Role and Value of the Corporate Medical Director.

ABSTRACT: The role of the Corporate Medical Director (CMD) has received increased attention during the COVID-19 pandemic and has continued to evolve. This updated guidance addresses the role and value of the CMD in: health policy, strategy, and leadership; fostering a culture of health and well-being; supporting worker health and productivity/performance; addressing mental health; collaborating on employer benefits design; developing programs for global health, travel medicine, and remote/extreme environments; overseeing on- and near-site clinics; incorporating digital technology, artificial intelligence, and telehealth in health programs; supporting critical incident preparedness and business continuity planning; addressing workplace hazards; and overseeing periodic executive health examinations.

Effect of an Artificial Intelligence Clinical Decision Support System on Treatment Decisions for Complex Breast Cancer.

PURPOSE: To examine the impact of a clinical decision support system (CDSS) on breast cancer treatment decisions and adherence to National Comprehensive Cancer Center (NCCN) guidelines. PATIENTS AND METHODS: A cross-sectional observational study was conducted involving 1,977 patients at high risk for recurrent or metastatic breast cancer from the Chinese Society of Clinical Oncology. Ten oncologists provided blinded treatment recommendations for an average of 198 patients before and after viewing therapeutic options offered by the CDSS. Univariable and bivariable analyses of treatment changes were performed, and multivariable logistic regressions were estimated to examine the effects of physician experience (years), patient age, and receptor subtype/TNM stage. RESULTS: Treatment decisions changed in 105 (5%) of 1,977 patients and were concentrated in those with hormone receptor (HR)-positive disease or stage IV disease in the first-line therapy setting (73% and 58%, respectively). Logistic regressions showed that decision changes were more likely in those with HR-positive cancer (odds ratio [OR], 1.58; P < .05) and less likely in those with stage IIA (OR, 0.29; P < .05) or IIIA cancer (OR, 0.08; P < .01). Reasons cited for changes included consideration of the CDSS therapeutic options (63% of patients), patient factors highlighted by the tool (23%), and the decision logic of the tool (13%). Patient age and oncologist experience were not associated with decision changes. Adherence to NCCN treatment guidelines increased slightly after using the CDSS (0.5%; P = .003). CONCLUSION: Use of an artificial intelligence-based CDSS had a significant impact on treatment decisions and NCCN guideline adherence in HR-positive breast cancers. Although cases of stage IV disease in the first-line therapy setting were also more likely to be changed, the effect was not statistically significant (P = .22). Additional research on decision impact, patient-physician communication, learning, and clinical outcomes is needed to establish the overall value of the technology.

Elimination of the Out-of-Pocket Charge for Children's Primary Care Visits: An Application of Value-Based Insurance Design.

OBJECTIVE: To evaluate the impact of a value-based insurance design for primary care among children. STUDY DESIGN: A retrospective analysis of health care claims data on 25 950 children (<18 years of age) was conducted. Individuals were enrolled in a large employer's health plans when zero out-of-pocket cost for primary care physician visits was implemented. A rigorous propensity score matching process was used to generate a control group of equal size from a database of other employer-sponsored insurees. Multivariate difference-in-differences models estimated the effect of zero out-of-pocket cost on 21 health services and cost outcomes 24 months after intervention. RESULTS: Zero out-of-pocket cost for primary care was associated with significant increases (P < .01) in primary care physician visits (+32 per 100 children), as well as decreases in emergency department (-5 per 100 children) and specialist physician visits (-12 per 100 children). The number of prescription drug fills also declined (-20 per 100 children), yet medication adherence for 3 chronic conditions was unaffected. The receipt of well child visits and 4 recommended vaccinations were all significantly (P < .05) greater under the new plan design feature. Employer costs for primary care increased significantly (P < .01) in association with greater utilization ($29 per child), but specialist visit costs declined (-$12 per child) and total health care costs per child did not exhibit a statistically significant increase. CONCLUSION: This novel application of value-based insurance design warrants broader deployment and assessment of its longer term outcomes. As with recommended preventive services, policymakers should consider exempting primary care from health insurance cost-sharing.

Spatio-temporal information and knowledge representation of disease incidence and respective intervention strategies.

The supplementation of medical data with environmental data offers rich new insights that can improve decision-making within health systems and the healthcare profession. In this study, we simulate disease incidence for various scenarios using a mathematical model. We subsequently visualise the infectious disease spread in human populations over time and geographies. We demonstrate this for malaria, which is one of the top three causes of mortality for children under the age of 5 years in sub-Saharan Africa, and its associated interventions within Kenya. We demonstrate how information can be collected, analysed, and presented in new ways to inform key decision makers in understanding the prevalence of disease and the response to interventions.

Mainstreaming modeling and simulation to accelerate public health innovation.

Dynamic modeling and simulation are systems science tools that examine behaviors and outcomes resulting from interactions among multiple system components over time. Although there are excellent examples of their application, they have not been adopted as mainstream tools in population health planning and policymaking. Impediments to their use include the legacy and ease of use of statistical approaches that produce estimates with confidence intervals, the difficulty of multidisciplinary collaboration for modeling and simulation, systems scientists' inability to communicate effectively the added value of the tools, and low funding for population health systems science. Proposed remedies include aggregation of diverse data sets, systems science training for public health and other health professionals, changing research incentives toward collaboration, and increased funding for population health systems science projects.

Consumer-directed health plans reduce the long-term use of outpatient physician visits and prescription drugs.

