Tag Archives: johns hopkins

How to Attack the Opioid Crisis

The vastness of the opioid crisis is all around us:

  • 259 million opioid prescriptions are made every year.
  • 91 Americans die every day of opioid overdose.
  • Workplace costs of prescription opioid use are more than $25 billion, driven by lost earnings from premature death, reduced compensation or lost employment and healthcare costs.

It’s time to take action.

See also: Opioids: A Stumbling Block to WC Outcomes  

As with any large-scale, complex phenomenon, there is no silver bullet. But a framework from the Johns Hopkins Bloomberg School of Public Health suggests three areas where we should focus our efforts: preventing new cases of opioid addiction, identifying opioid-addicted individuals early and ensuring access to effective opioid addiction treatment. We believe these areas must be attacked from a variety of clinical and operational angles.

From the clinical side, the emphasis has to be largely around better clinical training and urinary drug testing (UDT). A generation of doctors has been raised based on a curriculum emphasizing the need to manage pain aggressively. Retraining physicians on best practices is needed to reinforce safe opioid prescribing patterns. Research from Utah has shown that physician education on recommended opioid prescribing practices was associated with improved prescription patterns, including 60% to 80% fewer prescriptions for long-acting opioids for acute pain. When an opioid is prescribed, the use of UDT is a cost-effective way to monitor treatment compliance and drug misuse.

To address from the operational side, we need evidence-based opioid prescription guidelines in place and systems to track opioid prescriptions and adherence to guidelines. Further, we must ensure access to effective opioid addiction treatment.

Many health organizations and state health systems are aggressively adopting pain treatment guidelines that clearly lay out when opioids should and should not be used. And the preliminary results of implementing these guidelines are promising. For example, the introduction of opioid prescribing guidelines in the Washington state workers’ compensation system was associated with a decline in opioid prescriptions, the average morphine equivalent doses prescribed and the number of opioid-related deaths.

Prescription drug monitoring programs (PDMP) allow for health systems to analyze opioid prescribing data to find potentially inappropriate prescribing behavior and illegal activity. For example, using its PDMP, New York City found that 1% of prescribers wrote 31% of the opioid prescriptions.

While prevention of initial opioid exposure is important, the treatment of opioid addiction is an important safety net when prevention fails. Pharmacotherapies including methadone, buprenorphine and naltrexone are options for routine care of opioid dependence, but they are still in the early stages of the adoption cycle.

See also: Potential Key to Tackling Opioid Issues  

The foundation to address the clinical and operational approaches to opioid epidemic is two-fold:

  1. A strong system to determine what’s acceptable through well-defined, evidence-based guidelines; and
  2. A system to use these guidelines and trigger the right actions through processes and technology.

The next article will address the nature of these two systems.

Obesity as Disease: A Profound Change

The obesity rate in the U.S. has doubled in the past 15 years. More than 50% of the population is overweight, with a BMI (body mass index) between 25 and 30, and 30% have a BMI greater than 30 and are considered obese. Less than 20% of the population is at a healthy weight, with a BMI less than 25.

On June 16, 2013, the American Medical Association voted to declare obesity a disease rather than a comorbidity factor, a decision that will affect 78 million adults. The U.S. Department of Health and Human Services said the costs to U.S. businesses related to obesity exceed $13 billion each year. With the pending implementation of ICD (International Classification of Diseases) 10 codes, the reclassification of obesity is is fast becoming a reality and will dramatically affect workers’ compensation and cases related to the American Disability Act and amendments.

Before the AMA’s obesity reclassification, ICD-9 code 278 related to obesity-related medical complications rather than to obesity. The new ICD-10 coding system now identifies obesity as a disease, which needs to be addressed medically. Obesity can now become a secondary claim, and injured workers will be considered obese if they gain weight because of medications, cannot maintain a level of fitness because of a work-related injury or if their BMI exceeds 30. The conditions are all now considered work-related and must be treated as such.

