Legitimacy of Cost Concern for Health Insurance Coverage of Gender-Affirming Surgeries: Comparison of the Interest in Keeping Insurance Cost Down versus the Cost-Effectiveness of Including Gender-Affirming Surgeries in Employer Health Insurance Plans

This RCD discusses the recent development in Lange v Houston County. In this case, the United States District Court for The Middle District Of Georgia Macon Division found that an Exclusion Policy, prohibiting health insurance coverage of gender-affirming surgery for an employee, Anna Lange, violated Title VII of the Civil Rights Act. On appeal, the Defendants argued that the District Court erred in its decision and relied on the cost burden of gender-affirming surgery as one of their defenses. This RCD highlights that cost is a common defense tactic used by defendants in these cases. However, the author argues that these concerns are unfounded and meritless given the cost-effectiveness of including gender-affirming surgeries in health insurance plans, as highlighted in the RCD.

Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits

BACKGROUND

Pharmacy benefit can be purchased as part of an integrated medical and pharmacy health package-a carve-in model-or purchased separately and administered by an external pharmacy benefit manager-a carve-out model. Limited peer-reviewed information is available assessing differences in use and medical costs among carve-in versus carve-out populations.

OBJECTIVE

To compare total medical costs per member per year (PMPY) and utilization between commercially self-insured members receiving carve-in to those receiving carve-out pharmacy benefits overall and by 7 chronic condition subgroups.

METHODS

This study used deidentified data of members continuously enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018. Cambia covers 1.6 million members in Oregon, Washington, Idaho, and Utah. The medical cost PMPY comparison was performed using multivariable general linear regression with gamma distribution adjusting for age, gender, state, insured group size, case or disease management enrollment, 7 chronic diseases, risk score (illness severity proxy), and plan paid to total paid ratio (benefit richness proxy). Medical event objectives were assessed using multivariable logistic regression comparing odds of hospitalization and emergency department (ED) visit adjusting for the same covariates. Sensitivity analyses repeated the medical cost PMPY comparison excluding high-cost members, greater than $250,000 annually. Chronic condition subgroup analyses were performed using the same methods separately for members having asthma, coronary artery disease, chronic obstructive pulmonary disease, heart failure, diabetes mellitus, depression, and rheumatoid arthritis.

RESULTS

There were 205,835 carve-in and 125,555 carve-out members meeting study criteria. Average age (SD) was 34.2 years (18.6) and risk score (SD) 1.1 (2.3) for carve-in versus 35.2 years (19.3) and 1.1 (2.4), respectively, for carve-out. Members with carve-in benefits had lower medical costs after adjustment (4%, P < 0.001), translating into an average $148 lower medical cost PMPY ($3,749 carve-out vs. $3,601 carve-in annualized). After adjustment, the carve-in group had an estimated 15% (P < 0.001) lower hospitalization odds and 7% (P < 0.001) lower ED visit odds. Of 7 chronic conditions, significantly lower costs (12%-17% lower), odds of hospitalization (22%-36% lower), and odds of ED visit (16%-20% lower) were found among members with carve-in benefits for 5 conditions (all P < 0.05).

CONCLUSIONS

These findings suggest that integrated, carve-in pharmacy and medical benefits are associated with lower medical costs, fewer hospitalizations, and fewer ED visits. This study focused on associations, and defining causation was not in scope. Possible reasons for these findings include plan access to both medical and pharmacy data and data-informed care management and coordination. Future research should include investigation of integrated data use and its effect across the spectrum of integrated health plan offerings, provider partnerships, and analytic strategies, as well as inclusion of analyzing pharmacy costs to encompass total cost of care.

DISCLOSURES

This study received no external funding. The study was jointly conducted by employees of Cambia Health Solutions and Prime Therapeutics, a pharmacy benefit manager servicing Cambia Health Solutions. Smith, Lam, Lockwood, and Pegus are employees of Cambia Health Solutions. Qiu and Gleason are employees of Prime Therapeutics.

The impact of a sick pay waiting period on sick leave patterns

This article assesses how a waiting period for sick pay impacts sick leave patterns. In the French private sector, statutory sick benefits are granted after 3 days. However, 60 % of employers in this sector provide complementary sick pay to cover this waiting period. Linked employee-employer survey data compiled in 2009 are used to analyze the impact of this compensation on workers' sick leave behavior. The assessment isolates the insurance effect (moral hazard) from individual and environmental factors relating to sick leave (including health and working conditions). Results suggest that employees who are compensated during the 3-day waiting period are not more likely to have an absence. On the contrary, their sickness leaves are significantly shorter by 3 days on average. These results could be explained by consequences of presenteeism and ex post moral hazard when employees are exposed to a waiting period.

The Costs of Obesity among Full-Time Employees

Purpose.

To quantify annual costs attributable to obesity, including both increased medical expenditures and absenteeism, separately for overweight and three categories of obesity (i.e., obesity grades I, II, and III) among men and women with full-time employment.

Design.

Standard econometric methods were used to separately estimate overweight and obesity-attributable medical expenditures and absenteeism.

Setting.

The civilian noninstitutionalized population of the United States.

Sample.

Two nationally representative and publicly available datasets (with response rates of at least 60%) were restricted to participants 18 to 64 years old and employed fulltime for the entire year. The final datasets used to estimate obesity-attributable medical expenditures and absenteeism included 20,329 and 25,427 adults, respectively.

Measures.

Annual medical expenditures and missed work days due to illness or injury.

Analysis Results.

Overweight and obesity-attributable costs range from $175 per year for overweight male employees to $2485 per year for grade-II obese female employees. The costs of obesity (excluding overweight) at a firm with 1000 employees are estimated to be $285,000 per year.

Conclusions.

Obesity results in significant increases in medical expenditures and absenteeism among full-time employees. Approximately 30% of the total costs result from increased absenteeism, and although those with grade-III obesity represent only 3% of the employed population, they account for 21% of the costs due to obesity. These estimates do not consider other potential costs associated with obesity, including disability and presenteeism.

Direct and indirect costs of employees with treatment-resistant and non-treatment-resistant major depressive disorder

OBJECTIVE

Treatment-resistant depression (TRD) imposes substantial cost from the perspective of employers. The objective of this study was to assess direct healthcare costs and indirect (disability and medical-related absenteeism) costs associated with TRD compared with non-treatment-resistant major depressive disorder (MDD).

METHODS

Employees with one or more inpatient, or two or more outpatient/other MDD diagnoses (ICD-9-CM: 296.2x, 296.3x) from 2004 through 2007, ages 18-63 years, were selected from a claims database. Employees who initiated a third antidepressant following two antidepressant treatments of adequate dose and duration or who met published TRD criteria were classified as TRD likely (N = 2312). The index date was the date of the first antidepressant, starting 1/1/2004. The control group was an age- and sex-matched cohort of employees with MDD but without TRD. All had continuous eligibility during the 6-month pre-index (baseline) and 24-month post-index (study) period. McNemar tests were used to compare baseline comorbidities. Wilcoxon signed-rank tests were used to compare costs from employer perspective.

