Harris Allen Group

Case Studies

A unique blend of market-based innovation, experience, and methodological/ technical rigor has distinguished the Harris Allen Group as a pioneer and leader in the measurement and management of a wide variety of issues related to health and health care.

Recent projects include the following. We can be contacted if you would like copies of these reprints and/or further information on any of these engagements.

Tracking Low Back Problems in a Major Self-Insured Workforce: Toward Improvement in the Patient’s Journey

Objectives: Assess the cost outcomes of treatment approaches to care for back problems in a major self-insured workforce, using published guidelines to focus on low back pain (LBP).

Methods: Longitudinally tracked episodes of three types of ICD-9 diagnosis code-identified back problems (n=14,787) during 2001-2009. Identified five patterns of care based on the first six weeks of claims and compared their total costs per episode with tests that included splits by episode type and duration, use of guidelines, and propensity-derived adjustments.

Results: Care congruent with ten of eleven guidelines was linked to lower total costs. Of the five patterns, Complex Medical Management and Chiropractic reported the highest and lowest rates, respectively, of guideline-incongruent use of imaging, surgeries and medications, and the highest and lowest total cost.

Conclusions: Approaches marked by higher resource utilization and lower guideline congruence are linked to greater LBP total costs. Total cost is a needed input for guideline development.

(Abstract from Allen H, Wright M, Craig T, Markadian J, Cheung R, Sanchez R, Bunn W & Rogers W. (2014). Tracking low back problems in a major self-insured workforce: Toward improvement in the patient’s journey. Journal for Occupational & Environmental Medicine. 56: 604-620.)

Reducing Total Burden: A Major Employer's Counter-trend Success & Implications for Health Care Reform

Objectives: Examine total health burden for an employer whose health-related focus is direct and indirect costs. Explore implications for the Final Rule for Accountable Care Organizations recently issued by the Centers for Medicare & Medicaid Services, whose focus includes direct but not indirect costs.

Methods: Used 42 claims and survey-based measures to track this employer's continental U.S. workforce burden in the aggregate and by healthy and selected disease designations from 2001-2002 to 2008-2009.

Results: Starting from equivalent baselines, this employer's aggregate total direct costs decreased 16% (8.5% adjusted) while comparable U.S. per capita expenditures rose 22.1%. Even larger decreases were recorded in total indirect costs. The healthy and disease designations replicated this pattern. Minimal employee cost-shifting occurred.

Conclusions: Attention to direct and indirect costs helped put this employer's healthcare investment on a markedly more sustainable path than comparable national cost trends. Fully tapping the applicable lessons this and other purchasers have learned will be facilitated by amending the Final Rule to include measures of indirect costs.

(Abstract from Allen H, Rogers W, Bunn W, Pikelny D & Naim A. (2012).  Reducing Total Health Burden from 2001 to 2009:  A Major Self-Insured Employer’s Counter-Trend Success Story and Implications for Health Care Reform. Journal for Occupational & Environmental Medicine.  54:  904-916.)

Using Self-reports and Claims to Manage the Burden of Autoimmune Disease

Objectives: Examine the self-reported health and productivity burden of three autoimmune disorders: rheumatoid arthritis, psoriasis, and inflammatory bowel disease.

Methods: A 2009 representative survey of a major employer’s US workforce, with two approaches for disease identification: (1) self-report and (2) self-report replicated by claims-based International Classification of Diseases, 9th Revision (ICD-9), codes.

Results: Self-reported prevalence: rheumatoid arthritis, 4.2%; psoriasis, 3.0%; inflammatory bowel disease, 1.2%. Psoriasis and inflammatory bowel disease replicated rheumatoid arthritis’ pattern of health and productivity effects though not as strongly. The three autoimmune disorders combined significantly affected health at all severity levels. They also significantly affected productivity at higher severity but not at no symptom/lower severity levels.

Conclusions: When employees with autoimmune disorders with lower severity/no symptoms do not progress to higher severity, their work performance remains on par with healthy employees. Autoimmune disorders’ high impact/low prevalence offers much promise for lowering costs through benefit design.

(Abstract from Allen H, Bunn W & Naim A (2012) The Self-Reported Health and Productivity Burden of Autoimmune Disorders at a Major Self-Insured Employer.Journal for Occupational & Environmental Medicine.  54:  1049-1063.)

A Model Employer Takes on Unique Challenges Posed by COPD

Objective: To develop new evidence for advancing a leading employer’s capacity to manage the burden of chronic obstructive pulmonary disease (COPD).

Methods: Retrospective analyses of an integrated database tracking active employees (n = 19,989) from 2001–2009. Tests on 29 measures of direct/indirect costs and drivers examined unique disease burden and impact over time.