The problem of obesity for employers is not confined to workers’ compensation. The Americans with Disability Act Amendment of 2008 allows for a broader scope of protection for disabilities. The classification of obesity as a disease now places an injured worker in a protected class pursuant to the ADA amendment. In fact, litigation in this area has already started. A federal district court ruled in April 2014 that obesity itself may be a disability and will be allowed to move forward under the ADA (Joseph Whittaker v. America’s Car-Mart, Eastern District of Missouri).

Obesity as an impairment

Severe obesity is a physical impairment. A sales manager of a used car dealership was terminated for requesting accommodation and won $128,000. He was considered disabled, and the essential function of the job was walking, so he was terminated without reasonable accommodation.

The judge ruled that obesity is an accepted disability and allowed him to pursue his claim against his employer. This could have substantial impact for employers as injured workers could more easily argue that their obesity is a permanent condition that impedes their ability to return to work, as opposed to a temporary life choice that can be reversed.

The Equal Employment Opportunities Commission (EEOC) has recently chimed in on obesity. According to the EEOC, severe [or morbid] obesity body weight, of more than 100% over the norm, qualifies as impairment under the ADA without proof of an underlying physiological disorder. In the last year, we have seen an increasing number of EEOC-driven obesity-related lawsuits. Federal district courts support the EEOC’s position that an employee does not have to prove an underlying condition, especially in cases where there is evidence that the employer perceived the employee’s obesity as a disability or otherwise expressed prejudice against the employee for being obese.

Workers’ compensation claims are automatically reported to CMS Medicare with a diagnosis. When the new ICD-10 codes take effect, an obesity diagnosis will be included in the claim and will require co-digital payments, future medical care or continued treatment by Medicare.

There is good news on the horizon. Reporting of a claim only happens if there is a change in condition not primarily for obesity. It is recommended that baseline testing for musculoskeletal conditions be conducted at the time of hiring and on the existing workforce. In the event of a work-related injury, if a second test is conducted that reveals no change in condition, it results in no reportable claim and no obesity issue. In the event of ADA issues, the baseline can serve to determine pre-injury condition or the need for accommodations.

What does this mean to employers?

Obesity is now considered a physical impairment that may affect an employees’ ability to perform their jobs and receive special accommodations pursuant to the ADA.

An increasingly unhealthy workforce will pose many challenges for employers in the next few years. Those that can effectively improve the health and well-being of their employee population will have a significant advantage in reducing work comp claim costs, health and welfare benefits and retaining skilled workers.

Recent studies

In a four-year study conducted by Johns Hopkins with an N value of 7,690, 85% of the injured workers studied were classified as obese. In a Duke University study involving 11,728 participants, researchers revealed that employees with a BMI greater than 40 had 11.65 claims per 100 workers, and the average claim costs were $51,010. Employees with a BMI less than 25 had 5.8 claims per 100 workers, with average claim costs of $7,503. This study found that disability costs associated with obesity are seven times higher than for those with a BMI less than 30.

A National Institute of Health study with 42,000 participants found that work-related injuries for employees with a BMI between 25 and 30 had a 15% increase in injuries, and those with a BMI higher than 30 had an increase in work-related injuries of 48%.

The connection between obesity and on the job injuries is clear and extremely costly for employers. Many employers have struggled with justifying the cost of instituting wellness programs just on the basic ROI calculations. They were limiting the potential return on investment solely to the reduction in health insurance costs rather than including the costs on the workers’ comp side of the equation and the potential for lost business opportunities because of injury rates that do not meet customer performance expectations. Another key point is that many wellness programs do not include a focus on treating chronic disease that may cause workers to be more likely to be injured and prolong the recovery period.

Customer-driven safety expectations

There are many potential customers (governments, military, energy, construction) who require that their service providers, contractors and business partners meet specific safety performance requirements as measured by OSHA statistics (recordable incident rates) and National Council on Compensation Insurance (NCCI) rating (experience modifiers) and, in some cases, a full review by 3rd party organizations such as ISNet World.

Working for the best customers often requires that your company’s safety record be in the top 25th percentile to even qualify to bid. To be a world-class company with a world-class safety record requires an integrated approach to accident and injury prevention.

