Legitimacy of Cost Concern for Health Insurance Coverage of Gender-Affirming Surgeries: Comparison of the Interest in Keeping Insurance Cost Down versus the Cost-Effectiveness of Including Gender-Affirming Surgeries in Employer Health Insurance Plans.

This RCD discusses the recent development in Lange v Houston County. In this case, the United States District Court for The Middle District Of Georgia Macon Division found that an Exclusion Policy, prohibiting health insurance coverage of gender-affirming surgery for an employee, Anna Lange, violated Title VII of the Civil Rights Act. On appeal, the Defendants argued that the District Court erred in its decision and relied on the cost burden of gender-affirming surgery as one of their defenses. This RCD highlights that cost is a common defense tactic used by defendants in these cases. However, the author argues that these concerns are unfounded and meritless given the cost-effectiveness of including gender-affirming surgeries in health insurance plans, as highlighted in the RCD.

Receipt of and Spending on Cessation Medication Among US Adults With Employer-Sponsored Health Insurance, 2010 and 2017.

OBJECTIVE: Studies examining the use of smoking cessation treatment and related spending among enrollees with employer-sponsored health insurance are dated and limited in scope. We assessed changes in annual receipt of and spending on cessation medications approved by the US Food and Drug Administration (FDA) among tobacco users with employer-sponsored health insurance from 2010 to 2017. METHODS: We analyzed data on 439 865 adult tobacco users in 2010 and 344 567 adult tobacco users in 2017 from the IBM MarketScan Commercial Database. We used a negative binomial regression to estimate changes in receipt of cessation medication (number of fills and refills and days of supply). We used a generalized linear model to estimate spending (total, employers', and out of pocket). In both models, covariates included year, age, sex, residence, and type of health insurance plan. RESULTS: From 2010 to 2017, the percentage of adult tobacco users with employer-sponsored health insurance who received any cessation medication increased by 2.4%, from 15.7% to 16.1% (P < .001). Annual average number of fills and refills per user increased by 15.1%, from 2.5 to 2.9 (P < .001) and days of supply increased by 26.4%, from 81.9 to 103.5 (P < .001). The total annual average spending per user increased by 53.6%, from $286.40 to $440.00 (P < .001). Annual average out-of-pocket spending per user decreased by 70.9%, from $70.80 to $20.60 (P < .001). CONCLUSIONS: Use of smoking cessation medications is low among smokers covered by employer-sponsored health insurance. Opportunities exist to further increase the use of cessation medications by promoting the use of evidence-based cessation treatments and reducing barriers to coverage, including out-of-pocket costs.

Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits.