RESULTS

TRD-likely employees were on average 48 years old, and 64.8% were women. Compared with MDD controls, TRD-likely employees had significantly higher rates of mental-health disorders, chronic pain, fibromyalgia, and higher Charlson Comorbidity Index. Average direct 2-year costs were significantly higher for TRD-likely employees ($22,784) compared with MDD controls ($11,733), p < 0.0001. Average indirect costs were also higher among TRD-likely employees ($12,765) compared with MDD controls ($6885), p < 0.0001.

LIMITATIONS

Limitations of claims data related to accuracy of diagnosis coding and lack of clinical information apply to this study.

CONCLUSIONS

Based on comorbidities and healthcare resources used, patients with TRD appeared to represent a clinically complex subgroup of individuals with MDD. TRD was associated with significant cost burden.

A cost-benefit analysis of Wisconsin's screening, brief intervention, and referral to treatment program: adding the employer's perspective

OBJECTIVE

A previous cost-benefit analysis found Screening, Brief Intervention, and Referral to Treatment (SBIRT) to be cost-beneficial from a societal perspective. This paper develops a cost-benefit model that includes the employer's perspective by considering the costs of absenteeism and impaired presenteeism due to problem drinking.

METHODS

We developed a Monte Carlo simulation model to estimate the costs and benefits of SBIRT implementation to an employer. We first presented the likely costs of problem drinking to a theoretical Wisconsin firm that does not currently provide SBIRT services. We then constructed a cost-benefit model in which the firm funds SBIRT for its employees. The net present value of SBIRT adoption was computed by comparing costs due to problem drinking both with and without the program.

RESULTS

When absenteeism and impaired presenteeism costs were considered from the employer's perspective, the net present value of SBIRT adoption was $771 per employee.

CONCLUSIONS

We concluded that implementing SBIRT is cost-beneficial from the employer's perspective and recommend that Wisconsin employers consider covering SBIRT services for their employees.

The cost and impact of health conditions on presenteeism to employers: a review of the literature

Employers are becoming concerned with the costs of presenteeism in addition to the healthcare and absenteeism costs that have traditionally been explored. But what is the true impact of health conditions in terms of on-the-job productivity? This article examines the literature to assess the magnitude of presenteeism costs relative to total costs of a variety of health conditions. Searches of MEDLINE, CINAHL and PubMed were conducted in July 2008, with no starting date limitation, using 'presenteeism' or 'work limitations' as keywords. Publications on a variety of health conditions were located and included if they assessed the total healthcare and productivity cost of one or more health conditions. Literature on presenteeism has investigated its link with a large number of health conditions ranging from allergies to irritable bowel syndrome. The cost of presenteeism relative to the total cost varies by condition. In some cases (such as allergies or migraine headaches), the cost of presenteeism is much larger than the direct healthcare cost, while in other cases (such as hypertension or cancer), healthcare is the larger component. Many more studies have examined the impact of pharmaceutical treatment on certain medical conditions and the resulting improvement in on-the-job productivity. Based on the research reviewed here, health conditions are associated with on-the-job productivity losses and presenteeism is a major component of the total employer cost of those conditions, although the exact dollar amount cannot be determined at this time. Interventions, including the appropriate use of pharmaceutical agents, may be helpful in improving the productivity of employees with certain conditions.

[Motivating instruments behind occupational health activities and their efficiency in expert judgment]

BACKGROUND

The aim of the study was to analyze and compare economic incentives practices in occupational safety and health (OSH) in the chosen EU countries and the USA, based on expert judgment.

MATERIAL AND METHOD

The information for the analysis was collected by using a questionnaire filled by experts from international organizations. It was supplemented by direct consultations with experts and experts' reports.

RESULTS

Economic incentives in OSH do exist in each country under study. The institutions engaged in providing economic incentives are as follows: social insurance, disability pension private insurance, state institutions supervising occupational health, health insurance, state institutions providing regulations, accident insurance. Experts evaluated the influence of state and insurance institutions on economic incentives promotion, as medium, and that of employers' organizations and trade unions as weak. They also confirmed a particular role of cost/benefit analysis.

CONCLUSIONS

Economic incentives are considered as a managerial instrument enabling individual and flexible health protection management at different levels in enterprises as opposed to the legislation that only provides for the observation of minimum standards. Economic incentives can be used faster and more effectively. Legal regulation is a slow process and proves to be a less effective tool.

The cost of disability and medically related absenteeism among employees with multiple sclerosis in the US

Studies have not previously reported the indirect cost burden of multiple sclerosis (MS) from an employer perspective. To compare annual indirect costs between privately insured US employees with MS and matched employee controls. A retrospective analysis of a privately insured claims database containing disability data from 17 US companies was conducted. Employees with >/=1 MS diagnosis (ICD-9-CM: 340.x) after 1 January 2002, aged 18-64 years, were selected. Employees with MS were matched by age and sex to employee controls without MS. All were required to have continuous health coverage 3 months before MS diagnosis (baseline) and 12 months after (study period). Main outcomes measures included study period annual indirect (disability and medically related absenteeism) costs. For completeness, we also included measures of direct (medical and drug) costs. Chi-squared tests were used to compare baseline co-morbidities and differences in indirect resource use (disability and medically related absenteeism) between employees with MS and controls. Wilcoxon rank-sum tests were used for univariate comparisons of disability and medically related absenteeism days and associated annual indirect and direct costs between employees with MS and controls. Generalized linear models, controlling for differences in baseline characteristics, were used to estimate risk-adjusted annual costs for employees with MS and controls. Employees with MS (n = 989) averaged 44 years of age, and 66% were female. Compared with employee controls, employees with MS had significantly higher rates of mental health disorders, other neurological disorders and physical disorders measured by the Charlson Co-morbidity Index. Employees with MS were more likely to have short-term or long-term disability than employee controls (21.4% vs 5.2%, respectively; p < 0.0001), resulting in a higher mean number of disability days per year (29.8 vs 4.5; p < 0.0001). Employees with MS also had a higher rate of medically related absenteeism and associated absenteeism days than employee controls. On average, annual costs (year 2006 values) for disability were significantly higher for employees with MS ($US3868) than employee controls ($US414; p < 0.0001). Annual medically related absenteeism costs were also higher for employees with MS than for controls ($US1901 vs $US1003, respectively; p < 0.0001). On average, total annual indirect costs for employees with MS were $US5769 compared with $US1417 for controls (p < 0.0001). MS is a chronic and debilitating disease that poses a substantial employer burden in terms of medically related absenteeism and disability costs. Indirect costs of employees with MS were >4 times those of employee controls.

[Inability to work before and after operation for carpal tunnel syndrome]

INTRODUCTION

Carpal tunnel syndrome is the most common compressive neuropathy, affecting approximately 5.8% women and 0.6% men. In consideration of its commonness and occurrence in persons in employment age it is considered a cause of significant work absence. Operative treatment of the syndrome results in temporary decreasing of the power and dexterity of the hand, what is also a cause of inability to work. There is lack of information in Polish literature about the dimension of this problem. The objective of this study was to determinate a work absence caused by carpal tunnel syndrome, both before and after the operation.