Challenges of an aging workforce

The Bureau of Labor Statistics projects that the labor force will increase by 12.8 million by 2020. The number of workers between ages 16 and 24 will decline 14%, and the number of workers ages 25 to 54 will increase by only 1.9%. The overall share of the labor force for 25- to 54-year-olds will decline from 68% to 65%. The number of workers 55 and older is projected to grow by 28%, or 5.5 times the rate of growth in the overall labor force.

Employers must recognize the challenge that an aging workforce will bring and begin to prepare their workforce for longer careers. A healthy and physically fit 55-year-old worker is more capable and less likely to be injured than a 35-year-old worker who is considered obese.

Treating chronic disease

Employers who want a healthy work force must recognize and treat chronic disease. Many companies have biometric testing programs (health risk assessments) and track healthcare expenditures through their various providers (brokers and insurance carriers).

The results are quite disappointing. On average, only 39% of employees participate in biometric screenings even when they are provided free of charge. For those employees who do participate and who are identified with high biometric risk (blood pressure, glucose, BMI, cholesterol), fewer than 20% treat or even manage these diseases.

This makes these employees much more susceptible to injury and significantly lengthens the disability period. The resulting financial impact on employers can be devastating.

Conclusion

Best-in-class safety results will require a combined approach to reduce injuries and to accommodate new classes of disability such as obesity. It is important that employers focus on improving the health and well-being of their workforce while creating well-developed job descriptions, identifying the essential functions, assessing physical assessments and designing job demands to fall within the declining capabilities of the American workers. It is important for an employer to only accept claims that arise out of the course and scope of employment. This is especially true with the reclassification of obesity as a disease. Baseline testing will play an essential role in separating work-related injuries from pre-existing conditions in this changing environment.

11 Questions for Ron Goetzel on Wellness

We thank Ron Goetzel, representing Truven Health and Johns Hopkins, for posting on Insurance Thought Leadership a rebuttal to our viral November posting, “Workplace Wellness Shows No Savings.” Paradoxically, while he conceived and produced the posting, we are happy to publicize it for him. If you’ve heard that song before, think Mike Dukakis’s tank ride during his disastrous 1988 presidential campaign.

Goetzel’s rebuttal, “The Value of Workplace Wellness Programs,” raises at least 11 questions that he has been declining to answer. We hope he will respond here on ITL. And, of course, we are happy to answer any specific questions he would ask us, as we think we are already doing in the case of the point he raises about wellness-sensitive medical events. (We offer, for the third time, to have a straight-up debate and hope that he reconsiders his previous refusals.)

Ron:

(1)    How can you say you are not familiar with measuring wellness-sensitive medical events (WSMEs), like heart attacks? Your exact words are: “What are these events? Where have they been published? Who has peer-reviewed them?” Didn’t you yourself just review an article on that very topic, a study that we ourselves had hyperlinked as an example of peer-reviewed WSMEs in the exact article of ours that you are rebutting now? WSMEs are the events that should decline because of a wellness program. Example: If you institute a wellness program aimed at avoiding heart attacks, you’d measure the change in the number of heart attacks across your population as a “plausibility test” to see if the program worked, just like you’d measure the impact of a campaign to avoid teenage pregnancies by observing the change in the rate of teenage pregnancies. We’re not sure why you think that simple concept of testing plausibility using WSMEs needs peer review. Indeed, we don’t know how else one would measure impact of either program, which is why the esteemed Validation Institute recognizes only that methodology. (In any event, you did already review WMSEs in your own article.) We certainly concur with your related view that randomized controlled trials are impractical in workplace settings (and can’t blame you for avoiding them, given that your colleague Michael O’Donnell’s journal published a meta-analysis showing RCTs have negative ROIs).

(2)    How do you reconcile your role as Highmark’s consultant for the notoriously humiliating, unpopular and counterproductive Penn State wellness program with your current position that employees need to be treated with “respect and dignity”? Exactly what about Penn State’s required monthly testicle check and $1,200 fine on female employees for not disclosing their pregnancy plans respected the dignity of employees?

