How to present the business case for healthcare quality to employers

Productivity Loss and Indirect Costs for Patients Newly Diagnosed with Early- versus Late-Stage Cancer in the USA: A Large-Scale Observational Research Study

BACKGROUND

The total economic burden of cancer reflects direct and indirect costs, including productivity loss due to employment change, absenteeism, and presenteeism of patients and caregivers.

OBJECTIVE

This study estimated the magnitude of employment decrease, work absence (WA), short-term disability (STD), long-term disability (LTD), and associated indirect costs among employees newly diagnosed with metastatic versus non-metastatic cancer in the USA.

METHODS

IBM® MarketScan® Commercial Claims and Encounters and Health and Productivity Management databases were used to identify employees aged 18-64 years and newly diagnosed with any cancer from 2009 to 2019. Proportions of patients with employment decrease, WA, STD, and LTD claims, and number of days missing from work were summarized by metastatic status during the first 12 months after diagnosis and the entire follow-up period. Subgroup analyses were conducted by age (< 50 years, ≥ 50 years) and cancer type (breast, lung, colon, pancreatic, and liver cancer).

RESULTS

During the first year after diagnosis, compared to patients without metastases, significantly higher proportions of patients with metastases had employment decrease and STD or LTD claims (p < 0.001). The mean total number of days missing from work for patients with versus without metastases was 33.39 versus 14.91 (ratio = 2.40), 64.05 versus 27.15 (ratio = 2.36), and 105.93 versus 46.29 (ratio = 2.29) days within 3, 6, and 12 months after diagnosis, respectively. Estimates of indirect cost differences between the two groups ranged from $6,877 to $22,283 in the first year.

CONCLUSION

Earlier detection of cancer may reduce productivity loss of patients and indirect costs by initiating treatment before cancer progresses to late stage.

Accounting for employee health: The productivity cost of leading health risks

BACKGROUND

"Workplace health promotion and protection" broadly refers to an integrated approach to workplace health and safety initiatives. There are substantial benefits to adopting such an approach, including the potential for: improvements to individual employees' health and well-being; increased productivity; and reduced safety risks and expenses. Yet many employers remain reluctant to shift from traditional safety initiatives and spending. This paper aims to demonstrate the value of investing in an integrated health promotion and protection approach by calculating the productivity costs associated with 11 modifiable health risks and 14 chronic conditions in an Australian mining company.

METHOD

Eight hundred and ninety-seven employees participated in a self-report health survey aimed at investigating employee health behaviours, health conditions and productivity.

RESULTS

Overall, modifiable health risks and chronic health conditions were calculated to contribute to an estimated $22.15 million (AUD) and $7.95 million (AUD) in lost productivity per 1000 employees per annum, respectively. Although employee stress was identified as the third highest prevalence health risk across the employee sample (at 42%), it accounted for the highest financial burden.

CONCLUSION

Employee health plays a vital role in the profitability, productivity, and safety outcomes of an organisation. For modifiable health risks and chronic conditions, ailments that affected cognition resulted in the highest financial burden (ie, stress and migraine headaches). SO WHAT?: These findings make a strong financial and business case for the integration of preventative health and safety initiatives, with particular emphasis on modifiable health risk behaviours.

Work productivity loss from depression: evidence from an employer survey

BACKGROUND

National working groups identify the need for return on investment research conducted from the purchaser perspective; however, the field has not developed standardized methods for measuring the basic components of return on investment, including costing out the value of work productivity loss due to illness. Recent literature is divided on whether the most commonly used method underestimates or overestimates this loss. The goal of this manuscript is to characterize between and within variation in the cost of work productivity loss from illness estimated by the most commonly used method and its two refinements.