Consumer-directed health plans (CDHPs) are designed to make employees more cost- and health-conscious by exposing them more directly to the costs of their care, which should lower demand for care and, in turn, control premium growth. These features have made consumer-directed plans increasingly attractive to employers. We explored effects of consumer-directed health plans on health care and preventive care use, using data from two large employers-one that adopted a CDHP in 2007 and another with no CDHP. Our study had mixed results relative to expectations. After four years under the CDHP, there were 0.26 fewer physician office visits per enrollee per year and 0.85 fewer prescriptions filled, but there were 0.018 more emergency department visits. Also, the likelihood of receiving recommended cancer screenings was lower under the CDHP after one year and, even after recovering somewhat, still lower than baseline at the study's conclusion. If CDHPs succeed in getting people to make more cost-sensitive decisions, plan sponsors will have to design plans to incentivize primary care and prevention and educate members about what the plan covers.

Medication utilization and adherence in a health savings account-eligible plan.

OBJECTIVES: To evaluate the impact of a consumerdirected health plan with a health savings account (CDHP-HSA) on utilization of and adherence to medications among individuals with chronic disease. STUDY DESIGN: Pre-post comparison study with matched control group (difference-in-differences analysis). METHODS: Data on workers and dependents with 1 or more of 5 chronic conditions--hypertension, dyslipidemia, diabetes, asthma/chronic obstructive pulmonary disease (COPD), and depression--were obtained from an employer that fully replaced its preferred provider organizations (PPOs) with a CDHP-HSA in 2007. A control group of participants from an employer that maintained its PPO throughout the 3-year study period (2006-2008) was created by matching on preperiod (2006) individual characteristics. Difference-in-differences estimates of the impact of the CDHP-HSA were derived by chronic condition for number of prescriptions, proportion of days covered (PDC), and an indicator for a PDC of 0.80 or higher. RESULTS: During the first year after implementation, enrollees with hypertension, dyslipidemia, and diabetes had significantly less medication utilization (by 1-2 prescriptions) and lower adherence rates (by 0.05-0.09 in PDC; 0.04-0.13 in the proportion adherent). These reductions abated, yet remained, after 2 years among hypertension and dyslipidemia patients. The PDC was significantly lower in patients with depression by 0.07 and 0.05 after 1 and 2 years under the new plan, respectively. No statistically significant impacts were detected on enrollees with asthma/COPD. CONCLUSIONS: A CDHP-HSA full replacement was associated with reduced adherence for 4 of 5 conditions. If this reduced adherence is sustained, it could adversely impact productivity and medical costs.

Large employers that have lived through transformation say payment reform alone won't cut costs and reengineer care.

As payment reform in health care gathers momentum, employers, as major payers, endorse the effort to move away from volume-driven payment to incentivizing and rewarding the delivery of better health care at lower cost. In this commentary we discuss large employers' perspectives on three particular challenges that payment reform alone, as important as it is, may not be sufficient to address: high health care prices, inefficient and complex systems, and an outdated work environment ill designed to meet the pressing goals of better health care at lower cost. We believe that policies that support health care organizations in redesigning work processes will be essential to reducing prices and simplifying interactions in care delivery. We also believe that health care organizations will need to redesign their compensation systems to align their employees' pay with improvements in performance. To that end, we describe the major transformation that IBM underwent in the 1990s to position itself to compete in a radically changed computer marketplace. We also offer several policy recommendations to support health care organizations in making the necessary changes.

An observational study of an employer intervention for children's healthy weight behaviors.

OBJECTIVE: This observational study was undertaken to assess whether changes in healthy weight behaviors could be advanced in a short-term intervention involving parents and children at IBM. METHODS: IBM's Children's Health Rebate offered a cash incentive for parents to complete a 12-week program of self-selected activities in family food planning and meals, family physical activity, and sedentary time related to electronic entertainment ("screen time"). A preprogram/postprogram comparison of self-reported activities was used to assess behavior change. RESULTS: A total of 22,265 (52.3%) employees elected to participate, 11,631 (52.2%) of whom completed all program requirements and earned a $150 cash rebate. Families completing the program reported significant changes in levels of physical activity, amount of entertainment screen time, and proportion of healthy meals. For example, family physical activity >3 times per week increased by 17.1 percentage points (from 23.2% to 40.3%), eating healthy dinners ≥ 5 days/week increased by 11.8 percentage points (from 74.9% to 86.7%), and entertainment screen time <1 hour/day increased by 8.3 percentage points for children (from 22.4% to 30.7%) and by 6.1 percentage points for adults (from 18.1% to 24.2%). CONCLUSIONS: The results of this short-term observational study suggest that healthy weight behaviors in children, adolescents, and parents can be improved by using a Web-based intervention linked with a cash incentive. The results also show that employers can activate parents and support a role for employers in community-based strategies for obesity prevention in children. Experimental designs with biometric data would strengthen the suggestion of positive impact.

Impact of childhood obesity on employers.

The impact of childhood obesity on the workplace is not well understood. A study conducted for one large employer indicated that average per capita health insurance claims costs were as high as $2,907 in 2008 for an obese child and $10,789 for a child with type II diabetes. The average claims cost for children with type II diabetes actually exceeded the level of the average claims cost for adults with type II diabetes ($8,844). This paper reviews the evidence on the impact of childhood obesity on employers and discusses opportunities for business engagement-including two current examples of activities involving employers.

Primary care: can it solve employers' health care dilemma?

Employers are beginning to recognize that investing in the primary care foundation of the health care system may help address their problems of rising health care costs and uneven quality. Primary care faces a crisis as a growing number of U.S. medical graduates are avoiding primary care careers because of relatively low reimbursement and an unsatisfying work life. Yet a strong primary care sector has been associated with reduced health care costs and improved quality. Through the Patient-Centered Primary Care Collaborative and other efforts, some large employers are engaged in initiatives to strengthen primary care.