(3)    Which of your programs adhere to U.S. Preventive Services Task Force (USPSTF) screening guidelines and intervals that you now claim to embrace? Once again, we cite the Penn State example, because it is in the public domain — almost nothing about that program was USPSTF-compliant, starting with the aforementioned testicle checks.

(4)    Your posting mentions “peer review” nine times. If peer review is so important to wellness true believers,  how come none of your colleagues editing the three wellness promotional journals (JOEM, AJPM and AJHP) has ever asked either of us to peer-review a single article, despite the fact that we’ve amply demonstrated our prowess at peer review by exposing two dozen fraudulent claims on They Said What?, including exposés of four companies represented on your Koop Award committee (Staywell, Mercer, Milliman and Wellsteps) along with three fraudulent claims in Koop Award-winning programs?

(5)    Perhaps the most popular slide used in support of wellness-industry ROI actually shows the reverse — that motivation, rather than the wellness programs themselves, drives the health spending differential between participants and non-participants. How do we know that? Because on that Eastman Chemical-Health Fitness Corp. slide (reproduced below), significant savings accrued and were counted for 2005 – the year before the wellness program was implemented. Now you say 2005 was “unfortunately mislabeled” on that slide. Unless this mislabeling was an act of God, please use the active voice: Who mislabeled this slide for five years; where is the person’s apology; and why didn’t any of the analytical luminaries on your committee disclose this mislabeling even after they knew it was mislabeled? The problem was noted in both Surviving Workplace Wellness and the trade-bestselling, award-winning Why Nobody Believes the Numbers, which we know you’ve read because you copied pages from it before Wiley & Sons demanded you stop? Was it because HFC sponsors your committee, or was it because Koop Committee members lack the basic error identification skills taught in courses on outcomes analysis that no committee member has ever passed?

wellness-article

(6)    Why doesn’t anyone on the Koop Committee notice any of these “unfortunate mislabelings” until several years after we point out that they are in plain view?

(7)    Why is it that every time HFC admits lying, the penalty that you assess — as president of the Koop Award Committee — is to anoint their programs as “best practices” in health promotion? (See Eastman Chemical and Nebraska in the list below.) Doesn’t that send a signal that Dr. Koop might have objected to?

(8)    Whenever HFC publishes lengthy press releases announcing that its customers received the “prestigious” Koop Award, it always forgets to mention that it sponsors the awards. With your post’s emphasis on “the spirit of full disclosure” and “transparency,” why haven’t you insisted HFC disclose that it finances the award (sort of like when Nero used to win the Olympics because he ran them)?

(9)    Speaking of “best practices” and Koop Award winners, HFC’s admitted lies about saving the lives of 514 cancer victims in its award-winning Nebraska program are technically a violation of the state’s anti-fraud statute, because HFC accepted state money and then misrepresented outcomes. Which is it: Is HFC a best practice, or should it be prosecuted for fraud?

(10)    RAND Corp.’s wellness guru Soeren Mattke, who also disputes wellness ROIs, has observed that every time one of the wellness industry’s unsupportable claims gets disproven, wellness defenders say they didn’t really mean it, and they really meant something else altogether. Isn’t this exactly what you are doing here, with the “mislabeled” slide, with your sudden epiphany about following USPSTF guidelines and respecting employee dignity and with your new position that ROI doesn’t matter any more, now that most ROI claims have been invalidated?

(11)    Why are you still quoting Katherine Baicker’s five-year-old meta-analysis claiming 3.27-to-1 savings from wellness in (roughly) 16-year-old studies, even though you must be fully aware that she herself has repeatedly disowned it and now says: “There are very few studies that have reliable data on the costs and benefits”? We have offered to compliment wellness defenders for telling the truth in every instance in which they acknowledge all her backpedaling whenever they cite her study. We look forward to being able to compliment you on truthfulness when you admit this. This offer, if you accept it, is an improvement over our current Groundhog Day-type cycle where you cite her study, we point out that she’s walked it back four times, and you somehow never notice her recantations and then continue to cite the meta-analysis as though it’s beyond reproach.