PATIENTS AND METHODS

Fifty-six employed patients, 44 women and 12 men in a mean age of 49 years (range 27-63) who underwent a mini-invasive carpal tunnel release were analyzed. Patients were asked for duration of the disease and time off work before the operation and were followed-up for 6 months with a time off work to be noted. At 6 months, a self-assessment of the satisfaction with the result was performed in a simple four-grade scale.

RESULTS

A mean duration of the disease in 56 employed patients was 34 months (range 2 months-20 years). Prior to the surgery, 22 patients (39%) were on sickness related sick leave for an average 2.9 months (range 3-12), After the operation all patients availed of sick leave for a mean of 2.3 months (range 1-6). Eight (14%) of the employed patients did not return to work in a 6 months follow-up for various reasons, but mostly due to weakness and reduced dexterity of the involved hand. None of the patients complained of symptoms similar to the pre-operative and in none any complication occurred. In subjective evaluation of the effectiveness of the surgery, comparing to the status before operation 31 patients (26%) were completely free of pain and other symptoms, in 80 (66%) complaints significantly reduced, in 5 (4%) remained the same and in 5 (4%) deteriorated. Statistical analysis revealed that 22 patients who availed of sick leave prior to surgery, were statistically significantly longer off work (a mean of 3 months) than 34 patients who did not were on sick leave (a mean of 1.8 months). Similarly, in 8 patients who did not return to work, 7 availed of sick leave before the operation and only one did not.

CONCLUSION

Our results show that carpal tunnel syndrome is in Poland a cause of considerable work absence. In comparison to other countries, time off work after surgery is relatively long and a proportion of patients did not return to work within 6 months, regardless that no complications occurred in these patients. We intuitively think, that a main cause of a long lasting time work off in majority of patients after carpal tunnel release is an unwillingness but no an inability to work.

Benefit design critical to protecting out-of-pocket costs for employees

In the past few years, employers have struggled with finding the optimal approach to healthcare benefit cost sharing. Recently, a leading actuarial firm analyzed employer out-of-pocket (OOP) data and the financial impact of OOP expenses on employers and employees. Findings were shared with a group of leading employers who meet periodically to discuss innovative benefit design strategies. Attendees viewed models that showed what effects various copayment and coinsurance amounts would have on employer and employee costs. Many attendees were intrigued with results that indicated increasing OOP costs for the sickest employees would do little to lower overall benefit costs.

Direct and indirect costs among employees with diabetic retinopathy in the United States

OBJECTIVE

To examine, from the employer perspective, the direct (healthcare) and indirect (workloss) costs of employees with diabetic retinopathy (DR) compared to control non-DR employees with diabetes, and within DR subgroups.

METHODS

Compared annual costs using claims data from 17 large companies (1999-2004). 'DR employees' (n = 2098) had >or= 1 DR (International Classification of Disease, 9th Revision [ICD-9]) diagnosis; DR subgroups included employees with diabetic macular edema (DME), proliferative DR (PDR), and employees receiving photocoagulation or vitrectomy procedures. Descriptive and multivariate tests were performed.

RESULTS

DR employee annual direct costs were $18,218 (indirect = $3548) compared to $11,898 (indirect = $2374) for controls (Delta = $2032 (adjusted); p < 0.0001). Costs differences were larger across DR employee subgroups: DME/non-DME ($28,606/$16,363); PDR/non-PDR ($30,135/$13,445; p < 0.0001); DR with/without photocoagulation ($34,539/$16,041; p < 0.0001); and DR with/without vitrectomy ($63,933/$17,239; p < 0.0001).

LIMITATIONS

This study examined the incremental costs of treating DR employees, which may be higher than the incremental costs of DR itself. Some measures of diabetes severity (e.g., duration of diabetes) were not available in the claims data, and were therefore not included in the multivariate models. The cost of photocoagulation and vitrectomy procedures pertain to individuals who underwent these procedures, and not the cost of the procedures themselves.

CONCLUSION

DR employees had significantly higher costs than controls, and larger differences existed within DR subgroups. Indirect costs accounted for about 20% of total cost.

[Financial incentives in workers' health management]

In the countries of the European Union, several million workers meet with an accident every year. In the national economy, the costs of accidents at work and occupational diseases are born by different institutions in different proportions, and they are estimated at several percent of the gross domestic product of each of these countries. The issue concerning economic consequences of occupational diseases and accidents at work has been emphasized in the section on health and safety at work of the Community Strategy for 2007-2012. Bearing this in mind, the need have arose to strengthen the efficiency of legal instruments and economic stimuli to motivate actions aimed at improving work conditions. Economic stimuli and legal instruments complement each other in the process of motivating various institutions. The following kinds of economic stimuli have been distinguished: subsidies, grants and financial assistance of the state and stimuli incorporated into tax and insurance systems. Economic evaluation at the information, allocation and educational levels, being an economic tool, may support policymakers who can use this tool to asses economic efficiency of decisions made in the area of health and safety of workers as well as to asses economic consequences of the functioning of legal instruments. The aim of the project, implemented under the Seventh Framework Program by the Nofer Institute of Occupational Medicine, is to promote the system of economic stimuli understood as an incentive to undertake actions for the improvement of work conditions. Owing to this project the discussion forum, addressed to relevant and interested social partners, will be established, and experts in the field will assist in determining directions of further actions aimed at advancing motivation systems.

The burden of illness associated with renal cell carcinoma in the United States

BACKGROUND

There were over 36,000 new cases of kidney cancer reported in the United States in 2004, the most common type being renal cell carcinoma (RCC). Available treatments for localized RCC frequently lead to cure; however RCC patients with advanced disease have limited treatment options and low survival rates. Data on the economic burden of RCC are limited.

METHODS

A prevalence-based model was used to estimate the aggregate annual societal cost burden of RCC in the U.S., including costs of treatment and lost productivity. Key parameters in the model include: the annual number of patients treated for RCC by age group and cancer stage; utilization of cancer treatments; unit costs; work-days missed; and wage rates. Multiplying stratum-specific distributions of treatment by annual quantities of treatments and unit costs yields estimates of RCC-related health-care costs. Multiplying stratum-specific estimates of annual workdays missed by average wage rates yields estimates of RCC-related lost productivity.

RESULTS

The annual prevalence of RCC in the U.S. was estimated to be 109,500 cases. The associated annual burden (inflated to 2005 U.S.$) was approximately $4.4 billion ($40,176 per patient). Health-care costs and lost productivity accounted for 92.4% ($4.1 billion) and 7.6% ($334 million), respectively. Reflecting its higher prevalence, the total cost associated with localized RCC accounted for the greatest share (78.2%), followed by regional, distant, and unstaged RCC, at 18.3%, 2.8%, and 0.7%, respectively.

CONCLUSIONS

The economic burden of RCC in the U.S. is substantial. Interventions to reduce the prevalence of RCC have the potential to yield considerable economic benefits.

Cost of gastro-oesophageal reflux disease to the employer: a perspective from the United States

BACKGROUND

Employers pay more than just salary for their employees. Previous studies have largely focused on direct medical and prescription drug costs of gastro-oesophageal reflux disease (GERD), and few have reported on total absenteeism costs.

