a mental disorder at some point in his or her life; nearly two-thirds never seek help from a health professional.
- Global rates of depression and anxiety have increased 15% to 20% in the past decade.
- 800,000 people die by suicide each year, equivalent to one person every 40 seconds.
It is noteworthy that mental health impacts employers in a range of adverse ways. Even if there was not an altruistic reason why employers should seek to alleviate mental health problems in their staffs, impacts on productivity and absence are an argument for making them a matter of immediate concern.
- Financial and job security are leading sources of stress globally, and there are strong links between financial worries, stress and poor health.2
- Employees who are in the poorest health report more than double the absences and more than 25% higher presenteeism than other colleagues, and they are more than twice as likely to be disengaged from their jobs and almost three times as likely to experience high stress as those in very good health.
- In many developed countries, 35% to 45% of absenteeism from work is due to mental health problems.3
Global economic losses related to mental health disorders between 2011 and 2030 are estimated to total $16.3 trillion, comparable to those of cardiovascular diseases and higher than cancer, chronic respiratory diseases and diabetes.
Coverage for mental health conditions
Mental health coverage is offered more widely in Latin America as a whole than any other region, irrespective of whether group policies are for less than 50, up to 500 or more than 500 employees. Over 84% of providers in this region offer coverage that is related to mental health, stress and substance use. Digging beneath the averages, on the one hand, in Brazil mental health treatments are part of the mandatory coverage, which provides for psychiatric consultations in an unlimited number, hospitalization, attendance and follow-up in a hospital, consultation with a psychologist and occupational therapist, as well as psychotherapy sessions. On the other hand, in Mexico neither mental health nor substance abuse treatments are covered under private major medical expenses. This excludes all psychiatric and psychological treatment. At best, a few sessions might be covered due to traumatic situations such as natural disasters or for victims of violent crimes.
The region of the Middle East and Africa provides the weakest coverage. Sixty percent of respondents in that region covered mental health in their large group policies, a number that fell to 41% when the policy covered under 500 lives and 30% when 50 lives or less were covered.
What is concerning is that up to 45% of providers in the Middle East and Africa do not plan to offer this coverage within the next three years, although the exclusion rate is already high.
This number falls to 24% of providers that offer very large policies. Asia Pacific countries are similar to Middle East and Africa, with only around half of insurers covering mental health conditions and little sign that this will dramatically change within the next three years.
Anecdotal evidence suggests that Europe and Latin America are both markets where there may be a more sophisticated understanding of mental health conditions and their wider effects. The survey additionally asked about specific exclusions, and the rates were high in both the Middle East and Africa region and Asia Pacific.
Seeing the increase in costs
Despite the enhanced provision in the Americas and Europe, both regions expect that mental health will be responsible for the bulk of medical health expense increase in the next five years. Sixty-one percent of respondents in Latin America foresaw a moderate increase, and 60% in Europe reported the same. Unsurprisingly, just 24% in the Middle East and Africa predicted a moderate increase.
Behavioral and mental health conditions are now the third most costly medical condition behind pharmacy and hospital or inpatient care. Given that pharmacy costs have already been identified in previous iterations of the report as a significant source of concern and that inpatient care is obviously expensive, this rate of increase is a matter of real concern. Whether it reflects greater awareness, more accurate reporting or perhaps another unknown factor, only time will tell.
For the time being, mental health coverage does not account for a particularly high number of claims being processed. This reflects the volume of limitations and exclusions often included in relation to these conditions. Most regions state that less than 5% of claims processed are related to mental health conditions, with the Middle East and Africa the lowest of all, although Asia Pacific is not far behind. Predictions about the rate of increase are already coming true: Globally, 21% of respondents reported between 5% and 10% of their total claims processed are related to mental health coverage, and this number will certainly go higher.
The current low utilization does not mean that employees are not experiencing problems with their mental health; it purely reflects that the required services are not being covered.
Providing treatment
Interrogating where the increased spending will be allocated gives some significant indications as to where and how the providers will seek to manage mental health conditions. Above and beyond the simple reimbursement of mental health claims, insurers are likely to use an employee assistance program provided by an external partner, with a global rate of 47%. In-house programs are less popular at 19%.
Similarly, mental health and/or substance abuse programs are slightly more likely to be provided by an external partner or vendor than being integrated in a medical plan or offered as an optional extra. The global rate is 46% for provision by external providers and 35% for the integrated equivalent. By contrast, provision provided in-house has a global rate of just 15%.
Where emotional resilience and stress management programs are offered, it is once again more likely to be provided through an external source and not something that an insurer typically provides in-house. Of more interest for future developments is the increasing use of virtual and telebehavioral health services.
Twenty-three percent of respondents offer these services in-house, the highest global total for any in-house provision save for in-house counseling. A global total of 35% use an external provider. This collectively shows that where expertise around the treatment of mental health conditions is not adequately provided for, there is a readiness to use external expertise to expand provision.
Advice to employers
The global mental health burden is staggering. Mental health disorders and stress are increasing in incidence and in detection all over the world, and inevitably, employers shoulder a large share of that burden. In addition to its action plan, the WHO has taken practical steps toward the alleviation of mental distress by starting work on a series of guidelines that are intended to address mental health in the workplace.
These guidelines will address psychological support to manage and overcome mental health conditions in the workplace but also the organizational and managerial systems conducive to employees’ emotional wellbeing.
In line with this approach, employer organizations are increasingly moving the focus beyond programs to broader organizational factors that play a critical role in supporting mental health and emotional wellbeing.
A range of factors play a part in this, and employers may want to include them in their planning:
- Stigma and significant gaps exist globally that prevent individuals from discussing mental health at work or accessing resources and care.
- Market maturity varies considerably by region and individual countries, as do employee preferences around employer involvement. This requires a tailored and culturally relevant communication and engagement approach.
- Employers should be cognizant of the drivers of stress, such as financial insecurity, making sure to align provision with employee preferences.
- The global market for stress and resilience solutions is emerging but less established outside of the U.S. and U.K.
- All employers should also focus on broader organizational factors such as creating an inclusive culture, reducing stigma, thinking about the work environment and policies that impact mental health.
1,2 Willis Towers Watson’s 2017/2018 Global Benefits Attitudes Survey
3 World Health Organization, 2005, Mental health policies and programmes in the workplace. https://www.who.int/mental_health/policy/workplace_policy_programmes.pdf
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