To end on a positive note, while we see many differences between your words and your deeds, let us give you the benefit of the doubt and assume you mean what you say and not what you do. In that case, we invite you to join us in writing an open letter to Penn State, the Business Roundtable, Honeywell, Highmark and every other organization (including Vik Khanna’s wife’s employer) that forces employees to choose between forfeiting large sums of money and maintaining their dignity and privacy. We could collectively advise them to do exactly what you now say: Instead of playing doctor with “pry, poke, prod and punish” programs, we would encourage employers to adhere to USPSTF screening guidelines and frequencies and otherwise stay out of employees’ personal medical affairs unless they ask for help, because overdoctoring produces neither positive ROIs nor even healthier employers. And we need to emphasize that it’s OK if there is no ROI because ROI doesn’t matter.

As a gesture to mend fences, we will offer a 50% discount to all Koop Committee members for the Critical Outcomes Report Analysis course and certification, which is also recognized by the Validation Institute. This course will help your committee members learn how to avoid the embarrassing mistakes they consistently otherwise make and (assuming you institute conflict-of-interest rules as well to require disclosure of sponsorships) ensure that worthy candidates win your awards.

The Value of Workplace Wellness

The recent blog post by Al Lewis, Vik Khanna and Shana Montrose titled, “Workplace Wellness Produces No Savings,” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine, titled, “Do Workplace Health Promotion (Wellness) Programs Work?” That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Frakt and Carroll, who answered the above question with: “usually not.”

There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.

Where we agree…

Biometric screenings. Biometric screenings are important for collection of baseline health risk data and are often viewed as an added value by employees participating in workplace health promotion programs. Lewis et al. and I agree that employers should screen their workers for health risks in accordance with guidelines recommended by the U.S. Preventive Services Task Force (USPSTF). These guidelines are clear about the necessity and periodicity of biometric screenings for high blood pressure, obesity, cholesterol, glucose, triglycerides, cervical cancer, colon cancer, breast cancer and other conditions.

We agree that over-testing people is not a good idea and may lead to false positives, as well as unnecessary medical interventions that are costly and add little value. For readers seeking guidance on biometric screenings in a workplace setting, I refer them to a peer-reviewed article published in the October 2013 issue of the Journal of Occupational and Environmental Medicine.

Incentives. Workplace health promotion programs are not the same as incentive programs. “Smart” incentives are part of a well-designed program, but such programs need to be embedded in healthy company cultures where employers encourage and reward healthy behaviors. Comprehensive wellness programs often use financial incentives to attract participation and, in some instances, encourage behaviors that lead to risk reduction.

Most experts in workplace health promotion agree that creating intrinsic motivation for health improvement is an essential component of an effective program. As Daniel Pink points out in his book Drive, people are motivated to behave a certain way when they feel a sense of autonomy, when they are able to master certain skills needed to change a behavior and when they can connect changing that behavior to a larger purpose in life. This applies to individuals wishing to achieve certain health goals, such as quitting smoking, being more physically active and eating a healthier diet.

Paying people to improve their health in an unhealthy work environment is a futile strategy. Workers will expect higher payments each year, will view “non-compliance” as a penalty and will mistrust their employer for trying to do things to them instead of with them.

To summarize, incentives need to be practical, ethical and legal. The Affordable Care Act (ACA) legislation should not be used as a vehicle or excuse for “blaming” workers for poor health habits, or to penalize them financially for not achieving certain health outcomes. Employers share responsibility for the health and well-being of workers and can do much to create a healthy company culture.

For readers interested in a more in-depth discussion of health promotion incentive programs, I refer them to a series of Health Affairs blog posts and a guidance document prepared by the Health Enhancement Research Organization, American College of Occupational and Environmental Medicine, American Cancer Society and American Cancer Society Cancer Action Network, American Diabetes Association and American Heart Association.

Culture of health. We also agree that effective workplace health promotion programs need to be embedded within a culture of health that respects workers’ rights to make informed choices about personal health matters. Without question, workplaces need to be safe, and employees need to be treated with respect and dignity. Workers also have a right to be in a healthy work environment where positive health behaviors are encouraged and supported. That means making healthy food available in vending machines and cafeterias, encouraging physical activity, prohibiting on-site smoking, offering vaccination programs and providing health insurance.