Results: The costs of COPD exceeded workforce-wide costs by wide margins in 2001–2002. Direct costs linked to the disease rose in 2008– 2009; whereas, its indirect costs dropped sharply. Differences between yet to- be-diagnosed versus diagnosed and newly diagnosed versus established diagnosed groups were directionally consistent on driver and cost measures in 2001–2002. In 2008–2009, these comparisons were similarly consistent on indirect measures but not direct measures. Medication use helped to explain the inconsistencies.

Discussion: New action on COPD-oriented unit price escalation, prevention, and medical management concerns raised by these results could strengthen an already exemplary health and productivity program.

(Abstract from Allen H, Rogers W & Bunn W (2012). Managing the Burden of Chronic Obstructive Pulmonary Disease on Workforce Health and Productivity: Upping a Leading Employer’s Game. Journal for Occupational & Environmental Medicine.  54:  1064-1077.)

Purchaser Involvement and National Health Care Reform

Context: Leading corporate practitioners of health and productivity (H&P) approaches have reported striking gains in cost control alongside advances in employee health. These successes illustrate how a national H&P strategy can promote the sustainability of U.S. healthcare reform. Yet, H&P has been – and continues to be — absent as an explicit policy priority in the recent national debate and the legislation emerging from that debate.

Methods: This paper seeks to promote public dialogue on such a strategy by: 1) outlining the rationale for long-term investment in health; 2) defining components that comprise H&P in implementation; 3) identifying steps for promoting the needed collaboration of other stakeholders; and 4) recommending policies for broadening public acceptance.

Findings: 1) The nation’s expenditures on health and healthcare are best looked upon as a long-term investment not a short-term cost. 2) Clinical and physiological criteria are not enough to assess this investment; productivity criteria are also needed. 3) Employers are uniquely positioned to champion the need to incorporate H&P criteria into the policy mix. 4) The successful transition from individual employer successes to a national H&P strategy will hinge not only on broader acceptance among employers but also the cooperation and collaboration of other stakeholder groups. 5) Successful implementation will also equire surmounting logistical hurdles stemming from the expected variation in skill sets, expertise and data and program infrastructure within and across communities.

Conclusions: Employer participation has been an important variable in recent health policy initiatives, and it is suggested that greater employer involvement will boost the sustainability of current reform efforts. Recommendations are made to promote the convergence of interests that the major stakeholder groups share in a national H&P strategy. In addition, lessons adapted from existing models for dissemination are invoked to improve the prospects for successful implementation.

(Abstract for Allen H, Mendonsa R, O’Brien P & Brandt-Rauf P.  “Sustainable Health Care Reform:  Toward a National Strategy Built on Recent Employer ‘Health and Productivity’ Successes” . Journal for Health and Productivity. 5(2): 2-12.)

Evidence-based Health Care Benefit Design: Rationale

Healthcare costs for employers are rising much faster than inflation. The common approach to health benefit design of increasing cost-sharing has failed to contain costs. However, some employers have been successful at mitigating the cost trend or actually reducing healthcare costs. These employers have in common a dedication to data analysis, a search for cost drivers, and a willingness to adjust their approach to health benefit design to address these cost drivers. This approach has much in common with the movement in clinical practice toward evidence-based medicine. We propose that employers adopt a similar approach toward health benefits termed evidence-based benefit design, which is based on a health and productivity framework focused on direct and indirect costs. Evidence-based benefit design incorporates the relevant literature and employer specific data that is integrated and regularly analyzed.

(Abstract from Bunn W, Stave G, Allen H & Naim A. (2010). “Evidence-based Benefit Design:  Toward a Sustainable Healthcare Future for Employers.” Journal for Occupational and Environmental Medicine.   52(10): 951-955.)

Evidence-based Health Care Benefit Design: Case Study

Objective:  To illustrate how to use evidence-based benefit design (EBD) by presenting the case study of a major manufacturer.

Method:   Key components of the company’s measurement and management approach to EBD are introduced.  Descriptive results on the direct and indirect cost and utilization trends of the company’s US active workforce during 2002-2008 are presented.

Results:   From 1999-2002 aggregated to 2008, health care costs dropped sharply, with 2006, 2008 and projected 2009 reporting decreases even as annualized increases in national expenditures approximated 10%.  Annualized rates for hospitalizations, office visits and prescriptions showed corresponding decreases from 2004-2008. From 2002-2008, workers’ compensation/disability and absenteeism costs decreased 38% and 46%. 

Conclusions:  These results support the company’s direction in health benefit design although further confirmation is needed. On-going quality improvement processes are discussed, as are implications for implementing evidence-based benefit design.

(Abstract from Bunn W, Allen H, Stave G & Naim A. (2010). "How to Align Evidence-based Benefit Design with the Employer Bottom-line: A Case Study." Journal for Occupational and Environmental Medicine. 52(10): 956-963.)

