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HEALTH, WORKPLACE, AND ENVIRONMENT: CULTIVATING CONNECTIONS
October 17, 2013
Measuring Effective Investment in Worksite Preventive and Health Promotion Programs
Health, Workplace, and Environment: Cul8va8ng Connec8ons Conference
Thursday October 17, 2013 University of Connec<cut Students Ballroom
Storrs, CT Martin Cherniack, MD, MPH DOEM, UConn Health Center Co-Director CPH-NEW
.
www.uml.edu/centers/CPH-NEW
“
The impact of a healthier, more productive workforce is quantifiable; when combined with other business measures it helps determine the overall economic value of an enterprise. The business community, ranging from financial analysts to investors, should develop and institutionalize additional accounting and valuation methods that include health and productivity metrics to more accurately determine the business value of workforce health assets in a company.
• Raise awareness in the business community of the relationship between the health of the workforce, the productivity of the workforce and the profitability of employers.
• Educate the business community on the benefits of considering the health and productivity assets of a business when considering the accounting and valuation methods for determining enterprise value. --Benefits Institute consensus statements on productivity 2008
Two World Views Apart: productivity as value added
Dilemma #1: The Productivity Paradox– when benefit and utility differ
Dilemma #2: The problems of accounting for negative value and discounting--when substitutions cannot be summarily valued
Dilemma #3: Monetizing the Multiple Dimensions of WHP – when valuing quality of life and output differ
Dilemma #4: The Anomalies -- when employers do the right thing for the wrong economic reason
The Four Dilemmas of Health and Productivity:
A Linear Pathway for Work and Health Synthesis -- non-integrated
Multilevel Conception of Work Organization concept of integration
Company Level Work Organization: E.g., structure, culture, organizational practices, technology
Division/Department Work Organization: E.g., resources; relation to other departments
Job Level Work Organization: E.g., work pace, supervision, work flow
Physical Exposures
Psychosocial Exposures
Other workplace exposures: • Chemical, dust, biological, etc. • Noise, temperature, radiation, etc. • Safety hazards • Others
Worker Outcomes:
Positive: • Good health • Improved productivity
Negative: • Disease/injury • Reduced productivity
Organizational Outcomes:
Positive or Negative: • Productivity • Quality • Customer Satisfaction • Health Care Costs • Workers Compensation • Absenteeism • Turnover
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Dilemma #1: The Productivity Paradox
• 1. Assigning Value, when ↑Productivity=↓Utility • 2. Sunk Benefits, when negative opportunity
cost discourages intervention Result: Investment in workforce health has (-) ROI for hospital workers,
despite lowering chronic disease hospitalization rates by 33% (Gowrisarkanan et al., Health Affairs, 2013)
Dilemma #1: Work Related Injury by NAICS Sector, 2012
incidence per 1000
Dilemma #1: Impact of RN Staffing Levels on Inpatient
Mortality
Study Design Retrospective cross-sectional 2002-2006
Population 197,961 admissions 176,696 shifts
Below target staffing definition
∆= (targeted staffing hours) – (%FTE, extended shift)
High turnover shift definition
(admissions, transfers, discharges) > 1 SD daytime mean
Needleman J, Buerhaus P, Pankratz S, Leibson CL, Stevens SR, Harris M. Nurse Staffing and Inpatient Hospital Mortality. NEJM 364:11, 1037-1045. (March 17, 2011)
Dilemma #1: Impact of RN Staffing Levels on Inpatient Mortality n=197,961
90 shifts post admission Hazard Ratio
(95% CI) P Value
5 days post admission RN Staffing (shift) > 8 hr less than target 1.12 (1.08–1.16) <0.001 Shift with high patient turnover 1.15 (1.07–1.24) 0.001
30 days post admission RN Staffing (shift) > 8 hr less than target 1.04 (1.03–1.06) <0.001
Shift with high patient turnover 1.07 (1.02–1.13) 0.006
©2011 MFMER | slide-10
Variable
Needleman J, Buerhaus P, Pankratz S, Leibson CL, Stevens SR, Harris M. Nurse Staffing and Inpatient Hospital Mortality. NEJM 2011;364:11, 1037-1045.
Dilemma #1: Staffing Impact - Patient to RN Ratio 1998-1999
Study Design Cross-sectional
Population 232,342 patients discharged/ 18 mos 1 patient per nurse increase
• 7% increase in deaths within 30 days • 7% increase in failure-to-rescue • 23% increase in RN burnout* • 15% increase in job dissatisfaction*
*Job Dissatisfaction and Burnout measures were brief survey determinations
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA, 2002: 288:1987-1993
©2011 MFMER | slide-12
Dilemma #1: Reduction in Health Care Cost Growth Johnson and Johnson Live for Life (Henke et al. 2011)
Dilemma #1: Johnson and Johnson Live for Life Comparative Risks per 100
Dilemma #2: the problems of accounting for negative value and discounting
ROI = benefit/cost ratio, where discounted inflation-adjusted benefits are divided by costs.
ROI = net present value/present value [NPV / PV of costs], where NPV is defined as the difference between the total discounted inflation-adjusted benefits and the costs of the program over its useful life.