The list of programs, policies and environmental supports for a healthy workplace is long, and there are hundreds of environmental and policy interventions available to employers who wish to send a clear message that the company encourages and supports good health. For a more complete discussion of how companies can achieve a healthy culture, see the May 2013 issue of The Art of Health Promotion.

The importance of studying “wellness-sensitive” events…in addition to overall utilization and costs. Lewis et al. highlight the need to focus on “wellness-sensitive” medical events when conducting cost analyses. I agree but ask the authors: What are these events? Where have descriptions been published? Who has reviewed them? Why do they only apply to in-patient claims? Are there not any “wellness-sensitive” events that would appear in out-patient settings?

The idea of analyzing claims for conditions likely to be most readily influenced by health promotion programs is sensible. In many of our studies, we have analyzed utilization and cost patterns for what we call “lifestyle diagnosis groups,” or LDGs. For example, in a 1998 peer-reviewed study, we evaluated Procter & Gamble’s health promotion program and found a 36% difference in lifestyle-related costs in the third study year when comparing 3,993 program participants with 4,341 non-participants.

Although it’s important to analyze a subset of diagnoses when evaluating wellness programs, it is equally important to analyze utilization and costs for all conditions. After all, one’s actual well-being and perception of well-being influences health holistically, not just any one particular organ or body system.

Where we disagree…

Whether only randomized trials can determine whether workplace programs are effective. Health services research and the field of epidemiology have a long track record of studying naturally occurring phenomena and drawing conclusions from observations of those phenomena. That’s how we have learned what causes hospital-acquired infections. We have also learned from long-lasting epidemiological investigations like the Framingham studies that a sedentary lifestyle, smoking and obesity are causes of heart disease, diabetes and cancers.

These “natural experiments” inform the scientific community about what happens to individuals or groups “exposed” to a condition, where others are not. Natural experiments are employed when a randomized controlled trial (RCT) is impractical or unethical.

How does this apply to evaluation of workplace health promotion programs? Imagine trying to convince the head of human resources of a company to approve a double-blinded randomized trial that would test the effectiveness of a wellness program, over three to five years, by randomly assigning some workers to a comprehensive health promotion program that includes health coaching on smoking cessation, weight management, physical activity and stress reduction while other workers are denied access to the program. Not only that, the HR executive would be asked to allow the researcher to administer a series of blood tests to participants and non-participants, access their medical claims and ask workers to complete periodic health surveys. The employer would also be prohibited from instituting organizational policies promoting health while this experiment is underway.

It’s hard to imagine a situation in which a company executive would allow this, never mind an institutional review board at a university.

Alternatively, when health services researchers conduct natural experiments, care is taken to control for any confounding variables and address alternative hypotheses. In our research, we use statistical techniques such as propensity score matching and multivariate regression to compare the health and cost experience of “treatment” workers (those offered health-promotion programs) and “comparison” workers (those not offered the programs). Most often, when comparing participants with non-participants, we match entire populations exposed to a program (whether or not individuals participate in that program) and those not exposed. In that regard, we are investigating program impacts on population health and not only comparing outcomes for motivated participants in programs compared with less motivated non-participants.

We publish our analyses in peer-reviewed journals so that the scientific community can review and critique our methods. We are also transparent about the limitations to our research in these peer-reviewed articles.

By the way, there are experimental studies focused on large populations (not necessarily at the workplace) demonstrating the value of health-promotion programs. One such trial was recently concluded by the Centers for Medicare and Medicaid Services (CMS) as part of the senior risk reduction demonstration (SRRD). Two vendors were involved in the demonstration, which lasted two to three years.  Beneficiaries participating in Vendor A’s risk-reduction programs achieved statistically significant improvements in stress, general well-being and overall risk, and beneficiaries participating in Vendor B’s program achieved statistically significant improvements in back care, nutrition, physical activity, stress, general well-being and overall risk.