AIMS

To examine the annual cost of illness of GERD in an employed US population by benefit category and by place of service for direct medical costs.

METHODS

Retrospective data analysis from 2001 to 2004. International Classification of Diseases (ICD)-9 codes (530.1, 530.10, 530.11, 530.12, 530.19, 530.81, 787.1x, 787.2x or 251.5x) were used to identify employees with and without GERD (the control group). Measures included medical and prescription drug claims, plus indirect costs for sick leave, short- and long-term disability, and workers' compensation. For a subset of the population, the direct medical claims were analysed by place of service.

RESULTS

Data were available for 267,269 eligible employees of which 11,653 had gastro-oesophageal reflux disease. GERD was associated with a mean incremental cost of US $3,355 per employee of which direct medical costs accounted for 65%, prescription drug costs 17%, and indirect costs 19%. The place of service 'out-patient hospital or clinic' accounted for the largest part (47%) of the difference in medical costs.

CONCLUSIONS

GERD is associated with substantial direct and indirect costs, which highlight the importance of managing the disease effectively.

An employer-based cost-benefit analysis of a novel pharmacotherapy agent for smoking cessation

INTRODUCTION

An employer-based cost-benefit analysis for varenicline versus bupropion was conducted using clinical outcomes from a recently published trial.

METHODS

A decision tree model was developed based on the net benefit of treatment to produce a nonsmoker at 1 year. Sensitivity analyses were conducted based on quit rates with placebo and varenicline and the cost of varenicline.

RESULTS

Estimated 12-month employer cost savings per non-smoking employee were $540.60 for varenicline, $269.80 for bupropion SR generic, $150.80 for bupropion SR brand, and $81.80 for placebo. Varenicline was more cost beneficial than placebo, which had quit rates of 16.9% or less. The quit rate with varenicline would have to be <or=16.9% to lose cost benefit over bupropion SR generic.

CONCLUSIONS

The economic benefit of varenicline is improved over bupropion, despite the increased initial cost of varenicline.

Indirect cost burden of migraine in the United States

OBJECTIVE

The purpose of this study was to determine the indirect cost burden associated with migraine.

METHODS

Data were obtained from Thomson-Medstat's Health and Productivity Management (HPM) database for the 2002 through 2003 calendar years. The migraine cohort was composed of patients who had a diagnosis of migraine or migraine-specific abortive prescription medication, or both. A control cohort of patients without migraine was matched to patients in the migraine cohort. The average annual indirect burden of illness (BOI) of migraine and a national indirect BOI were estimated.

RESULTS

Annual indirect expenditures were significantly higher in the migraine group compared with the control group ($4453 vs $1619; P<0.001). The national annual indirect BOI, excluding presenteeism, was estimated to be $12 billion (mostly attributed to absenteeism).

CONCLUSIONS

Migraine imparts a substantial indirect cost burden. Projected to a national level, this amounts to an annual cost to US employers of approximately $12 billion.

The costs and benefits of enhanced depression care to employers

CONTEXT

Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment.

OBJECTIVE

To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives.

DESIGN

Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature.

PARTICIPANTS

Hypothetical cohort of 40-year-old workers. Intervention Enhanced depression care consisting of a depression screen and care management for those depressed vs usual care.

MAIN OUTCOME MEASURES

Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer's perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon.

RESULTS

From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19 976 per quality-adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer's perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In 1-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions.

CONCLUSION

If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers.

[Models of workers' health and safety insurance in the selected European Union member states: certain economic problems]

BACKGROUND

The project entitled "An analysis of insurance models in the selected European Union (EU) member States" has recently been accomplished in the Nofer Institute of Occupational Medicine in the section concerning the health and safety of the working population. One of the aims of the project was to identify differences between EU and Polish models, which may provide the basis for a possible involvement of insurance providers (existing and/or created on purpose) in the implementation of tasks in the area of the workers' health protection in Poland.

MATERIAL AND METHODS

Documents and publications issued in Poland and elaborated by international organizations were used in the analysis. Of the existing models, those which differ in the solutions concerning the limitation of growing costs of insurance systems, the level of centralization of insurance system management, and the range of cooperation between public and private insurance providers were selected for the analysis.

RESULTS

The results of the analysis show that the functioning of insurance systems in the countries under study has been the subject of constant modifications and improvements. Their major aims are to limit the growth of costs of social insurance systems, to shape new qualitative relations between private and public insurance institutions, and to take account of new forms of work regarded as a factor contributing to changes in insurance systems.

DISCUSSION AND CONCLUSIONS

The conclusions arising from the analysis of European insurance systems in the area of workplace accidents and occupational diseases, as well as a possible direction of insurance system transformation in Poland address the following issues: the scope of centralization of insurance system management and the role of the state, the degree of independence of insurance institutions and their priority actions for prevention, motivation mechanisms targeted at employers, participation of employers in the consequences of occupational diseases and workplace accidents, as well as the role of additional voluntary workers' health insurance.

Magnetic resonance imaging for low back injuries: appropriate use in managing workers' compensation claims

Workers' compensation claims resulting from low back injuries are a major concern for U.S. employees and employers. Employees seek resolution of their injuries and related symptoms and rapid return to gainful employment. Employers are eager to help them, as they must absorb the health care and disability costs incurred. Health care providers involved with workers' compensation claims are charged with providing appropriate services to meet the needs of both employees and employers. Magnetic resonance imaging has become the gold standard for diagnosing low back injuries. This study provided data necessary for health care providers to design protocols using magnetic resonance imaging in managing workers' compensation claims for low back injuries.

Acidentes de trabalho: custos previdenciários e dias de trabalho perdidos

OBJETIVO: Estimar a contribuição de benefícios concedidos por acidentes de trabalho dentre o total de benefícios relacionados com a saúde da Previdência Social, focalizando os custos conforme o tipo de benefício, e o impacto sobre a produtividade relativa a dias perdidos de trabalho. MÉTODOS: Utilizam-se registros dos despachos de benefícios do Sistema Único de Benefícios do Instituto Nacional de Seguridade Social da Bahia, em 2000. Acidentes de trabalho foram definidos com o diagnóstico clínico para Causas Externas, Lesões e Envenenamentos (SS-00 a T99) da Classificação Internacional de Doenças 10ª Revisão, e o tipo de benefício que distingue problemas de saúde ocupacionais e não ocupacionais. RESULTADOS: Foram estudados 31.096 benefícios concedidos por doenças ou agravos à saúde, dos quais 2.857 (7,3%) eram devidos a acidentes de trabalho. Maiores proporções foram estimadas entre os trabalhadores da indústria da transformação e construção/eletricidade/gás, 18% do total dos benefícios. Os custos com os benefícios para acidentes de trabalho foram estimados em R$8,5 milhões, com aproximadamente meio milhão de dias perdidos de trabalho no ano. CONCLUSÕES: Apesar do conhecimento de que esses dados são sub-enumerados, e restritos aos trabalhadores que conseguiram receber benefícios relacionados com a saúde, os achados revelam o grande impacto sobre a produtividade e o orçamento do Instituto Nacional de Previdência Social de agravos reconhecidos como evitáveis, reforçando a necessidade de sua prevenção.