Managing Workplace Depression through Measurement

Objectives:  Test the workplace impact of depression when it is stratified by severity and considered in broader context.

Methods:  Structural equation models of health risk appraisal data (n=39,097) involving 41 measures of contextual characteristics, depression severity, health & job performance.  

Results:  15.7% exhibited mild depression while 6.9% recorded moderate to severe symptoms.  Depression severity exerted large effects on general health and productivity loss, with the mild group posting the largest aggregate impact. Adverse personal life impact and financial concerns more significantly affected moderate to severe depression, while factors more directly amenable to employer health management efforts (e.g., stressful job) better predicted mild depression.

Conclusions:  These results link depression to large health and productivity deficits. They call fo public-private collaboration, mental and physical health insurance parity, and resource allocation that is proportionate across the depression spectrum and facilitated by symptom severity screening

(Abstract from Allen H., Hyworon Z & Colombi A. (2010). "Using Self-Reports of Symptom Severity to Measure and Manage Workplace Depression." Journal for Occupational and Environmental Medicine. 52(4): 363-374.)

Treating Stress as a Window for Managing Depression in the Workplace

Introduction:  This presentation will examine stress and its predictive relationship to workplace depression when the latter is stratified by severity and considered in the broader context of health and productivity (H&P) measurement and management.   It will discuss results from a recently published study undertaken to examine depression symptom severity as 1) a predictor of employee health and productivity loss and 2) an outcome of demographic/personal, job/company, and other contextual characteristics.  The focus will be findings on the impact of stress in relation to these objectives.

Methods:  For objective #1, tests were conducted that pitted depression symptom severity with 21 contextual characteristics as predictors of health and productivity loss. For objective #2, tests were conducted that differentiated the prediction of contextual characteristics on mild versus moderate to severe depressive symptoms.  Both sets of tests were based on structural equation models (SEM) estimated on an international employee sample comprised of 39,097 administrations of the Wellness Checkpoint health risk appraisal (HRA). 

Results. Key findings, gleaned from the final SEM models, included the following: 

• 15.7% exhibited mild depression while 6.9% posted moderate to severe symptoms
• Depression severity was among the largest of 21 predictors of general H&P loss, with the mild group recording the largest aggregate impact
• Personal life impact and financial concerns exerted greater impacts on the three higher severity depression groups combined than the mild severity group
• Conversely, predisposition toward stress and stress on the job exerted the first and third greatest impacts on mild severity depression levels

Discussion. While these results link depression to large H&P deficits, of keener interest to policymakers and practitioners charged with managing the burden of the condition will be the differences in its prediction by severity level. Although it stands to reason that certain factors are more likely to be co-occur at lower levels of depression severity and others at higher severity, this possibility has yet to be reported, despite the very real likelihood that differentiated profiles along these lines could help to improve the positioning of resources for managing the condition. 

Here, adverse personal impact and overall financial concerns – themselves measures indicative of potentially deep-seated issues involving well-being and functioning in home, work and personal life likely to require clinical treatment and monitoring – were the more potent predictors of higher severity.  In contrast, predisposition toward stress and stress on the job were among the most potent predictors of mild depression, as were other factors that are more likely to be subject to the influence of employer-sponsored health management and disease prevention programs. 

These results strengthen the business case for an integrated approach – one that combines access to professional detection, diagnosis and treatment for moderate to severe depression cases with access to employer initiatives such as employee assistance programs for mild severity cases -- for managing the burden of depression.  Implications for resource allocation that is proportionate across the depression spectrum and facilitated by symptom severity screening are discussed, as is the importance of employer-sponsored stress reduction programs for managing mild depression and its surprisingly large contribution to the overall impact of the condition.

(Abstract from Allen H & Colombi A. "Stress: A Pivotal Window into the Management of Workplace Depression". Presentation at national conference, 6/11)

Relationship Break-up as a Health and Productivity Issue in the Workplace

For clinical practitioners and researchers who by virtue of their profession gain exposure to and perspective on those going through relationship breakup, it is a virtual given that such experiences – both before, during and after any negotiated settlements are reached and/or any court decrees are issued -- exert huge effects on employee health and productivity (H&P).  In the course of their work, these practitioners and researchers get a bird’s eye view of the toll that relationship breakup can take on individual functioning and well being. 

Yet, although employers are mounting increasing efforts to identify and manage the sources of poor health and lost productivity among their employees, they have yet to devote systematic attention to the impact of relationship breakup. Other often associated factors like mild depression and stress have become the focus of employer educational and outreach initiatives (e.g., employee assistance programs, but relationship breakup itself has yet to be singled out for employer-sponsored measurement and/or management efforts. 