BACKGROUND: Pharmacy benefit can be purchased as part of an integrated medical and pharmacy health package-a carve-in model-or purchased separately and administered by an external pharmacy benefit manager-a carve-out model. Limited peer-reviewed information is available assessing differences in use and medical costs among carve-in versus carve-out populations. OBJECTIVE: To compare total medical costs per member per year (PMPY) and utilization between commercially self-insured members receiving carve-in to those receiving carve-out pharmacy benefits overall and by 7 chronic condition subgroups. METHODS: This study used deidentified data of members continuously enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018. Cambia covers 1.6 million members in Oregon, Washington, Idaho, and Utah. The medical cost PMPY comparison was performed using multivariable general linear regression with gamma distribution adjusting for age, gender, state, insured group size, case or disease management enrollment, 7 chronic diseases, risk score (illness severity proxy), and plan paid to total paid ratio (benefit richness proxy). Medical event objectives were assessed using multivariable logistic regression comparing odds of hospitalization and emergency department (ED) visit adjusting for the same covariates. Sensitivity analyses repeated the medical cost PMPY comparison excluding high-cost members, greater than $250,000 annually. Chronic condition subgroup analyses were performed using the same methods separately for members having asthma, coronary artery disease, chronic obstructive pulmonary disease, heart failure, diabetes mellitus, depression, and rheumatoid arthritis. RESULTS: There were 205,835 carve-in and 125,555 carve-out members meeting study criteria. Average age (SD) was 34.2 years (18.6) and risk score (SD) 1.1 (2.3) for carve-in versus 35.2 years (19.3) and 1.1 (2.4), respectively, for carve-out. Members with carve-in benefits had lower medical costs after adjustment (4%, P < 0.001), translating into an average $148 lower medical cost PMPY ($3,749 carve-out vs. $3,601 carve-in annualized). After adjustment, the carve-in group had an estimated 15% (P < 0.001) lower hospitalization odds and 7% (P < 0.001) lower ED visit odds. Of 7 chronic conditions, significantly lower costs (12%-17% lower), odds of hospitalization (22%-36% lower), and odds of ED visit (16%-20% lower) were found among members with carve-in benefits for 5 conditions (all P < 0.05). CONCLUSIONS: These findings suggest that integrated, carve-in pharmacy and medical benefits are associated with lower medical costs, fewer hospitalizations, and fewer ED visits. This study focused on associations, and defining causation was not in scope. Possible reasons for these findings include plan access to both medical and pharmacy data and data-informed care management and coordination. Future research should include investigation of integrated data use and its effect across the spectrum of integrated health plan offerings, provider partnerships, and analytic strategies, as well as inclusion of analyzing pharmacy costs to encompass total cost of care. DISCLOSURES: This study received no external funding. The study was jointly conducted by employees of Cambia Health Solutions and Prime Therapeutics, a pharmacy benefit manager servicing Cambia Health Solutions. Smith, Lam, Lockwood, and Pegus are employees of Cambia Health Solutions. Qiu and Gleason are employees of Prime Therapeutics.

Burden and Cost of Outpatient Hemorrhoids in the United States Employer-Insured Population, 2014.

INTRODUCTION: Although hemorrhoids are a common indication for seeking health care, there are no contemporary estimates of burden and cost. We examined data from an administrative claims database to estimate health care use and aggregate costs. METHODS: We conducted a cross-sectional study using the MarketScan Commercial Claims and Encounters Database for 2014. The analysis included 18.9 million individuals who were aged 18-64 and continuously enrolled with prescription coverage. Outpatient hemorrhoid claims were captured using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes in the first position, as well as Common Procedural Terminology codes. Prescription medications were identified using National Drug Codes. Annual prevalence and costs were determined by summing gross payments for prescription medications, physician encounters, and facility costs. We used validated weights to standardize annual cost estimates to the US employer-insured population. RESULTS: In 2014, we identified 227,638 individuals with at least one outpatient hemorrhoid-related claim (annual prevalence, 1.2%). Among those, 119,120 had prescription medication claims, 136,125 had physician claims, and 28,663 had facility claims. After standardizing, we estimated that 1.4 million individuals in the US employer-insured population sought care for hemorrhoids in 2014 for a total annual cost of $770 million. This included $322 million in physician claims, $361 million in outpatient facility claims, and $88 million in prescription medication claims. CONCLUSIONS: The estimated economic burden of hemorrhoids in the employer-insured population approaches $800 million annually. Given the substantial and rising burden and cost, expanded research attention should be directed to hemorrhoidal etiology, prevention, and treatment.

Employers as Consumers of Healthcare.

Amazon, Berkshire Hathaway, and JP Morgan Chase shocked the industry with its announcement to join forces to cut healthcare costs and improve healthcare services for its employees. This is just the latest of employer efforts to disrupt the industry by the creation of alternative healthcare delivery networks that demonstrate high-value, low-cost services as compared with what traditional provider systems have to offer. What factors are behind this industry disruption, and what are the key implications for nurse executives?

Combining fixed effects and instrumental variable approaches for estimating the effect of psychosocial job quality on mental health: evidence from 13 waves of a nationally representative cohort study.