METHODS

One senior health benefit specialist from each of 325 companies employing 100+ workers completed a cross-sectional survey describing their company size, industry and policies/practices regarding work loss which allowed the research team to derive the variables needed to estimate work productivity loss from illness using three methods. Compensation estimates were derived by multiplying lost work hours from presenteeism and absenteeism by wage/fringe. Disruption correction adjusted this estimate to account for co-worker disruption, while friction correction accounted for labor substitution. The analysis compared bootstrapped means and medians between and within these three methods.

RESULTS

The average company realized an annual $617 (SD = $75) per capita loss from depression by compensation methods and a $649 (SD = $78) loss by disruption correction, compared to a $316 (SD = $58) loss by friction correction (p < .0001). Agreement across estimates was 0.92 (95% CI 0.90, 0.93).

CONCLUSION

Although the methods identify similar companies with high costs from lost productivity, friction correction reduces the size of compensation estimates of productivity loss by one half. In analyzing the potential consequences of method selection for the dissemination of interventions to employers, intervention developers are encouraged to include friction methods in their estimate of the economic value of interventions designed to improve absenteeism and presenteeism. Business leaders in industries where labor substitution is common are encouraged to seek friction corrected estimates of return on investment. Health policy analysts are encouraged to target the dissemination of productivity enhancing interventions to employers with high losses rather than all employers.

TRIAL REGISTRATION

CLINICAL TRIALS REGISTRATION NUMBER

NCT01013220.

Integrated worker health protection and promotion programs: overview and perspectives on health and economic outcomes

OBJECTIVE

To describe integrated worker health protection and promotion (IWHPP) program characteristics, to discuss the rationale for the integration of occupational safety and health and worksite health promotion programs, and to summarize what is known about the impact of these programs on health and economic outcomes.

METHODS

A descriptive assessment of the current state of the IWHPP field and a review of studies on the effectiveness of IWHPP programs on health and economic outcomes were undertaken.

RESULTS

Sufficient evidence of effectiveness was found for IWHPP programs when health outcomes were considered. Impact on productivity-related outcomes is considered promising, but inconclusive, whereas insufficient evidence was found for health care expenditures.

CONCLUSIONS

Existing evidence supports an integrated approach in terms of health outcomes but will benefit significantly from research designed to support the business case for employers of various company sizes and industry types.

Reducing the incidence of short-term disability: testing the effectiveness of an absence prediction and prevention intervention using an experimental design

OBJECTIVE

This multi-employer, prospective, randomized, controlled trial validated a quantitative model to identify employees at high risk of short-term disability (STD) and evaluated the impact of a health advocate nurse-led intervention on STD incidence.

METHODS

Following prospective randomization, the control group received usual and customary services while the intervention group received usual and customary plus additional services from Cigna.*

RESULTS

At the 12-month assessment, 16.8% of the intervention group had documented STD claims compared with 19.8% of the control group (P = 0.06). Duration of STD and return to work rate were not statistically different.

CONCLUSION

While not statistically significant, these results suggest that the intervention for employees at high risk of STD achieves practical and clinical significance by achieving absolute and relative reductions in risk of STD of 3% and 15%, respectively.

Systematic review on the financial return of worksite health promotion programmes aimed at improving nutrition and/or increasing physical activity

This systematic review summarizes the current evidence on the financial return of worksite health promotion programmes aimed at improving nutrition and/or increasing physical activity. Data on study characteristics and results were extracted from 18 studies published up to 14 January 2011. Two reviewers independently assessed the risk of bias of included studies. Three metrics were (re-)calculated per study: the net benefits, benefit cost ratio (BCR) and return on investment (ROI). Metrics were averaged, and a post hoc subgroup analysis was performed to compare financial return estimates between study designs. Four randomized controlled trials (RCTs), 13 non-randomized studies (NRSs) and one modelling study were included. Average financial return estimates in terms of absenteeism benefits (NRS: ROI 325%, BCR 4.25; RCT: ROI -49%, BCR 0.51), medical benefits (NRS: ROI 95%, BCR 1.95; RCT: ROI -112%, BCR -0.12) or both (NRS: ROI 387%, BCR 4.87; RCT: ROI -92%, BCR 0.08) were positive in NRSs, but negative in RCTs. Worksite health promotion programmes aimed at improving nutrition and/or increasing physical activity generate financial savings in terms of reduced absenteeism costs, medical costs or both according to NRSs, whereas they do not according to RCTs. Since these programmes are associated with additional types of benefits, conclusions about their overall profitability cannot be made.

