Health & Productivity: A Research Agenda from the Private Employer

Sector: What Works.. What Doesn’t

Kenneth Mitchell, Ph.D..Chattanooga, TN

Nuts and Bolts Research Methods SymposiumUT College of Medicine Chattanooga

September 29, 2006

2

Health & Productivity Management: Connections

All lost time is connected

Lost time and healthcare costs are connected

Impairment is objective… Disability is subjective …. …and depends on…….

Understand that corporate policies and practices “disable” more individuals than any injury or illness.

3

The Health & Productivity Realities

The following health and productivity issues are common issues for all employers in the public and private sector.

1. Create affordable and accessible health care2. Reduce the cost of lost productivity 3. Understand workforce health trends – Increased chronic disease & ambiguous

impairments4. Prepare for aging workforce – Increased longevity & productive aging5. Create solutions for ambiguous impairments (e.g. Depression, chronic pain) &

performance management6. Recognize work/life predicaments that turn into “Disabilities” or Who will be the last

well person?

The H&P Points of Contact that can be enhanced though

research & education

4

The Real Problem: The Full Cost of Employee Illness

Medical & Pharmacy Costs

*$6,020 PEPY

Health-related Productivity Costs

$12,000 PEPY

33%

66%

Workers’ CompMedical CostsSalary Continuation

Personal Health CostsMedical CarePharmacyHospitalizationBehavioral Health

Productivity Costs

Presenteeism

Turnover

Replacement Training

Temporary Staffing

Administrative Costs

Variable Product Quality

Employee Dissatisfaction Customer Dissatisfaction

Overtime

Off-Site Travel for Care

STDLTD

Sources: Loeppke, et.al., JOEM, 2003; 45:349-359 and Brady, et.al., JOEM, 1997; 39:224-231

Total PEPY= $18,020

*2003 PEPY Avg.

Absenteeism

5

The Context

0

5

10

15

20

25

30

2000 2010 2020 2030 2040 2050 2060 2070 2080

Percent of GDP - Social Security, Medicare, and Medicaid Spending:

Social Security

Medicaid

Medicare

Note: Social Security and Medicare projections based on the intermediate assumptions of the 2005 Trustees’ Reports. Medicaid projections based on CBO’s January 2005 short-term Medicaid estimates and CBO’s December 2003 long-term Medicaid projections under mid-range assumptions.

Source: GAO analysis based on data from the Office of the Chief Actuary, Social Security Administration, Office of the Actuary, Centers for Medicare and Medicaid Services, and the Congressional Budget Office.

6

Healthcare Costs by Age x Risk

Source: Musich, McDonald, Hirschland, Edington, Disease Managements & Health Outcomes 2002; 10(4): 251-258; University of Michigan Health Management Research Center.

Used with permission. Dee Edington, Ph.D. University of Michigan, Ann Arbor, Michigan

7

Pain Costs Compared to Other Conditions: A Case Study

Disease

Prevalence

Rate Cost% of Grand Total Cost

Coronary Artery 1.18 $5,329,189 1.16

Heart Failure 0.21 $18,487,808 4.03

Diabetes 3.19 $59,279,346 12.93

Asthma 2.68 $36,432,797 7.95

Depression 2.12 $44,181,502 9.64

Pain 8.36 $154,130,320 34.62

Subtotal ----- $317,840,962 70.33

Grand Total ----- $458,433,071 100.00

8

Pain and Co-morbid Conditions

Condition % Pain Patients w/ Condition

% Total Population with Condition

Diabetes 8.34% 3.19%

Depression 7.91% 2.37%

Arthritis 9.14% 1.30%

Hypertension 18.06% 6.07%

Injuries 24.24% 7.19%

Anxiety 4.20% 1.27%

9

Source-of-Pain Categories

Source of Pain # of

Patients % of MSCP patients

Nerve compression

2,775 15.04%

Carpal tunnel syndrome (cts)

1,189 6.45%

Myalgia

12,390 67.17%

Nerve damage

3,929 21.30%

Migraine

2,134 11.57%

Joint

2,911 15.78%

Other drug dependency

2,946 15.97%

10

Pain Related Events

77.91

15.54

4.41 1.23 0.910

10

20

30

40

50

60

70

80

% o

f Pai

n Pat

ient

s

0 1 2 3 4+

# of Admissions

Percent of Pain Patients Admitted to Hospital

36.08

17.49

8.706.40 4.53 3.63 2.78 2.26 1.96 1.79

14.37

0

5

10

15

20

25

30

35

40

% o

f Pai

n Pat

ient

s

0 1 2 3 4 5 6 7 8 9 10+

# of Visits

Percent of Pain Patients with Visits for Health Care Utilization (all events)