Background: Previous studies suggest that poor psychosocial job quality is a risk factor for mental health problems, but they use conventional regression analytic methods that cannot rule out reverse causation, unmeasured time-invariant confounding and reporting bias. Methods: This study combines two quasi-experimental approaches to improve causal inference by better accounting for these biases: (i) linear fixed effects regression analysis and (ii) linear instrumental variable analysis. We extract 13 annual waves of national cohort data including 13 260 working-age (18-64 years) employees. The exposure variable is self-reported level of psychosocial job quality. The instruments used are two common workplace entitlements. The outcome variable is the Mental Health Inventory (MHI-5). We adjust for measured time-varying confounders. Results: In the fixed effects regression analysis adjusted for time-varying confounders, a 1-point increase in psychosocial job quality is associated with a 1.28-point improvement in mental health on the MHI-5 scale (95% CI: 1.17, 1.40; P < 0.001). When the fixed effects was combined with the instrumental variable analysis, a 1-point increase psychosocial job quality is related to 1.62-point improvement on the MHI-5 scale (95% CI: -0.24, 3.48; P = 0.088). Conclusions: Our quasi-experimental results provide evidence to confirm job stressors as risk factors for mental ill health using methods that improve causal inference.

Biometric Screening and Future Employer Medical Costs: Is It Worth It to Know?

OBJECTIVE: To study the relationship between a biometric wellness data and future/actual medical costs. METHODS: A relationship between total cholesterol to high density lipoprotein ratio, blood pressure, and blood glucose and medical costs, based on analysis of claims data, was explored in 1834 employees that had both wellness program biometric and claims data in 2016. RESULT: Increased total cholesterol to HDL ratio is strongly associated with increased average costs (P < 0.01). Similarly, an increased glucose level is strongly associated with increased average costs (P = 0.001). There was no evidence of a relationship between elevated blood pressure and higher costs. CONCLUSIONS: By investing in an employer-sponsored biometric screening of full cholesterol and glucose profiles, medium-sized employers can identify high-risk employees who are expected to incur significantly higher healthcare costs, as compared with low-risk level employees, and improve treatment outcomes.

Health Care Use And Spending Patterns Vary By Wage Level In Employer-Sponsored Plans.

Employees face an increasing financial burden for health services as health care costs increase relative to earnings. Yet little is known about health care utilization patterns relative to employee wages. To better understand this association and the resulting implications, we examined patterns of health care use and spending by wage category during 2014 among 42,936 employees of four self-insured employers enrolled in a private health insurance exchange. When demographics and other characteristics were controlled for, employees in the lowest-wage group had half the usage of preventive care (19 percent versus 38 percent), nearly twice the hospital admission rate (31 individuals per 1,000 versus 17 per 1,000), more than four times the rate of avoidable admissions (4.3 individuals per 1,000 versus 0.9 per 1,000), and more than three times the rate of emergency department visits (370 individuals per 1,000 versus 120 per 1,000) relative to top-wage-group earners. Annual total health care spending per patient was highest in both the lowest-wage ($4,835) and highest-wage ($5,074) categories relative to the middle two wage groups ($3,952 and $3,987, respectively). These findings provide new insights about wage-associated variations in health care use and spending in employer-sponsored plans. For policy makers, these findings can inform employer benefit design strategies and research priorities, to encourage effective use of health care services.

Associations Between Supportive Leadership Behavior and the Costs of Absenteeism and Presenteeism: An Epidemiological and Economic Approach.