A simulation model approach to analysis of the business case for eliminating health care disparities

BACKGROUND

Purchasers can play an important role in eliminating racial and ethnic disparities in health care. A need exists to develop a compelling "business case" from the employer perspective to put, and keep, the issue of racial/ethnic disparities in health care on the quality improvement agenda for health plans and providers.

METHODS

To illustrate a method for calculating an employer business case for disparity reduction and to compare the business case in two clinical areas, we conducted analyses of the direct (medical care costs paid by employers) and indirect (absenteeism, productivity) effects of eliminating known racial/ethnic disparities in mammography screening and appropriate medication use for patients with asthma. We used Markov simulation models to estimate the consequences, for defined populations of African-American employees or health plan members, of a 10% increase in HEDIS mammography rates or a 10% increase in appropriate medication use among either adults or children/adolescents with asthma.

RESULTS

The savings per employed African-American woman aged 50-65 associated with a 10% increase in HEDIS mammography rate, from direct medical expenses and indirect costs (absenteeism, productivity) combined, was $50. The findings for asthma were more favorable from an employer point of view at approximately $1,660 per person if raising medication adherence rates in African-American employees or dependents by 10%.

CONCLUSIONS

For the employer business case, both clinical scenarios modeled showed positive results. There is a greater potential financial gain related to eliminating a disparity in asthma medications than there is for eliminating a disparity in mammography rates.

Economic evaluation of a worksite obesity prevention and intervention trial among hotel workers in Hawaii

OBJECTIVE

Economic evaluation of Work, Weight, and Wellness (3W), a 2-year randomized trial of a weight loss program delivered through Hawaii hotel worksites.

METHODS

Business case analysis from hotel perspective. Program resources were micro-costed (2008 dollars). Program benefits were reduced medical costs, fewer absences, and higher productivity. Primary outcome was discounted 24-month net present value (NPV).

RESULTS

Control program cost $222K to implement over 24 months ($61 per participant), intervention program cost $1.12M ($334). Including overweight participants (body mass index >25), discounted control NPV was -$217K; -$1.1M for intervention program. Presenteeism improvement of 50% combined with baseline 10% productivity shortfall required to generate positive 24-month intervention NPV.

CONCLUSIONS

3W's positive clinical outcomes did not translate into immediate economic benefit for participating hotels, although modest cost savings were observed in the trial's second year.

Workplace wellness programs can generate savings

Amid soaring health spending, there is growing interest in workplace disease prevention and wellness programs to improve health and lower costs. In a critical meta-analysis of the literature on costs and savings associated with such programs, we found that medical costs fall by about $3.27 for every dollar spent on wellness programs and that absenteeism costs fall by about $2.73 for every dollar spent. Although further exploration of the mechanisms at work and broader applicability of the findings is needed, this return on investment suggests that the wider adoption of such programs could prove beneficial for budgets and productivity as well as health outcomes.

A web-based nutrition program reduces health care costs in employees with cardiac risk factors: before and after cost analysis

Background

Rising health insurance premiums represent a rapidly increasing burden on employer-sponsors of health insurance and their employees. Some employers have become proactive in managing health care costs by providing tools to encourage employees to directly manage their health and prevent disease. One example of such a tool is DASH for Health, an Internet-based nutrition and exercise behavior modification program. This program was offered as a free, opt-in benefit to US-based employees of the EMC Corporation.

Objective

The aim was to determine whether an employer-sponsored, Internet-based diet and exercise program has an effect on health care costs.