93.42

5.47 0.86 0.17 0.01 0.01 0.01 0.01 0.00 0.02 0.030102030405060708090100

% o

f Pai

n Pat

ient

s

0 1 2 3 4 5 6 7 8 9 10+

# of Surgeries

Percent of Pain Patients with Surgeries

11

Pain Related Events

79.70

17.17

2.50 0.45 0.12 0.03 0.02 0.01 0.00 0.00 0.010

10

20

30

40

50

60

70

80

% o

f Pai

n Pat

ient

s

0 1 2 3 4 5 6 7 8 9 10+

# of MRIs

Percent of Pain Patients with MRIs

71.47

3.07 2.84 3.43 2.80 2.13 1.67 1.64 1.21 1.028.71

0

10

20

30

40

50

60

70

80

% o

f Pai

n Pa

tient

s

0 1 2 3 4 5 6 7 8 9 10+

# of Visits

Percent of Pain Patients with Chiropractic Visits

59.02

5.77 4.33 4.01 3.35 2.79 2.40 2.04 1.69 1.63

12.98

0

10

20

30

40

50

60

% o

f Pai

n Pat

ient

s

0 1 2 3 4 5 6 7 8 9 10+

# of Visits

Percent of Pain Patients with Physical Therapy Visits

12

Medical & Disability Costs* Related to Medical Conditions

52

287

120

199

182

39

192

20

$0

$50

$100

$150

$200

$250

$300

$350

MusculoskelStrains

DepressionAnxiety

Cancer Ischemic HeartDisease

D

oll

ars

PE

PY

(p

er

em

plo

yee p

er

year)

Medical*Disability

,Includes direct disability costs, but does not include related absenteeism٭presenteeism and productivity costs/losses

13

Medical vs. Productivity Costs of Pain

Costs of Selected Pain Related Conditions

Condition Annual Direct Medical Costs

Annual Productivity Costs

Repetitive Strain Injuries, including

Carpal tunnel syndrome

$1 billion $26 billion

Lower back pain $25 billion $28 - $56 billion

Migraine $1 billion $13 - $17 billion

American Academy of Orthopedic Surgeons. www.aaos.org2.Hu, X.H., Markson, L.E., Lipton, R.B., Stewart, W.F., Berger, M.L. “Burden of migraine in the United States: disability and economic costs.” Arch Intern Med. 1999; 159:813-818.3.Osterhaus, J.T., Gutterman, D.L., Plachetka, J.R. “Healthcare resource use and lost labor costs of migraine headache in the United States.” Pharmacoeconomics 1992; 2:67-76.4.Patterson, J.D., Simmons, B.P. “Outcomes assessments in carpal tunnel syndrome.” Hand Clin 2002 May; 18(2):359-63, viii.

14

Medical Conditions & Productivity Connections

AmbiguousImpairmentsAmbiguousImpairments

High ScoresHigh Scores

Prevalence =% of ee’sreporting condition

Prevalence =% of ee’sreporting condition

15

Health Risk and Absenteeism

0

2

4

6

8

10

12

14

1 Risks 3 Risks 4+ Risks

6.4 Days

9.3 Days

12.6 Days

Tsai, et al. JOEM: Vol. 47, No. 8, August, 2005

16

Health Risk and Presenteeism

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

0-2 Risks 3-4 Risks 5+ Risks

14.7%

20.9%

26.9%

Source: Burton, et al, JOEM: Vol. 47. No. 8, August, 2005

17

Risk Dynamics – Top STD x Industry & Age > 40

* Based on UPC STD Database/2004

0% 10% 20% 30% 40% 50%

Musculoskeletal/Injury

Circulatory

Cancer

Digestive

Other/Metabolic Diseases

Manufacturing Transportation Education Banking Healthcare

Source: UnumProvident Disability Database, 2002-2004.

18

Risk Dynamics – Top Long Term Impairments x Age

* Based on UPC Long Term Disability Database, 2000-2004

13%

12%

10%

7%

3%

15%

10%

7%

17%

8%

26%0%

0% 10% 20% 30%

Maternity

Back

Accident

Mental Nervous

Cancer

Circulatory

< 40 40 +

19

. . . Continuing for Our Working Lives!

Age of Workers

Percent Growth in U.S. Workforce by Age: 2000-2020

7% 8% 7%

-10%

3%

73%

54%

-20%

0%

20%

40%

60%

80%

under 14 15-24 25-34 35-44 45-55 55-64 65+

Source: US Census Bureau International Data Base

20

Short (STD) and Long (LTD) Term Disability

Source: UnumProvident Disability Database, 2002-2004.

Distribution by age

21

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

Month Claim Began

Qu

arte

rly

Med

ical

Co

st T

ren

d p

er S

TD

C

laim

ant

0

10

20

30

40

50

60

ST

D C

laim

Ave

rag

e D

ays

Du

rati

on

Tre

nd

Quarterly Employee Claimant Costs Average STD Claim Duration

40% Decrease in Per Claimant

Medical Costs

28% Decrease in STD Claim Duration

STD Claim Duration to Claimant Medical Costs

Discussion: Comparing cost reduction per employee to the claim duration patterns suggests a direct and positive relationship between the two outcomes.