Hurdle Rate = the employer’s acceptable rate of return
Dilemma #2: How Health Improvement and Improved Performance Represent negative ROI
Net-Cost Model for Weight Loss in the Nursing Home Sector
Average Subject
Cost Average
weight loss in pounds
ROI (productivity
+absenteeism) ROI
(absenteeism only)
Incentivized Group n=51 $129 7.3 6.5 0.2
Non-Incentivized Group n=48
$97 2.1 6.6 0.6
Lahiri and Faghri 2012
Dilemma #2 cont. The Effects of Changing Basic Assumptions -- Inputs
Assumptions: Duration 5 years Inflation Rate 0% Discount Rate 4% (ann) Thin tailed health uncertainty No Time preference
Benefits ↓Absenteeism 75 bitcoins ↓Hospitalization/WC 75 bitcoins
Costs Programmatics 50 bitcoins Staffing 50 bitcoins
Negative value?? QWL activity 25 bitcoins ↑OPC/coaching 25 bitcoins Workforce participation 25 bitcoins
Dilemma #2 : The Effects of Changing Basic Assumption -- Output
Return on Investment: BCR 0.70 BCR (no discount) 0.83 RA adj. (4%) 1.05 (-) negative value adj. 1.23 RA adj. (-) neg value 1.83 QWL as (+) value 2.14 RA = long-term catastrophic risk avoidance BCR = benefit cost ratio
Dilemma #3: Monetizing the Multiple Dimensions of Productivity
• Quantified outcomes measures – org level
• Quantified outcomes measures – Ind level
• Qualitative assessment ‘presenteeism’
• Absenteeism • Lost work time indemnification • Output or turnover time
• Morbidity and co-morbidity effects
on productivity • Current and future healthcare
costs
• QWL, Job Satisfaction • Self or observer described output
Dilemma #3: Contributions to ROI in Studies Using Productivity Estimators
Study Identification
Productivity Measure
Calculation Result Net Effect Effect on ROI
Meenan et al 2010 Self report Presenteeism + Absenteeism
Presenteeism ↓ Y2 Y1 + No net effect No effect
Lahiri & Faghri 2012 Self-report Productivity + Absenteeism
Productivity 80% of avoided cost
↑↑
80% of effect based on productivity
Mills et al 2007
Observed absenteeism Self-report Productivity
Productivity + Absenteeism
↓0.36 days lost 10.4% productivity
↑↑
72% of effect based on productivity
Golaszewski et al 1992
Productivity based on literature
Sensitivity @ 4% productivity gain (std), 0% and 25%
ROI 4.0 @ 4% ROI 1.4 @ 0 % ROI 14 @ 25%
↑↑
65% of ROI based on productivity
Baiker et al 2010 Productivity based on literature
Weight loss + 1RF ↓ = 40 hours $143 per person ↑↑ 41% of ROI based on
productivity
Burton et al. 2005 Produc2vity based on 10 min. self-‐evalua2on
1.9% ↓ per RF $950 per person produc2vity lossx RF-‐1
↑↑
1.6% natural retest↑ ~3.0% ↓ produc2vity
Dilemma #3: Distinguishing between the value of a working life and a saved life (VSL)
Period Description $ Value Source
Annual Average investment in WHP
$144 Baiker et al. 2010 Health Affairs
Insurance value of new medical procedure
$50,000 NYT 5/20/08
QOL lost on dialysis $129,000 Lee et al. 2009 (Stanford)
Lifetime EPA valuation $6,900,000 Appelbaum, Binyamin (2001)
Prime working Age $7,000,000 Viscusi 2004
Dilemma #3: Issues most effecting employee productivity: employers perspective
Towers Watson Staying@Work Report, 2009
Dilemma #3: Source of Worklife Stress: Employees Perspective
Towers Watson Staying@Work Report, 2011-2012
Odds Ratios for New CHD Events in Civil Service Workers – Whitehall Studies
Low Risk Intermediate Risk ♂ High Risk
Low Risk
Intermediate Risk ♀ High Risk
From Marmot et al., 1997
Dilemma #3: Monetizing work organization and the quality of life
Dilemma #4: The Anomalies, when employers do the right thing for the wrong economic reason
• Google: defining absenteeism without formal work hours
• Green Mountain Coffee: when estimating benefits precedes costs
How work-health health protection/health promotion integration can utilize team problem solving
Defining Productivity-based Interventions through Participatory Action
Selec8on Criteria Key performance indicators (KPIs) set by the group that can be used to measure the effec<veness of ac<vi<es and overall success of interven<on alterna<ves in regard to: Scope, Benefits/Effec<veness, Obstacles/Barriers, and Resources/Costs.
Scope The part of the organiza2on (e.g., individuals, groups, whole parts of the organiza2on) that the interven2on is intended to benefit.
Benefits/Effec8veness Benefits of any kind that the interven<on should provide; for example, fewer accidents, cost savings, improved job performance, improved health, improved safety, improved sense of wellbeing, lower job turnover, etc., etc.
Obstacles/Barriers Anything that is likely to work against the interven2ons being considered; for example, uncertainty about con2nued financial resources, long delays in geTng needed materials or equipment, difficulty in scheduling mee2ngs, a lack of top-‐down support, resistance to change, etc., etc.
Resources/Costs Some es<mates by the group of the financial or other types of resources available for an interven<on. Need to consider both the short and long-‐term resources/costs.
Current Status of Intervention Research
• What we know
• What we don’t quite know, but should know
• What we need to know
• HC and individual prevention ↓ hospital admissions
• Positive work climate (WAI) predicts longevity
• Risk profiles can be reduced over time
• Association between workforce health and outcomes in healthcare
• Integrated Assessment Modeling • General VSL estimators for work life
• Age-specific VSL estimators for QOL, QWL and workplace prevention
• Value based heath care cost adjustments