Purchasing health insurance coverage for smoking cessation treatment: Employers describe the most influential information in this decision

Employer provision of insurance coverage for smoking cessation treatment (SCT) remains spotty despite a body of treatment efficacy and cost-effectiveness evidence available to inform and support this health care purchasing decision. This qualitative study examined the information on which this coverage decision is made. In this study, state employers describe the content and sources of the most influential information in their decision to provide insurance coverage for SCT as well as a second health benefit for comparative purposes. We provide insight into the extent to which SCT evidence informs the SCT coverage decision and suggest topics and targets for research dissemination. We interviewed 55 employee benefit staff in 35 states. Responses were compared from states with and without SCT coverage to explore the types of information that may be more effective at promoting coverage. The content and sources of the information employers judged most useful varied notably between states with and without SCT coverage. Compelling evidence of the efficacy of SCT and its cost-effectiveness did not appear to play an influential role in the SCT decision among states without SCT coverage relative to states with SCT coverage. States with SCT coverage relied significantly on benefit consultants and actuaries for the information they described as most influential; in comparison, noncovered states reported service providers, staff, and the Internet as major information sources. To foster employers' provision of SCT coverage, research dissemination efforts should emphasize SCT efficacy and cost-effectiveness information and tailor communication to benefit consultants and actuaries in addition to employers themselves.

Pharmacy benefit spending on oral chemotherapy drugs

BACKGROUND

Pharmacy benefits have historically excluded injectable drugs, resulting in coverage of injectable drugs under the medical benefit. High-cost biologics and other new drug therapies are often injectables and therefore have not presented cost threats to pharmacy benefits. The U.S. Food and Drug Administration approval of capecitabine, an oral form of fluorouracil, in 1998, and imatinib mesylate in oral dose form for chronic myeloid leukemia, in 2001, signaled a new period in budget forecasting for pharmacy benefits, particularly for small, self-insured employers for whom a drug with a cost of 25,000 dollars per year of therapy for 1 patient could increase total pharmacy benefit costs by 10% or more.

OBJECTIVE

To quantify the actual relative costs of the oral chemotherapy drugs in pharmacy benefits in 2006 and identify the history of spending on oral chemotherapy drugs relative to total pharmacy benefit spending for small, self-insured employers over the 4.5 years through May 2006.

METHODS

Administrative pharmacy claims from the database of a pharmacy benefits manager (PBM) for approximately 500,000 members of small, self-insured employer plans were used to calculate the net plan cost of oral chemotherapy drugs relative to total drug benefit costs for the period January 1, 2002, through May 31, 2006. Current costs for oral chemotherapy drugs for small employers were compared with an insured health plan of approximately the same number of members for dates of service January 1, 2006, through May 31, 2006.

RESULTS

This descriptive analysis found that oral chemotherapy drugs represented 0.27% of total drug benefit costs, or approximately 0.08 dollars per member per month (PMPM) for small, self-insured employers in 2002, rising linearly to 0.73%, or approximately 0.24 dollars PMPM in the first 5 months of 2006. Members in pharmacy benefit plans sponsored by small employers paid an average 6.9% cost share for oral chemotherapy drugs in 2006, nearly identical to the average 8.5% paid by members of an insured health plan of similar size in total membership, versus 26.9% average cost share for all drugs. Imatinib mesylate accounted for 45% of total spending on oral chemotherapy agents in 2002 versus 40% in 2006.

CONCLUSION

Spending on oral chemotherapy drugs as a proportion of total pharmacy benefit costs has more than doubled, from about 0.3% in 2002 to 0.7% in 2006. For small, self-insured employers, this represents a nearly 3-fold increase in spending, from about 0.08 dollars PMPM in 2002 to about 0.24 dollars PMPM in 2006.

The economic impact of bipolar disorder in an employed population from an employer perspective

OBJECTIVE

To determine the economic impact of bipolar disorder on health benefit costs and health-related work absences from an employer perspective.

METHOD

Data on health benefit costs and health-related absences during 2001 and 2002 were retrieved from a database and retrospectively examined. Regression modeling measured the cost differences while controlling for potentially confounding factors. The study population consisted of employees at multiple large employers who were widely dispersed throughout the United States. These employees were grouped into 2 cohorts: (1) employees with a bipolar disorder diagnosis (primary, secondary, or tertiary ICD-9 code of 296.0x, 296.1x, 296.4x, 296.5x, 296.6x, 296.7x, or 296.8x) in 2001 and (2) employees with no bipolar disorder diagnosis during 2001 or 2002 (comparison cohort). Specific outcome measures included annual health benefit claim costs and salary-replacement payments for the following employee health benefits: health care insurance, prescription drug, sick leave, short- and long-term disability, and workers' compensation. Additional outcome measures included annual absence days due to workers' compensation, short- and long-term disability, and sick leave (separately).

RESULTS

The analysis identified 761 employees (0.3%) with bipolar disorder and 229,145 eligible employees without bipolar disorder. Employees with bipolar disorder annually cost $6836 more than employees without bipolar disorder (p < .05) and were more costly in every health benefit cost category. Employees with bipolar disorder missed an average of 18.9 workdays annually, while employees without bipolar disorder missed 7.4 days annually (p < .05).

CONCLUSION

The impact of bipolar disorder can be costly in the workplace, leading to increased health benefit costs and increased absenteeism.

Cutting both ways

Health care coverage is by far the biggest cost of doing business for most American companies large and small. Many are trying to cope by reducing or eliminating health benefits for retirees. That's an unhappy shock for their former employees--and it is bound to have disturbing consequences for providers.

Generosity And Adjusted Premiums In Job-Based Insurance: Hawaii Is Up, Wyoming Is Down

This paper reports national and state findings on the generosity or actuarial value of U.S. employer-based plans and adjusted premiums in 2002. The basis for our calculations is simulated bill paying for a large standardized population. After adjusting for the quality of benefits, we find from regression analysis that adjusted premiums are 18 percent higher in the nation's smallest firms than in firms with 1,000 or more workers. They are 25 percent higher in indemnity plans and 18 percent higher in preferred provider organizations than in health maintenance organizations. The generosity of coverage increased from 1997 to 2002.

The costs and benefits of private sector provision of treatment to HIV-infected employees in Kampala, Uganda

OBJECTIVES

The objective of this study was to determine the financial incentives that companies have to treat HIV-infected employees, in a health care services company in Kampala, Uganda.

DESIGN

Cost-benefit analysis from the company's perspective of three interventions to treat HIV-infected employees.

METHODS

The costs and benefits of each intervention were compared with no intervention and with each other: cotrimoxazole prophylaxis (CTX) starting at WHO stage 2; highly active antiretroviral therapy (HAART) plus CTX starting at WHO stage 2; and a 'hybrid' strategy that begins with CTX at WHO stage 2 and later includes HAART. The 5-year health and economic outcomes were calculated using a Markov model. Inputs for disease progression rates and effects of HIV on company costs were derived from published and unpublished data and a survey administered to company officers.