22

62.6

49.5

53.7

64.5

49.0 48.1

37.5

52.2

48.2

42.2

34.4

30.1

0

10

20

30

40

50

60

70

Affective Disorders Normal Pregnancy/Delivery Other Mental Conditions Intervertebral Disc Disorders

Ca

len

da

r D

ay

s p

er

Cla

im

1999 2000 2001

• 23% reduction 15% reduction 36% reduction 53% reduction

Duration Comparison of the Four Most Frequent STD Conditions

Variation in Claim Duration Impact across Conditions

23

(Costs are per claimant incurred during the 90 days immediately following the start of the disability. Costs are adjusted for both claim runout and for inflation.)

$2,590

$5,430

$1,500

$4,057

$1,700

$5,708

$1,164

$4,199

$1,837

$5,295

$610

$4,026

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

Affective Disorders Normal Pregnancy/Delivery Other Mental Conditions Intervertebral Disc Disorders

Qu

art

erl

y M

ed

ica

l C

os

t p

er

Cla

ima

nt

1999 2000 2001

Variation in Medical Cost Reduction by Condition

29% Reduction 4% reduction 60% reduction < 1% reduction

Medical Cost Comparisonof the Four Most Frequent STD Conditions

24

Bridging the Gaps Through Research & Education

Increase fitness

of workers

Protect work

capacity

Create H&P

culture

Full Work Productivity

Working but Productivity

Impaired

Intermittent & Cyclic

Lost time

Lost Time < 30 days

Lost Time< 26 weeks

Health Promotion

Risk Reduction

Disease/Condition Management

DisabilityManagement

LeaveManagement

Increase compliance

with law

Track & monitor

absences

Reduce adminburden

Reduce onset of chronic

disease

Reduce suddendeath in

workforce

Reducework

related injuries

Reduce impairment

Reduce medical/

pharmacy costs

Reduce Presenteeism

Reduce STD incidence &

duration

Reduce LTD incidence &

duration

Reduce WC medical & indemnity

costs

Employer Based Services Partner Based Services UPC Based Services

Increase fitness

of workers

Protect work

capacity

Create H&P

culture

Full Work Productivity

Working but Productivity

Impaired

Intermittent & Cyclic

Lost time

Lost Time < 30 days

Lost Time< 26 weeks

Health Promotion

Risk Reduction

Disease/Condition Management

DisabilityManagement

LeaveManagement

Increase compliance

with law

Track & monitor

absences

Reduce adminburden

Reduce onset of chronic

disease

Reduce suddendeath in

workforce

Reducework

related injuries

Reduce impairment

Reduce medical/

pharmacy costs

Reduce Presenteeism

Reduce STD incidence &

duration

Reduce LTD incidence &

duration

Reduce WC medical & indemnity

costs

Employer Based Services Partner Based Services UPC Based Services

Increase fitness

of workers

Protect work

capacity

Create H&P

culture

Full Work Productivity

Working but Productivity

Impaired

Intermittent & Cyclic

Lost time

Lost Time < 30 days

Lost Time< 26 weeks

Health Promotion

Risk Reduction

Disease/Condition Management

DisabilityManagement

LeaveManagement

Increase compliance

with law

Track & monitor

absences

Reduce adminburden

Reduce onset of chronic

disease

Reduce suddendeath in

workforce

Reducework

related injuries

Reduce impairment

Reduce medical/

pharmacy costs

Reduce Presenteeism

Reduce STD incidence &

duration

Reduce LTD incidence &

duration

Reduce WC medical & indemnity

costs

Employer Based Services Partner Based Services UPC Based Services

Employers and various health and disability partners connect and compete with services. There are clear gaps on how the services are connected with the relative impact only guessed at. Research & education programs can measure a clear sense of impact and accurately communicate innovative combinations and connections.

25

Health & Productivity: What Works? What Doesn’t?

What Works

– Evidence Based Medicine

– Functional Work Capacities

– Psychosocial & corporate culture influences

– Determining a Return on Investment

– Patient centered investigations

– Public & corporate policy analysis

What Doesn’t

– Market research designed to support a target product

– “Research” supporting solutions of convenience

– The politics of incapacity & competing self interests

– Political correctness

– Lack of demonstration & application of “model” programs

26

A Proposed H & P Employer Research Agenda

• Develop & test models for accessible, affordable & effective healthcare

• Focus on lost productivity & treatment outcomes…

– Protecting work capacity in the aging work force

– Cancer survivors’ health, productivity and employability

– Depression as a comorbid condition

– Patient compliance – Patient motivation with metabolic Syndrome

• Demonstrating unique employer, healthcare, & insurance connections & partnerships

• Understand and control Iatrogenic/Bureaugenic disability

– Avoid/mitigate treatment/physician/employer collisions

• Prepare Physicians to accurately determine functional work capacity

• Build work transitions into treatment recommendations – a WorkRx model