Bruce W. Sherman

High-dose versus standard-dose epinephrine treatment of cardiac arrest after failure of standard therapy

Study Objective. To assess the efficacy of high‐dose epinephrine (HDE) compared with standard‐dose epinephrine (SDE) in emergency department patients in cardiac arrest after SDE failed to improve asystole or ventricular fibrillation.

Effectiveness of worksite interventions to increase influenza vaccination rates among employees and families.

Objective: To increase influenza vaccination rates among industrial employees and their families through a campaign at a large corporation. Methods: This prospective, multisite study used employee surveys and claims data to evaluate an evidence-based worksite vaccination program. Results: Vaccination rates among insured employees and dependents (N = 13,520) increased significantly after the intervention (P < 0.001). More than 90% of vaccinated employees received vaccine at employer-sponsored events. There was a strong association between employee and family vaccination status. Primary reasons for receiving the vaccine were economic (free 84%; convenient 80%; avoid absenteeism 82%), rather than health-related. Knowledge was associated with vaccination, but customized education did not change beliefs. Conclusions: Worksite programs can demonstrably increase vaccination rates among industrial employees and families. Consideration should be given to repositioning vaccination from medical treatment to community initiatives offered with other worksite health promotion programs.

Worksite Health Promotion: A Critical Investment

Although the significant majority of employers offer health promotion programs, for most companies the size and impact of existing programs is minor. Recent research has yielded substantial data in support of worksite health promotion activities, from both medical and economic perspectives. Yet despite this compelling information, corporations have been slow to incorporate more substantial health promotion activities.Employers must come to see that an investment in employee health promotion programs is an investment in their workforce, likely their greatest asset. The impact of health promotion programs needs to be viewed not simply in the context of a business operations cost. In the face of rapidly escalating healthcare costs, successful health promotion programs have the potential to reduce those expenditures as well as enhance employee performance, resulting in improved business productivity.To be effective, worksite health promotion programs must be implemented in a systematic manner. To gain senior management support, education regarding the principles of health and productivity is critical. Program selection and implementation must be carefully planned, reflecting the health promotion interests, needs, culture and resources of the organization. Objective, easily measurable parameters of program quality and outcome must be identified prior to program implementation, in order to assess program effectiveness, from both employee health and business productivity perspectives. Collaborative data review through regular reporting can identify program strengths and weaknesses, leading to corrective modifications.

The association of smoking with medical treatment adherence in the workforce of a large employer

Purpose Prior descriptive epidemiology studies have shown that smokers have lower compliance rates with preventive care services and lower chronic medication adherence rates for preventive care services in separate studies. The goal of this study was to perform a more detailed analysis to validate both of these findings for current smokers versus nonsmokers within the benefit-covered population of a large US employer. Patients and methods This study involved the analysis of incurred medical and pharmacy claims for employee and spouse health plan enrollees of a single US-based employer during 2010. Multivariate regression models were used to compare data by active or never-smoker status for preventive care services and medication adherence for chronic conditions. Analysis controlled for demographic variables, chronic condition prevalence, and depression. Results Controlling for demographic variables and comorbid conditions, smokers had significantly lower cancer screening rates, with absolute reductions of 6%–13%. Adherence to chronic medication use for hypertension was also significantly lower among smokers, with nearly 7% fewer smokers having a medication possession ratio of ≥80%. Smokers were less adherent to depression medications (relative risk =0.79) than nonsmokers (P=0.10). While not statistically significant, smokers were consistently less adherent to all other medications than nonsmokers. Conclusion Current smokers are less compliant with recommended preventive care and medication use than nonsmokers, likely contributing to smoking-related employer costs. Awareness of these care gaps among smokers and direct management should be considered as part of a comprehensive population health-management strategy.

A Pragmatic Approach for Employers to Improve Measurement in Workforce Health and Productivity

New forces are at play that will invariably change how employers manage the health of their employee populations and how employers work with their supplier partners to provide health-related benefits and associated programs. For employers, health care reform necessitates a ‘‘stay in’’ or ‘‘get out’’ decision and may change the design of the healthrelated benefit packages provided to employees. In order to make an informed choice, employers will need to understand more fully the value of health (moving well beyond simply the cost of health care) in all its dimensions. This necessity is particularly difficult because so many employers have carved out many of their health-related programs from traditional health benefits and now are overwhelmed with divergent data and reporting from their plethora of partners.

Quantifying the value of worksite clinic nonoccupational health care services: a critical analysis and review of the literature.

Objective: Confusion exists regarding the approach to quantifying employer value of worksite nonoccupational care. A literature review and analysis was performed to characterize and critically evaluate existing methods to quantify the value of these services. Methods: PubMed was searched for publications describing measurement of value of nonoccupational worksite clinic services in US locations. Nineteen studies and two methodologic reviews met criteria for further analysis. Results: Return-on-investment calculations were commonly based on the comparative cost-effectiveness of worksite clinic services relative to community health care. Only one study evaluated the impact of worksite clinics on health care cost trend among clinic users, and none assessed the impact on total health and productivity costs. Conclusions: Significant variability exists among current methods for calculating return on investment of nonoccupational worksite health care services; methodologic approaches are poorly aligned with employer health care cost containment objectives.

Missing variables: how exclusion of human resources policy information confounds research connecting health and business outcomes.