Interestingly, the interventions were determined to be “cost-neutral,” meaning that Medicare spending for participants in the intervention group was not statistically different from spending for participants in the control group. This was a large-scale study where about 50,000 beneficiaries were recruited and approximately 20,000 participated in the health-promotion program in any given year. The bottom line: Significant health improvements were achieved at no cost to the government.

Interpreting the data. Lewis et al. highlight errors in others’ presentation of results. I have no argument with that. That is, after all, what a peer review process is all about: Conduct the study, subject it to peer review and publish the findings. The problem is that Lewis et al. have not (yet) published any studies in which their interventions are evaluated, nor have their methods been subject to peer review. That is unfortunate because I believe (truly) that all of us can learn from vetted research studies and apply that knowledge to future evaluations.

I am the first to admit that the methods we use to evaluate wellness programs have evolved over time and are still undergoing revisions as we learn from our mistakes. I invite Lewis et al. to reveal their methods for evaluating workplace programs and to publish those methods in peer-reviewed publications — we can all benefit from that intelligence.

Lewis et al. point to a study conducted by Health Fitness Corp. (HFC) for Eastman Chemical, which earned the company the C. Everett Koop Award. (In the spirit of full disclosure, I am the president and CEO of the Health Project. which annually confers the Koop prize to organizations able to clearly and unambiguously document health improvements and cost savings for their employees.) Eastman Chemical’s application is online and subject to review.

In their analysis of the Eastman Chemical application, Lewis at al. complain that costs for participants and non-participants diverged in the baseline years of the program; therefore, it was not the program that explains cost savings. Here’s the real story: Eastman Chemical’s program has been in place since the early 1990s. The chart found on the website (unfortunately mislabeled) shows participant and non-participant medical costs at baseline (2004), in subsequent years and in the final year of the study (2008).

The study compares medical and drug claims for minimally engaged (non-participant) and engaged (participant) employees matched at baseline (using propensity score matching) on age, gender, employee status, insurance plan, medical costs and other variables. No significant differences were found between participant and non-participant costs at baseline, but their claims experience differed significantly at follow up. Although not a perfect study, the economic results, coupled with significant and positive health improvements in many of the health behaviors and risk factors examined for a multi-year cohort of employees, convinced the Health Project board that Eastman Chemical earned the C. Everett Koop prize in 2011.

Whether return-on-investment (ROI) is the only metric for evaluating workplace health promotion programs. It seems that too much of the debate and controversy surrounding workplace health promotion is focused narrowly on whether these programs save money. If that were the aperture by which we judged medical care, in general, we would withhold treatment from almost every patient and for almost every procedure, with the exception of a few preventive services that are either cost-neutral or minimally cost-saving. That makes no sense for a compassionate society.

In a February 2009 Health Affairs article, I argued that prevention should not be held to a higher standard than treatment; both should be evaluated on their relative cost-effectiveness (not cost-benefit) in achieving positive health outcomes and improved quality of life.

Take a simple example of two employees. One has just suffered a heart attack and undergoes a coronary bypass. If the individual is willing, he is then engaged in counseling that encourages him to quit smoking, become more physically active, eat a healthy diet, manage stress, take medications to control blood pressure and see the doctor for regularly scheduled preventive visits. For that individual, I would be surprised if an employer providing medical coverage would demand a positive ROI.

How about a second employee? That person is overweight, smokes cigarettes, eats an unhealthy diet, is sedentary, experiences stress at work and has hypertension. He has not (yet) suffered a heart attack, although most would agree he is at high risk. To justify a health promotion program for that employee and others in the company, many employers insist on a positive ROI. Why is that a requirement? If a well-designed program can achieve population health improvement (as demonstrated using valid measures and an appropriate study design), and the program is cost-neutral or relatively inexpensive, why wouldn’t an employer invest in a wellness program, especially if is viewed as high value to both workers and their organization?

It’s time to change the metric for success. Instead of demanding a high ROI, employers should require data supporting high engagement rates by workers, satisfaction with program components, population health improvement, an ability to attract and retain top talent, fewer safety incidents, higher productivity and perceived organizational support for one’s health and well-being. That’s where program evaluations should be focused, not simply on achieving a positive ROI.