OBJECTIVE: This study investigates associations between supportive leadership behavior (SLB) and presenteeism/absenteeism, and estimates related costs. METHODS: Cross-sectional data from a German industrial sample (n = 17,060) assessing SLB and presenteeism/absenteeism were used. Adjusted interval regressions were performed. The study population was split into tertiles with respect to SLB, and minimum and maximum costs for each tertile were estimated on the basis of national industry averages. RESULTS: Low SLB was associated with higher presenteeism [-0.31, 95% confidence interval (95% CI) -0.33 to -0.28)] and absenteeism (-0.36, 95% CI -0.40 to -0.32). Compared with high SLB, the costs of low SLB for absenteeism are between 534.54 and 1675.16 Euro higher per person and year. For presenteeism, this difference ranges between 63.76 and 433.7 Euro. CONCLUSIONS: SLB has the potential to reduce absenteeism, presenteeism, and associated costs. To contribute to workforce health, productivity, and efficiency, SLB merits being fostered by corporate policy.

The impact of a sick pay waiting period on sick leave patterns.

This article assesses how a waiting period for sick pay impacts sick leave patterns. In the French private sector, statutory sick benefits are granted after 3 days. However, 60 % of employers in this sector provide complementary sick pay to cover this waiting period. Linked employee-employer survey data compiled in 2009 are used to analyze the impact of this compensation on workers' sick leave behavior. The assessment isolates the insurance effect (moral hazard) from individual and environmental factors relating to sick leave (including health and working conditions). Results suggest that employees who are compensated during the 3-day waiting period are not more likely to have an absence. On the contrary, their sickness leaves are significantly shorter by 3 days on average. These results could be explained by consequences of presenteeism and ex post moral hazard when employees are exposed to a waiting period.

Implications of employer coverage of contraception: Cost-effectiveness analysis of contraception coverage under an employer mandate.

OBJECTIVES: Mandatory employer-based insurance coverage of contraception in the US has been a controversial component of the Affordable Care Act (ACA). Prior research has examined the cost-effectiveness of contraception in general; however, no studies have developed a formal decision model in the context of the new ACA provisions. As such, this study aims to estimate the relative cost-effectiveness of insurance coverage of contraception under employer-sponsored insurance coverage taking into consideration newer regulations allowing for religious exemptions. STUDY DESIGN: A decision model was developed from the employer perspective to simulate pregnancy costs and outcomes associated with insurance coverage. Method-specific estimates of contraception failure rates, outcomes and costs were derived from the literature. Uptake by marital status and age was drawn from a nationally representative database. RESULTS: Providing no contraception coverage resulted in 33 more unintended pregnancies per 1000 women (95% confidence range: 22.4; 44.0). This subsequently significantly increased the number of unintended births and terminations. Total costs were higher among uninsured women owing to higher costs of pregnancy outcomes. The effect of no insurance was greatest on unmarried women 20-29 years old. CONCLUSIONS: Denying female employees' full coverage of contraceptives increases total costs from the employer perspective, as well as the total number of terminations. IMPLICATIONS: Insurance coverage was found to be significantly associated with women's choice of contraceptive method in a large nationally representative sample. Using a decision model to extrapolate to pregnancy outcomes, we found a large and statistically significant difference in unintended pregnancy and terminations. Denying women contraception coverage may have significant consequences for pregnancy outcomes.

Absenteeism and Employer Costs Associated With Chronic Diseases and Health Risk Factors in the US Workforce.

INTRODUCTION: Employers may incur costs related to absenteeism among employees who have chronic diseases or unhealthy behaviors. We examined the association between employee absenteeism and 5 conditions: 3 risk factors (smoking, physical inactivity, and obesity) and 2 chronic diseases (hypertension and diabetes). METHODS: We identified 5 chronic diseases or risk factors from 2 data sources: MarketScan Health Risk Assessment and the Medical Expenditure Panel Survey (MEPS). Absenteeism was measured as the number of workdays missed because of sickness or injury. We used zero-inflated Poisson regression to estimate excess absenteeism as the difference in the number of days missed from work by those who reported having a risk factor or chronic disease and those who did not. Covariates included demographics (eg, age, education, sex) and employment variables (eg, industry, union membership). We quantified absenteeism costs in 2011 and adjusted them to reflect growth in employment costs to 2015 dollars. Finally, we estimated absenteeism costs for a hypothetical small employer (100 employees) and a hypothetical large employer (1,000 employees). RESULTS: Absenteeism estimates ranged from 1 to 2 days per individual per year depending on the risk factor or chronic disease. Except for the physical inactivity and obesity estimates, disease- and risk-factor-specific estimates were similar in MEPS and MarketScan. Absenteeism increased with the number of risk factors or diseases reported. Nationally, each risk factor or disease was associated with annual absenteeism costs greater than $2 billion. Absenteeism costs ranged from $16 to $81 (small employer) and $17 to $286 (large employer) per employee per year. CONCLUSION: Absenteeism costs associated with chronic diseases and health risk factors can be substantial. Employers may incur these costs through lower productivity, and employees could incur costs through lower wages.