RESULTS

The analysis showed that the 'hybrid' intervention is the most cost-effective. For 100 skilled employees it would save the company 38,939 US dollars and 73 disability adjusted life-years (DALYs). For unskilled workers 'CTX' is the most cost effective and would save 16,417 US dollars and 60 DALYs. 'Hybrid' has an incremental cost-effectiveness ratio of 45 US dollars per DALY for unskilled workers whereas HAART is far less economical at an incremental cost per DALY of 4118 US dollars. For 'CTX', net savings are preserved across the full range of input values.

CONCLUSION

A 'hybrid' intervention combining CTX prophylaxis followed by HAART would generate savings to a Ugandan company. Governments and other donors may find opportunities to share costs with the private sector as part of their phase-in strategy for antiretroviral therapy.

Employer choices of family premium sharing

In 1997, nearly two-thirds of married couples with children under age 18 were dual-earner couples. Such families may have a variety of insurance options available to them. If so, declining a high employee premium contribution may be a mechanism for one spouse to take money wages in lieu of coverage while the other spouse takes coverage rather than high wages. Employers may use these preferences and the size of premium contributions to encourage workers to obtain family coverage through their spouse. The purpose of this paper is to explore the effects of labor force composition, particularly the proportion of dual-earner couples in the labor market, on the marginal employee premium contribution (marginal EPC) for family coverage. We analyze data from the 1997-2001 Medical Expenditure Panel Survey--Insurance Component (MEPS-IC) List Sample of private establishments. We find strong evidence that the marginal EPC for family coverage is higher when there is a larger concentration of women in the workforce, but only in markets with a higher proportion of dual-earner households.

[Costs of occupational diseases and accidents at work in Poland]

BACKGROUND

The costs of occupational diseases and accidents at work in the state members of the European Union keep at a level of several percent of their gross national product (GNP). Employees, employers and the society as a whole have to incur this financial burden. Therefore, all social partners should be involved in the improvement of health and safety in the work environment through their concerted efforts. It should be pointed out that information in the field of economy is an inherent instrument of all activities. It allows to estimate economic consequences of occupational diseases and accidents at work as well as to formulate future strategies. The aim of this study was to estimate and assess the range of the expenditure of money on occupational diseases and accidents at work in Poland in 2004.

MATERIAL AND METHODS

The algorithm for estimating economic consequences of occupational diseases and accidents at work was developed, taking into account, e.g., the selected components of the costs, the estimation of economic consequences for the national economy, and the costs incurred by employers and social insurance institutions. In addition, the model for estimating economic consequences and defining the range of expenditure of money on occupational diseases and accidents at work relative to indicators of socioeconomic situation of the country was constructed. Economic consequences are understood as costs incurred by the health care and social insurance systems in Poland, institutions, companies, and individual employees.

RESULTS

The following cost components were estimated: the average-annual costs of lost production, sickness benefits, social insurance benefits and those incurred by enterprises related with accidents at work and occupational diseases.

CONCLUSIONS

Due to the lack of complete, reliable information essential for estimating economic consequences, a number of assumptions and study limitations were accepted. The range of identified and estimated costs of occupational diseases and accidents at work was set relative to GNP and to the value added in the national economy. Bearing in mind that the costs of occupational diseases and accidents at work are underestimated, it can be concluded that their share in values characteristic of the national economy do not depart from average values recorded in European countries.

The economic burden of schizophrenia in the United States in 2002

OBJECTIVE

This study quantifies excess annual costs associated with schizophrenia patients in the United States in 2002 from a societal perspective.

METHOD

Annual direct medical costs associated with schizophrenia were estimated separately for privately (N = 1090) and publicly (Medicaid; N = 14,074) insured patients based on administrative claims data, including a large private claims database and the California Medicaid program (MediCal) database, and compared separately to demographically/geographically matched control samples (1 case:3 controls). Medicare costs of patients over age 65 years were imputed using the Medicare/MediCal dual-eligible patients (N = 1491) and published statistics. Excess annual direct non-health care costs were estimated for law enforcement, homeless shelters, and research/training related to schizophrenia. Excess annual indirect costs were estimated for 4 components of productivity loss: unemployment, reduced workplace productivity, premature mortality from suicide, and family caregiving using a human capital approach based on market wages. All costs were adjusted to 2002 dollars using the Medical Care Consumer Price Index and were based on the reported prevalence in the National Comorbidity Survey Replication.

RESULTS

The overall U.S. 2002 cost of schizophrenia was estimated to be $62.7 billion, with $22.7 billion excess direct health care cost ($7.0 billion outpatient, $5.0 billion drugs, $2.8 billion inpatient, $8.0 billion long-term care). The total direct non-health care excess costs, including living cost offsets, were estimated to be $7.6 billion. The total indirect excess costs were estimated to be $32.4 billion.

CONCLUSION

Schizophrenia is a debilitating illness resulting in significant costs. The indirect excess cost due to unemployment is the largest component of overall schizophrenia excess annual costs.

Economic burden of osteoporosis, breast cancer, and cardiovascular disease among postmenopausal women in an employed population

BACKGROUND

Postmenopausal women have a significant risk of developing a number of chronic conditions including osteoporosis (OP), breast cancer (BrCa), and cardiovascular disease (CVD). These diseases can result in significant direct (medical treatment) and indirect (workplace) costs. The objective of this study is to assess these costs among an employed population.

METHODS

Deidentified medical and disability claims data from seven large employers (n = 585,441) were analyzed from 1998 through 2000 for female employees, age 50-64 years. Medical claim ICD-9CM codes were used to identify patients treated for: OP (n = 2,314), BrCa (n = 555), and CVD (n = 1,710). Each disease cohort was compared to a random sample of 50- to 64-year-old female employees (n = 7,575). Descriptive and multivariate techniques were used to characterize direct and indirect costs attributable to each condition.

RESULTS

Average annual direct costs were higher (p < .001) for female employees treated for OP (6,259 dollars), BrCa (13,925 dollars), or CVD (12,055 dollars) when compared with the random sample (2,951 dollars). In addition, average annual indirect costs associated with OP (4,039 dollars), BrCa (8,236 dollars), and CVD (4,990 dollars) were higher (p < .001) than indirect costs for the random sample (2,292 dollars). Even when controlling for each disease-state cohort's demographics and disease-specific comorbidities, patients treated for OP, BrCa, and CVD continued to have significantly greater direct and indirect costs (p < .001) than the random sample.

CONCLUSIONS

Chronic conditions such as OP, BrCa, and CVD, which occur more frequently in women after menopause, impose a significant financial burden. Greater health care utilization and work-loss prevalence among women treated for these conditions contribute to these additional costs.

Tegaserod treatment for IBS: a model of indirect costs

Irritable bowel syndrome (IBS) has been associated with substantial time lost from work (absenteeism) and reduced productivity at work (presenteeism), which are the indirect costs of illness. This article presents a productivity model demonstrating the indirect costs associated with IBS and the reduction in those costs for a cohort of female employees hypothetically treated with tegaserod, a new selective serotonin (5-hydroxytryptamine [5-HT]) type 4 (5-HT4) receptor agonist, which is approved by the US Food and Drug Administration for treating women with IBS-C. The model is based on economic and epidemiologic published literature and clinical trial results. In this model, tegaserod treatment resulted in 1882 dollars in avoided lost productivity per treated female employee. Considering only the benefits of decreased work loss and the costs of medical therapy, the model predicts a benefit/cost ratio of 3.75 in the base case. From an employer's perspective, medical therapy for IBS with tegaserod is cost-effective under a series of assumptions for the treatment of women with IBS with constipation.