I appreciate the reality that some employers may still require an ROI result. Fortunately, there is evidence, published in peer-reviewed journals, that well-designed and effectively executed programs, founded on best practices and behavior change theory, can achieve a positive ROI. I won’t re-litigate this point, other than to point newcomers to a large body of literature showing significant health improvements and net cost savings from workplace heath promotion programs. (See, for example, studies for Johnson & JohnsonHighmark and Citibank and several literature reviews on the topic).

I challenge proponents and opponents of workplace wellness to direct their energy away from proving an ROI to measuring one or several of the important outcomes of interest to employers. Achievement of these outcomes is only possible when management and labor work toward a mutually beneficial goal — creating a healthy workplace environment. Health promotion programs require time to take root and be self-sustaining, but the benefits to employees and their organizations are worth the effort.

Where To Search For Best-In-Class Doctors

No doubt you have seen the ad for Angie’s List. A good-looking male doctor is pictured with the caption, “He has been nothing but focused, dedicated and concerned about my health and well-being.” If searching for a contractor or hair dresser, this might be a good start. But searching this way for doctors? Absurd!

Finding doctors for injured workers through Angie’s List is a recipe for disaster. Subjective rating of medical treatment is not valid. Few patients understand enough about the science of medicine to venture a worthwhile opinion.

Yet, the methodology behind Angie’s List is a relatively common practice in the Workers’ Comp industry. Employers and payers sometimes survey their claimants in an effort to evaluate doctors. Unfortunately, most claimants report whether the doctor’s office has snacks, magazines they like, and the doctor was nice. The information is hardly a basis for utilizing the doctor and is about as helpful as that found in Angie’s List.

Measuring Provider Performance
Finding the right physicians for injured workers requires objective analysis of actual past performance, not patient opinions. Medical proficiency can be measured in terms of outcome, with the most positive outcomes evidenced by return to full work and reasonable medical costs. However, in Workers’ Compensation even more focus should be placed on the course of the claim from the non-medical standpoint.

Industry Research
Workers’ Comp industry research has clearly identified the attributes of good and bad medical performance. For instance, Dr. Ed Bernacki of Johns Hopkins lists characteristics of “cost intensive” physicians. The study1, using data from the Louisiana Workers’ Compensation Corporation, found that 3.8% of physicians accounted for 72% of the costs. In other words, a small number of physicians have a profound impact on Workers’ Compensation costs. Bernacki’s study identified the characteristics of these cost intensive physicians. They are elements that can be found in the data and used to monitor and score provider performance.

MedMetrics uses the results of industry research studies to design its algorithms that evaluate and score provider performance. The research identifies provider characteristics and claim events under the influence of providers that should be measured. Using those indicators, providers can be compared in their jurisdictions with others in the same specialty to identify the best-in-class.

Medicine Is A Cottage Industry
Medicine in the US is a cottage industry, with services delivered by individuals to individuals. Consequently, it is difficult for any one organization to gather enough individual provider data to create a critical mass for measurement. The problem is complicated by the fact that in Workers’ Comp states vary in fee schedules and other legal requirements so it is not valid to compare data across jurisdictions. Nevertheless, provider performance is more accurate and fairer when evaluated across many claims.

The industry needs an independent organization to collect and analyze the data across multiple organizations so that provider performance can be measured more accurately.

Master Provider Index
MedMetrics is offering Master Provider Index. Data is collected from multiple participating organizations, then validated, and integrated. Provider performance is measured across multiple entities’ claims in a state, thereby creating a richer data resource. The combined data is analyzed and provider performance is scored. Finally, a quick-search is offered online so that best-in-class providers can be found in specific geo-zip regions on demand, on-the-fly.

Not Angie’s List
Master Provider Index is not Angie’s List by any means. Provider performance analytics are based on intelligence gained through industry research and performed on data from multiple organizations by state. Based on Bernacki’s study, one can assume saving up to 72% of costs by avoiding cost intensive physicians!

1Bernacki, et.al. “Impact of Cost Intensive Physicians on Workers’ Compensation” JOEM. Vol. 52. No. 1. January, 2010.