Prevalence and Associated Cost and Utilization of Multiple Chronic Conditions in the Outpatient Setting among Adult Members of an Employer-Based Health Plan.

Patients with multiple chronic conditions (MCCs) are a significant concern for the US health care system. MCC patients represent an increasing proportion of the US population and are associated with increased health care cost and utilization, and poor quality of care. Research that has been conducted on MCC patients to date has been at the national level using large data sets, such as Medicare and Medicaid claims and the National Inpatient Sample. These studies have produced research evidence that may be of little utility to individual employer-based health plans given the inherent differences in the patient populations they serve. This study analyzed evaluation and management claims for patients ages 18 years and older (n=632,477) from the Beaumont Employee Health Plan (BEHP), a regional health insurance provider serving Beaumont Health System employees and their families across Southeastern Michigan. The study found that individuals with MCCs are associated with increased cost and visits, and decreased time between appointments in the outpatient setting. Despite decreasing prevalence of MCCs over the study period, substantial increases in cost and visits, and a decrease in time between appointments was observed for MCC patients. Asthma and chronic back pain were uniquely identified as additional primary targets for disease management programs for employer-based health plans. These findings speak to the value of studying MCCs at the employer-based health plan level, where population-specific MCCs can be identified for meaningful intervention and management. Significant opportunity exists for employer-based health plans to study, prevent, and manage MCCs among adult patients.

A gripe sob diferentes perspectivas / Influenza from different perspectives

A gripe é uma importante causa de doença e óbito. Estima-se que, anualmente, cause grave comprometimento em 3-5 milhões de pessoas e 250 a 500 mil mortes. Tanto os custos médicos diretos como os indiretos, que dependem grandemente do absenteísmo e da perda de produtividade no trabalho, são substanciais. A gripe pode ser responsável por 10%-12% de todas as faltas ao trabalho por doenças, e o custo-efetividade da imunização na população trabalhadora geral ainda está em debate...

Influenza is an important cause of disease and death. Yearly, it is estimated that the influenza causes severe harm in 3-5 million people and 250 to 500 hundred thousand deaths. Both the indirect and direct medical costs which depends on absenteeism and loss of productivity at work are substantials. The influenza can be responsible for 10%- 12% of sickness absences and the cost-efectiveness immunization of general employment- population is still in discussion...

Economic burden of urge urinary incontinence in the workplace.

OBJECTIVE: Quantify incremental employee medical, pharmacy, sick leave, short- and long-term disability, and workers' compensation costs, absence days, and turnover associated with urge urinary incontinence (UUI) in employees. METHODS: This retrospective 2001-2011 database comparison of employees with UUI versus those without UUI (controls) included employees aged 18.5 to 64.0 years at index, with 6-month preindex and 12-month postindex health plan enrollment. Logistic and generalized linear models measured postindex costs, absences, and turnover. RESULTS: The study included 1448 employees with UUI and 337,796 controls. Employees with UUI had statistically significantly higher medical (131% higher), pharmacy (52%), sick leave (30%), and short-term disability (74%) costs and more sick leave (22%) and short-term disability (99%) days than controls (all P < 0.02). CONCLUSIONS: Employees with UUI had 117% greater medical and pharmacy costs, 47% greater total absence costs, and 63% more absence days than employees without UUI.