When corporate health researchers examine the effects of health on business outcomes or the effect of health interventions on health and business outcomes, results will necessarily be confounded by the corporate environment(s) in which they are studied. In this research setting, most studies control for factors traditionally identified in public health, such as demographics and health status. Nevertheless, often overlooked is the extent to which company policies can also independently impact health care cost, work attendance, and productivity outcomes. With changes in employment and benefits practices resulting from health care reform, including incentives and plan design options, consideration of these largely neglected variables in research design has become increasingly important. This commentary summarizes existing knowledge regarding the implications of policy variations in research outcomes and provides a framework for incorporating them into future employer-based research.

Rethinking the Uses and Value of Employer-Sponsored Biometric Screening

P opulation-based biometric screening and laboratory testing has been a popular component of workforce wellness programs for many years. Current employer survey data indicate that biometric screenings are the most highly valued of all wellness program offerings. Businesses have traditionally viewed employee participation in this offering as a means to promote individual awareness and understanding of results outside the normal (‘‘ideal’’) range that may be indicative of increased health risk, with the overarching goal being to prompt appropriate self-referral or self-management of identified health risk concerns. As with other health benefits offerings, some employers have opted to use financial incentives in progressively increasing amounts to boost suboptimal participation rates and to encourage employee utilization. In the past few years, a number of employers have refocused their use of financial incentives to reward outcomes rather than simply participation in biometric screening. The rationale for this outcomes-based approach is to foster individual engagement seeking professional medical care and self-management, where appropriate, of health issues identified via biometric screenings, including hypertension, hyperlipidemia, obesity, diabetes, and metabolic syndrome. During the past 2 years, different viewpoints have been expressed regarding the value of biometric screening and its role in health promotion. Proponents assert that the tests help individuals to understand their health status and provide education for and, ideally, motivation for taking action, while detractors allege that the testing exceeds United States Preventive Services Task Force (USPSTF)-recommended treatment guidelines, causes discomfort and inconvenience, may lead to additional unnecessary testing, and all in the absence of a compelling value proposition. The goal of this commentary is to provide a review of some key considerations regarding biometric screening program outcomes and to propose an alternative use for biometric results that may afford greater value to all stakeholders.

Association of Wage With Employee Participation in Health Assessments and Biometric Screening

Purpose: To understand differences in health risk assessment (HRA) and biometric screening participation rates among benefits-enrolled employees in association with wage category. Design: Cross-sectional analysis of employee eligibility file and health benefits (wellness and claims) data. Setting: Data from self-insured employers participating in the RightOpt private exchange (Conduent HR Services) during 2014. Participants: Active employees from 4 companies continuously enrolled in health insurance for which wage data were available. Measures: Measures included HRA and biometric screening participation rates and wage status, with employee age, sex, employer, job tenure, household income, geographic location, and health benefits deductible as a percentage of total wages serving as covariates. Analysis: Employees were separated into 5 groups based on wage status. Logistic regression analysis incorporated other measures as covariates to adjust for differences between groups, with HRA and biometric screening participation rates determined as binary outcomes. Results: Participation rates for HRA and biometric screening were 90% and 87%, respectively, in the highest wage category, decreasing to 67% and 60%, respectively, among the lowest wage category. Conclusion: Employee wage status is associated with significant differences in HRA and biometric participation rates. Generalizing the results generated by modest participation in these offerings to entire populations may risk misinterpretation of results based on variable participation rates across wage categories.

Caveat Emptor: Employer Evaluation of Private Exchange Performance

In the face of rising health care expenditures, employers have moved from tactical cost containment approaches to consideration of higher level strategic initiatives. Private health insurance exchanges have emerged as one such option, by which employers effectively outsource benefits administration while also introducing new approaches to health care cost containment and employee choice. Employers are attracted by the potential of a flat or reduced health care cost trend, yet need to understand the impact that private exchanges may have on well-being, productivity, absence, disability, and ultimately, business performance. Near-term employer savings from private exchanges include 3 major areas: enhanced network discounts particularly in ‘‘quilted’’ or multicarrier networks, direct competition among health plans in multicarrier exchanges, and an enrollee shift toward lower cost-benefit plan design options. Although the first 2 cost savings may be apparent, employee ‘‘buy down’’ to less costly plan design options is an anticipated near-term outcome that has been demonstrated in many reports of benefits enrollment in private exchanges. Additionally, cost savings may accrue from employer benefits staff reductions as a result of outsourcing benefits-related administrative duties. Yet there has been surprisingly little discussion about population health management (PHM) as a means to improve workforce health among private exchange enrollees and to broaden the outcomes of interest to employers. Exchange communications have largely addressed consumer experience during benefits enrollment, along with early, high-level cost-trend data. What has not been described— and certainly represents a vital marketplace need—is how private exchanges are impacting the health status, use, and outcomes of health care services among the enrolled population. Arguably, there is value in near-term cost savings. However, the greatest potential likelihood of ‘‘bending the health care cost curve’’ is through improving enrollee health and enhancing their engagement as informed health care consumers. As the private exchange market matures, it is clear that substantial differences exist among the available offerings. These include levels of consumer support, clinical services components, and the extent of integration of available offerings. In addition, the capability for data integration and comprehensive reporting from the exchange sponsors and their contracted service delivery vendors are key differentiators. Accordingly, it is vital that employers understand not only how exchanges differ in the services provided, but also how exchanges generate near-term and long-term cost savings and better outcomes for all stakeholders. The intent of this paper is 2-fold: (1) to characterize critical population health metrics that employers should use as guideposts reflecting the effectiveness of exchangeprovided health management programs and activities, and (2) to advocate for the use of foundational workforce human resources metrics by employers as a means to gauge the broader workforce human capital impact of private exchange offerings.