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Agreeing on Value When Measuring Population Health Problems and Solutions

by Scott MacStravic

An on-demand webinar sponsored by IBM makes the point that consumers, payers and society must base their healthcare decisions on a shared definition of value. [“The Road to Healthcare 2015: Defining Success through Shared Stakeholder Value” HealthcareI IT News July 3, 2007 (www.bulldogsolutions.net)]  One of the glaring weaknesses in the science of population health management with respect to employees, i.e. employee health and productivity/performance management (EHPPM) today, is the lack of anything close to a common and shared definition of value.

When insurers and government agencies look for value in disease management and other health management efforts, they define “value” as reductions in the use and costs of healthcare services and insurance premiums.  They may aim for reductions in the rate of increase in these measures, or absolute declines therein, but that is the single success metric that dominates their thinking.  Other values, including the quality of care delivered, patient satisfaction, etc. may be included as added value, but the #1 concern is clearly costs.

By contrast, when employers look at EHPPM, and the majority of large employers already do so, they define value at least partly in terms of a host of dimensions other than healthcare costs.  These include: workers compensation and disability insurance costs; workers’ absenteeism, presenteeism, and turnover costs; errors and quality problems caused by workers’ poor performance; along with customer satisfaction and loyalty, even new business and revenue that can result from “abnormally” engaged, healthy, and committed employees.

Not only do they look for a far broader range of valued benefits from EHPPM – they also look at a far broader and often different range of problems to address through employee health investments.  This is because the factors that account for the majority of healthcare costs, i.e. chronic diseases and acute illness/injury, are often not the major causes of employee productivity and performance impairment.  Even more important, reducing the incidence and prevalence of acute and chronic conditions may not have anywhere near as much impact on their total labor costs, and total labor value as other health-related factors.
For example, the factors that assorted employers, along with researchers and suppliers they have hired to analyze productivity and performance impairment or conduct EHPPM interventions, have found linked to the majority of impairment costs and responsible for improvements include a wide range of health conditions and behaviors that are rarely called diseases, and are rarely the focus for disease or case management:

  • Hydration – where dehydration problems caused by both alcohol and caffeine consumption interfere to a significant degree with workers’ ability to do their best, a problem primarily recognized and addressed in Europe, and rarely mentioned in the US
  • Sleep problems, where both deprivation and too much sleep have been found to be linked to significant worker impairment
  • Allergies, particularly in “allergy seasons” of every year, where both absences and presenteeism spike among the high proportion of workers who suffer from allergies
  • Emotional problems, including feelings of depression, anxiety, etc. that are far more common than clinical diagnoses of mental health, and are often the most severe causes of impairment
  • Unhealthy eating habits and physical indolence, both risk factors for many unhealth conditions, and significant impairment factors as well
  • Smoking, a significant disease risk factor, but also a major impairment factor, especially considering “smoke breaks” away from work stations since most employers do not permit smoking at work
  • Stress, also a significant disease risk factor, but also the cause of productivity/performance impairment, along with employee turnover when severe enough
    Overweight/obesity, another direct impairment factor, as well as a health risk
  • Alcohol and drug abuse, usually much more an impairment factor than cause for added healthcare expense, and for employee discharge as well
  • Chronic fatigue syndrome, general malaise, aches and pains, particularly in the low back, neck, and joints, as well as migraine and chronic headache
  • Low motivation, job and life satisfaction, poor attitudes toward supervisors, and employer, major causes of turnover, as well as impairment
  • Absence/Impairment, itself, since the absence/impairment of one worker has a “multiplier effect” on the productivity/performance of teams, departments, units and entire organizations, with this effect ranging from as little as 1.0 (meaning no added effect) to as much as 11.0, but averaging roughly 1.25:1, though nurses are 1.40:1 [“Multiplier Effect: The Financial Consequences of Worker Absences” Knowledge&Wharton Dec 14, 2005 (knowledge.wharton.upenn.edu)]

None of these factors have ever been, to my knowledge at least, included in any employer or supplier EHPPM intervention or study.  They all present problems in the definition, measurement, and costs of doing so, and thereby add to the costs of such interventions.  When employers or suppliers are willing to “satisfice” their investments, by measuring only enough and particular measures to achieve a positive ROI, they choose this far more practical and inexpensive approach, leaving to others or their own future efforts a more complete evaluation.

Of course, this approach runs a severe risk.  Considering the uniformly unenthusiastic conclusions that federal agencies have reached on the cost-effectiveness of disease management, for example, any EHPPM effort that only dealt with diagnosed chronic diseases, and only looked at healthcare cost reductions for returns on EHPPM investments, could come to similar equivocal conclusions, and miss out on opportunities available in an entirely different set of problems, as well as results in entirely different measures of success.

Fortunately, employers both have faith in the cost effectiveness and ROI of EHPPM, even though they don’t have measures to prove success.  And if they gradually add to the problems they tackle and measures of success they use, the evidence so far strongly suggests that the further they look, the more satisfied they are likely to be. 
Literally hundreds of successful examples of EHPPM have been published, in American and European journals, reflecting just the limited measures of outcomes they have dealt with.

Suppliers of EHPPM services — including traditional healthcare organizations such as hospitals, physician practices, and integrated health systems – might be wise to lead by example, with their own workforce-focused EHPPM programs, as well as programs they offer as suppliers.  By mastering the art and science of measurement, of productivity/performance impairment and improvement, HCOs could become leaders in the overall EHPPM market, and become sources of an entirely new kind of value to businesses and consumers in their communities.

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