A more generalizable method to evaluate the association between commonly reported health risks and health care expenditures among employers of all sizes.

OBJECTIVE: To evaluate the association between health risks and health care expenditures for employers of all sizes, generalizing to all employees, even those who did not complete a health risk assessment (HRA). METHODS: Health risk assessments were obtained from 169,693 insured employees and spouses. Total health care expenditures were measured before HRA completion. Propensity score weighting, adjusting for HRA nonresponse, and multivariate regression analyses were used to estimate the relationship between health risks and health care expenditures. RESULTS: These at-risk categories were significantly associated with increased health care expenditures: elevated blood pressure, body weight and cholesterol, medication/drug use for relaxation, physical inactivity, and stress. CONCLUSIONS: The large sample size, the use of data from small firms, and generalizability made this study unique. Targeted programs that promote management of health risks could result in health care cost savings for employers of all sizes.

Employer-incurred health care costs and productivity losses associated with influenza.

The primary objective of this study was to assess trends in employer expenditures for both direct medical costs and indirect productivity losses associated with influenza. A retrospective analysis was performed using two of the MarketScan family of databases for 2005-2009. Patients with at least one diagnosis claim for influenza during an influenza season were selected. We estimated seasonal incidence of influenza in the employed population from the MarketScan Commercial Claims and Encounters database. Health care utilization and costs and productivity losses were assessed during the 21-d period following the influenza diagnosis date. Compared with the 2005-2006 season (493 per 100,000 plan members), influenza incidence increased during the 2006-2007 (598 per 100,000 plan members) and 2007-2008 (1,142 per 100,000 plan members) seasons and had a dramatic increase during the pandemic season of 2008-2009 (1,715 per 100,000 plan members) . The total influenza-related employer spending per 100,000 plan members also increased by over 400% during the 2008-2009 influenza season [$623,248; confidence interval (CI]):$601,518-$644,991], compared with 2005-2006 ($145,834; 95% CI: $135,067-$156,603). The primary drivers of the increased costs were emergency room, outpatient and inpatient visits. Total costs associated with influenza-related missed work time per 100,000 plan members increased over 4-fold from $26,479 in the 2005-2006 influenza season to $122,811 in 2008-2009. Overall, as expected, considerably higher direct and indirect costs were observed during the 2008-2009 influenza pandemic season than during other influenza seasons. In recent years, the influenza-related employer burden has increased considerably. In future, employers may need efficient resource allocation in order to address the productivity losses and increasing direct medical costs associated with increased influenza incidence. One of the strategies that employers may consider is increasing influenza vaccination rates among employees, which likely will help lower the influenza incidence and the associated downstream direct and indirect costs.

The economic cost of return to work: an employer's perspective.

BACKGROUND: Although return-to-work (RTW) interventions have been shown to be cost-effective, most previous economic analyses have focused on the insurer's perspective. Employers can also incur costs when supporting the RTW of their employees. OBJECTIVE: To identify a key set of items for estimating the costs of RTW interventions from the employer's perspective, and to identify and value the costs and consequences of a RTW intervention. PARTICIPANTS: Employers with knowledge of the economic costs of RTW. METHODS: A survey of 10 workplaces with RTW programs was conducted. The survey consisted of semi-structured interviews with a human resources or occupational health and safety representative from each enrolled workplace. RESULTS: The interviews were reviewed and from them key items were identified for estimating the costs of RTW interventions from the employer's perspective. Employers identified the following costs: medical, equipment, training and education, wage replacement and productivity, and claims administration when assisting an employee's RTW. CONCLUSIONS: Even in a jurisdiction with workers' compensation insurance, employers incur costs associated with RTW programs. It is important to consider these costs, from the perspective of the employer, when studying the cost-effectiveness of RTW interventions or programs.