Methods

There were 15,237 total employees and spouses who were included in our analyses, of whom 1967 enrolled in the DASH for Health program (DASH participants). Using a retrospective, quasi-experimental design, study year health care costs among DASH participants and non-participants were compared, controlling for baseline year costs, risk, and demographic variables. The relationship between how often a subject visited the DASH website and health care costs also was examined. These relationships were examined among all study subjects and among a subgroup of 735 subjects with cardiovascular conditions (diabetes, hypertension, hyperlipidemia). Multiple linear regression analysis examined the relationship of program use to health care costs, comparing study year costs among DASH participants and non-participants and then examining the effects of increased website use on health care costs. Analyses were repeated among the cardiovascular condition subgroups.

Results

Overall, program use was not associated with changes in health care costs. However, among the cardiovascular risk study subjects, health care costs were US$827 lower, on average, during the study year (P= .05; t₇₂₉ = 1.95). Among 1028 program users, increased website use was significantly associated with lower health care costs among those who visited the website at least nine times during the study year (US$14 decrease per visit; P = .04; t₁₀₂₂ = 2.05), with annual savings highest among 80 program users with targeted conditions (US$55 decrease per visit; P < .001; t₇₄ = 2.71).

Conclusions

An employer-sponsored, Internet-based diet and exercise program shows promise as a low-cost benefit that contributes to lower health care costs among persons at higher risk for above-average health care costs and utilization.

The role of economics in the QUERI program: QUERI Series

BACKGROUND

The United States (U.S.) Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) has implemented economic analyses in single-site and multi-site clinical trials. To date, no one has reviewed whether the QUERI Centers are taking an optimal approach to doing so. Consistent with the continuous learning culture of the QUERI Program, this paper provides such a reflection.

METHODS

We present a case study of QUERI as an example of how economic considerations can and should be integrated into implementation research within both single and multi-site studies. We review theoretical and applied cost research in implementation studies outside and within VA. We also present a critique of the use of economic research within the QUERI program.

RESULTS

Economic evaluation is a key element of implementation research. QUERI has contributed many developments in the field of implementation but has only recently begun multi-site implementation trials across multiple regions within the national VA healthcare system. These trials are unusual in their emphasis on developing detailed costs of implementation, as well as in the use of business case analyses (budget impact analyses).

CONCLUSION

Economics appears to play an important role in QUERI implementation studies, only after implementation has reached the stage of multi-site trials. Economic analysis could better inform the choice of which clinical best practices to implement and the choice of implementation interventions to employ. QUERI economics also would benefit from research on costing methods and development of widely accepted international standards for implementation economics.

Job strain predicts survey response in healthcare industry workers

OBJECTIVES

To examine the effect of job strain on survey response.

METHODS

1,613 health care workers received a self-administered questionnaire. Thirty percent of them completed the survey on personal time without any personal monetary compensation. Working conditions were extracted by job title from the national database O*NET 6.0. Job strain was defined as the ratio of job demands to job control. Two complementary models (multi-level logistic and binomial pseudo Poisson regressions) were used to model individual survey response as a function of individual level demographic variables (age and gender), job-level socioeconomic status (SES) and job strain, and facility type (third level).

RESULTS

Survey response was associated with higher SES and with less job strain. The association of SES and survey response was mediated by job strain.

CONCLUSION

Employees' exposure to job strain may be an important influence on survey response, at least for workers who are not compensated for their time in completing a survey.

A guide to economic evaluation: methods for cost-effectiveness analysis of person-level data

The authors introduce economic evaluation with particular attention to cost-effectiveness analysis. They begin by establishing why health care decisions should be guided by economics. They then explore different types of economic evaluations. To illustrate how to conduct and evaluate a cost-effectiveness analysis, a hypothetical study about the treatment of posttraumatic stress disorder with psychotherapy versus pharmacotherapy is considered. The authors conclude with recommendations for increasing the strength and relevance of economic evaluations.