Who Really Pays for Health Insurance? The Incidence of Employer-Provided Health Insurance with Sticky Nominal Wages

This paper addresses two seeming paradoxes in the realm of employer-provided health insurance: First, businesses consistently claim that they bear the burden of the insurance they provide for employees, despite theory and empirical evidence indicating that workers bear the full incidence. Second, benefit generosity and the percentage of premiums paid by employers have decreased in recent decades, despite the preferential tax treatment of employer-paid benefits relative to wages-trends unexplained by the standard incidence model. This paper offers a revised incidence model based on nominal wage rigidity, in an attempt to explain these paradoxes. The model predicts that when the nominal wage constraint binds, some of the burden of increasing insurance premiums will fall on firms, particularly small companies with low-wage employees. In response, firms will reduce employment, decrease benefit generosity, and require larger employee premium contributions. Using Current Population Survey data from 2000-2001, I find evidence for this kind of wage rigidity and its associated impact on the employment and premium contributions of low-wage insured workers during a period of rapid premium growth.

How to present the business case for healthcare quality to employers

Many employers in the US are investing in new programmes to improve the quality of medical care and simultaneously shifting more of the healthcare costs to their employees without understanding the implications on the amount and type of care their employees will receive. These seemingly contradictory actions reflect an inability by employers to accurately assess how their health benefit decisions affect their profits. This paper proposes a practical method that employers can use to determine how much they should invest in the health of their workers and to identify the best benefit designs to encourage appropriate healthcare delivery and use. This method could also be of value to employers in other countries who are considering implementing programmes to improve employee health. The method allows a programme that improves workers' health to generate four financial benefits for an employer - reduced medical costs, reduced absences, improved on-the-job productivity, and reduced turnover - and uses accurate estimates of the benefits of reducing absences and improving productivity.

Costs of occupational injury and illness across industries

OBJECTIVES

This study has ranked industries using estimated total costs and costs per worker.

METHODS

This incidence study of nationwide data was carried out in 1993. The main outcome measure was total cost for medical care, lost productivity, and pain and suffering for the entire United States (US). The analysis was conducted using fatal and nonfatal injury and illness data recorded in large data sets from the US Bureau of Labor Statistics. Cost data were derived from workers' compensation records, estimates of lost wages, and jury awards. Current-value calculations were used to express all costs in 1993 in US dollars.

RESULTS

The following industries were at the top of the list for average cost (cost per worker): taxicabs, bituminous coal and lignite mining, logging, crushed stone, oil field services, water transportation services, sand and gravel, and trucking. Industries high on the total-cost list were trucking, eating and drinking places, hospitals, grocery stores, nursing homes, motor vehicles, and department stores. Industries at the bottom of the cost-per-worker list included legal services, security brokers, mortgage bankers, security exchanges, and labor union offices.

CONCLUSIONS

Detailed methodology was developed for ranking industries by total cost and cost per worker. Ranking by total costs provided information on total burden of hazards, and ranking by cost per worker provided information on risk. Industries that ranked high on both lists deserve increased research and regulatory attention.

A cost analysis of the employer-based bednet programme in Coastal and Western Kenya

Malaria remains a major health problem in Africa. One preventative strategy currently advocated is the use of bednets, preferably treated with insecticide. Many approaches to bednet delivery have been adopted in Kenya, including an employer-based malaria control strategy (EBMC). The cost and sustainability of this approach have not previously been assessed. This paper presents the financial cost (cash expenditure) of the EBMC programme implemented in the Coastal and Western regions of Kenya by the African Medical and Research Foundation (AMREF) between April 1998 and February 2002. Getting a bednet and insecticide to an employee was estimated to cost the provider US$15.8. This could be reduced by US$0.5 if the remaining stocks were liquidated and by an additional US$1.3 if the salvage of capital items is considered. The venture of distributing bednets to employees through the programme proved lucrative to organized community groups (OCGs), for they made between 24 and 29% gross profit from the nets they sold. Consequently, OCGs in nine of the 13 companies involved had retained enough funds from which they could buy and sell bednets without further donor financial support, and this portrays some elements of a sustainable supply system.

The cost of high-fidelity supported employment programs for people with severe mental illness

OBJECTIVE

This study determined the costs of evidence-based supported employment programs in real-world settings.

METHODS

A convenience sample of 12 supported employment programs known to follow closely the principles of evidence-based supported employment was asked to provide detailed information on program costs, use, and staffing. Program fidelity was assessed by using the Supported Employment Fidelity Scale. Cost and utilization data were analyzed in a comparable manner to yield direct and total costs per client served, per full-year-equivalent client, and per employment specialist.

RESULTS

Usable data were obtained from seven programs in rural and urban locations in seven states: Indiana, Kansas, Massachusetts, New Hampshire, Oregon, Rhode Island, and Vermont. All programs received high fidelity ratings, ranging from 70 to the maximum value of 75. Annual direct costs per client served varied from dollars 860 in New Hampshire to dollars 2723 in Oregon, and direct costs per full-year-equivalent client varied from dollars 1423 in Massachusetts to dollars 6793 in Indiana. Direct costs per employment specialist did not show as much variation, ranging from dollars 37339 in Rhode Island to dollars 49603 in Massachusetts, with a mean of dollars 44082. Differences in cost per client arose in part from differences in rules for determining who is or is not considered to be on a program's caseload. By assuming a typical caseload of about 18 clients, it was estimated that the cost per full-year-equivalent client averaged dollars 2449 per year, ranging from dollars 2074 to dollars 2756.

CONCLUSIONS

The results point to the need for greater uniformity in caseload measurement and help specify the costs of high-fidelity supported employment programs in real-world settings.

Costs, benefits and effectiveness of worksite physical activity counseling from the employer`s perspective

OBJECTIVES

This study evaluated the impact of worksite physical activity counseling using cost-benefit and cost-effectiveness analyses.

METHODS

Civil servants (N = 299) were randomly assigned to an intervention (N = 131) or control (N = 168) group for 9 months. The intervention costs were compared with the monetary benefits gained from reduced sick leave. In addition, the intervention costs minus the monetary benefits from sick leave reduction were compared with the effects (percentage meeting the public health recommendation for moderate-intensity physical activity, energy expenditure, cardiorespiratory fitness, and upper extremity symptoms).

RESULTS

The intervention costs were EUR 430 per participant, and the benefits were EUR 125 due to sick leave during the intervention period, for net total costs of EUR 305 for the intervention. During the same 9-month period the year after the intervention, the benefits from sick leave reduction were EUR 635. No statistically significant differences in costs and benefits were found between the groups. As to the cost-effectiveness, improvement in energy expenditure and cardiorespiratory fitness was observed at higher costs. The point estimates of the cost-effectiveness ratios were EUR 5.2 (without imputation of effect data) and EUR 2.7 (with imputation of effect data) per extra kilocalorie of energy expenditure per day and EUR 235 (without imputation of effect data) and EUR 45.9 (with imputation of effect data) per beat per minute of decrease in submaximal heart rate.

CONCLUSIONS

This study does not provide a financial reason for implementing worksite counseling intervention on physical activity on the short-term. However, positive effects were shown for energy expenditure and cardiorespiratory fitness.

Costs of health care administration in the United States and Canada

BACKGROUND

A decade ago, the administrative costs of health care in the United States greatly exceeded those in Canada. We investigated whether the ascendancy of computerization, managed care, and the adoption of more businesslike approaches to health care have decreased administrative costs.

METHODS

For the United States and Canada, we calculated the administrative costs of health insurers, employers' health benefit programs, hospitals, practitioners' offices, nursing homes, and home care agencies in 1999. We analyzed published data, surveys of physicians, employment data, and detailed cost reports filed by hospitals, nursing homes, and home care agencies. In calculating the administrative share of health care spending, we excluded retail pharmacy sales and a few other categories for which data on administrative costs were unavailable. We used census surveys to explore trends over time in administrative employment in health care settings. Costs are reported in U.S. dollars.

RESULTS

In 1999, health administration costs totaled at least 294.3 billion dollars in the United States, or 1,059 dollars per capita, as compared with 307 dollars per capita in Canada. After exclusions, administration accounted for 31.0 percent of health care expenditures in the United States and 16.7 percent of health care expenditures in Canada. Canada's national health insurance program had overhead of 1.3 percent; the overhead among Canada's private insurers was higher than that in the United States (13.2 percent vs. 11.7 percent). Providers' administrative costs were far lower in Canada. Between 1969 and 1999, the share of the U.S. health care labor force accounted for by administrative workers grew from 18.2 percent to 27.3 percent. In Canada, it grew from 16.0 percent in 1971 to 19.1 percent in 1996. (Both nations' figures exclude insurance-industry personnel.)

CONCLUSIONS

The gap between U.S. and Canadian spending on health care administration has grown to 752 dollars per capita. A large sum might be saved in the United States if administrative costs could be trimmed by implementing a Canadian-style health care system.

Measuring the relationship between employees' health risk factors and corporate pharmaceutical expenditures

This study demonstrates the relationship between self-reported health risk factors on a health risk appraisal and pharmaceutical expenditures for a large employer. A total of 3554 employees who were participants in a pharmacy benefit plan for the entire year of 2000 completed a health risk appraisal. As the number of self-reported health risk factors increased from zero to six or more, corporate pharmaceutical costs increased in a stepwise manner: US dollars 345, 443, 526, 567, 750, 754, and 1121 US dollars, respectively. After controlling for age, gender, and the number of self-reported diseases, each additional risk factor was associated with an average annual increase in pharmacy claims costs of 76 US dollars per employee. Specific health risks were associated with significantly higher expenditures. The results provide estimates of incremental expenditures associated with common, potentially modifiable risk factors. Pharmaceutical expenditures should be considered by corporations in their estimates of total health-related costs and in prioritizing disease management initiatives based on health risk appraisal data.

The economic burden of depression with painful symptoms

The economic burden of depression is substantial. The condition is highly prevalent, with both psychiatric and physical symptoms that often inflict pain. The chronic and often debilitating nature of depression results in costly medical therapies, as well as impaired workplace productivity. As a result, the overall economic burden of depression is comparable to that of serious physical illnesses, such as cancer and heart disease. This article presents an overview of the economic burden of depression and provides background on the relationship between depression and pain in this context. Research findings are also presented on the economic burden associated with a particular manifestation of pain among depressed patients, fibromyalgia. When painful physical symptoms accompany the already debilitating psychiatric and behavioral symptoms of depression, the economic burden that ensues for patients and their employers increases considerably. On purely economic grounds, more aggressive outreach may be warranted for patients with depression and comorbid pain to initiate treatment before symptoms are allowed to persist. However, more research is needed to assess the comprehensive economic impact that depression with painful physical symptoms can have on society.

Surviving the impact of HIV-related illness in the Zambian business sector

The HIV epidemic in sub-Saharan Africa represents an obstacle to productive employment and economic development. Employers in the region are experiencing severe staff shortages, reduced productivity, and increased costs because of protracted ill health and death among their workforce. The scale of the problem has not been fully estimated and the extent to which it could be ameliorated by control measures including effective treatment of opportunistic infections is not well known. Employers and employees (n = 108) in seven Zambian firms were interviewed to assess direct and indirect costs of illness to the firms. Information was collected on diagnosis and treatment received, duration of illness, time off, and strategies adopted to compensate for absent workers using a combination of questionnaires, structured interviews and focus group discussions. The main causes of ill health were tuberculosis (TB) (46.8%), diarrhea (12.9%), and sexually transmitted diseases (STDs; 5.8%). Annual treatment costs to the firm ranged from Zambia Kwacha (K) 60,000 to 405,000 per person treated. Other firm costs included productivity losses because of ill health, paid sick leave, the cost of employee replacement, and funerals. Employees incurred K 67,773 on average per illness episode. The most common causes of ill health were those most frequently associated with HIV. They can be easily but were often ineffectively treated. Improving disease management would thus reduce wastage and costs both to employer and employee. The extent of the impact in these firms shows the need for the private sector to adopt a stronger role in prevention and care. Further research is required to assess what recommended treatment options might be, how they could be financed, and the extent of the economic impact of HIV on firms. This would foster the development of more appropriate responses to the epidemic in Zambia and the region as a whole.

Economic cost and epidemiological characteristics of patients with fibromyalgia claims

OBJECTIVE

Fibromyalgia (FM) is characterized by widespread pain that can lead to significant patient disability, complex management decisions for physicians, and economic burden on society. We investigated the total costs of FM in an employer population.

METHODS

Administrative claims data of a Fortune 100 manufacturer were used to quantify direct (i.e., medical and pharmaceutical claims) and indirect (i.e., disability claims and imputed absenteeism) costs associated with FM. A total of 4699 patients with at least one FM claim between 1996 and 1998 were contrasted with a 10% random sample of the overall beneficiary population. Employee-only subsets of both samples also were drawn.

RESULTS

Medical utilization, receipt of prescription drugs, and annual total costs were proportionately similar yet significantly greater among FM claimants than the overall sample (all p < 0.0001). Total annual costs for FM claimants were $5945 versus $2486 for the typical beneficiary (p < 0.0001). Six percent of these costs were attributable to FM-specific claims. The prevalence of disability was twice as high among FM employees than overall employees (p < 0.0001). For every dollar spent on FM-specific claims, the employer spent another $57 to $143 on additional direct and indirect costs.

CONCLUSION

Hidden costs of disability and comorbidities greatly increase the true burden of FM. Regardless of the clinical understanding of FM, when a claim for FM is present, considerable costs are involved. Findings suggest that within the management of FM there may be large cost-offset opportunities for reductions in patient, physician, and employer burdens.