For many employers, improved worker productivity has become a key organizational objective and, to this end, they are now investing in a host of strategies for reducing the direct and indirect costs associated with adverse impacts of health and the factors that shape them.  To date, various diseases have comprised the major focus of these efforts, although other factors like overtime have also been targeted.  Relationship breakup – or more precisely the experience of relationship breakup – can now be added to this list, as enough is now known with respect to how to develop and apply rigorous methods to generate credible measures of its effects and rank them relative to other predictors. Relationship breakup could well emerge from such comparisons in ways that compel the attention of employers and eventually lead them to reshape their benefit and prevention strategies and programs accordingly.

This presentation is predicated on the premise that, properly executed, a framework that measures the impact of relationship breakup and compares it to other sources of H&P loss will document repercussions for organizational performance and profitability that will provide the impetus for new employer action in this area.  Presentation objectives will be to: 1) introduce the science of H&P measurement and management; 2) probe how to document the burden of relationship breakup in ways that increase employer awareness; and 3) explore avenues for building linkages between the clinical/research community and employers that, in turn, will enable employers to come to grips with this issue. 

(Abstract from Allen, H. "Relationship Breakup and Workplace Health and Productivity: Coming to Grips with an Elephant in the Room". Presentation scheduled for a national conference in June 2011.)

Developing & Reporting on a Leading Integrated Database of a Major Self-insured Employer

In collaboration with several major sponsors -- Schering-Plough, Centocor Ortho-Biotech, Novartis Pharmaceuticals, and The Conference Board -- we have developed and periodically refreshed what has become a field-leading integrated database at Navistar, Inc.

Earlier iterations of this database encompassed two employee surveys of the company's US workforce in 2001 and its workers compensation/disability, medical/pharmaceutical and absenteeism activity spanning 2001-2002. It served as the data source for 12 peer-reviewed and non peer-reviewed publications whose topics ranged from the burden and management of allergies to validation studies of measures of presenteeism.

Later iterations of this database have added behavioral health claims and expanded the coverage for all administrative sources from 2001 through 2009. These claims data have covered the activity of active employees as well as retirees and dependents in the continental U.S. The "refresh" has also incorporating another company-wide US employee survey conducted in the fall of 2009.

This updated database is serving as the data source for a wide variety of longitudinal studies, ranging from the total cost burden of immune mediated diseases, hypertension, respiratory diseases and osteoporosis to employee engagement.

Pain and Employee Health & Productivity

Working with the field’s leading trade organization and a Fortune 100 Company, we evaluated the burden of pain on employee health, presenteeism and absenteeism.

Key findings:

• nearly 30% of employees were affected by pain
• pain was associated with reductions in physical and mental health of 45% and 23%, respectively
• pain was linked to a five-fold increase in health-induced limitations in work performance
• pain was responsible for the loss of 3 and 2/3 days in presenteeism and absenteeism over a 20-day period (a productivity loss of 18%)
• although employees with pain reported using a wide variety of treatment options, they also reported considerable room for improvement in pain control.

This work was published in the Journal of Occupational and Environmental Medicine(7/05) and Health and Productivity Management (10/05).  It also has been the subject of notable press attention (see News). 

Long Work Hours and Health & Productivity

Working with a major employer, the United Auto Workers, and the National Institute for Occupational Safety and Health, we have conducted a series of studies examining relationships between long work hours, employee health and productrivity.

Our results:

• Confirmed prior research linking hourly employees with extended hours to a greater likelihood of at least one workers comp episode over the next year.
• Limited this effect to workplace injuries, just one aspect of the broader health and productivity space. Workers with long hours were no more likely to incur adverse physical or mental health outcomes, or to report presenteeism outcomes, or to post a disability episode over the next year.
• Determined that antecedent factors (e.g., age, gender, prior diseases and health risks) had much more impact on adverse health and productivity outcomes than how many hours were worked.

This work led to several recommendations proposed to the employer (e.g., introducing new curbs for working 60+ hours). It has produced several papers in collaboration that are being prepared for publication. And, a symposium on this work was held -- with all major parties participating -- at the International Work, Stress and Health Conference in March 2006 in Miami, FL.

Allergy Burden and Drug Effectiveness

With a major heavy manufacturer and drug maker, we conducted a three-year research program comprised of validation, observation and intervention studies.  The focus was the burden of allergies on the health and productivity of employees at a heavy manufacturer. This program used a pre-post/experimental-control design, featuring an integrated database that included employee surveys, absenteeism and group health/pharmaceutical/disability/workers compensation claims.

Key findings:

• Nearly one in four employees were affected by allergies
• Employee health, productivity, absenteeism, workplace injury and workers comp episodes consistently worsened as allergy severity increased.
• Drug regimens including non-sedative antihistamines showed better capacity to reduce allergy burden than regimens including sedative antihistamines.
• An 8-modality educational program served to improve the knowledge of employees about allergies but did not succeed in promoting behavior change.
• Self reports of productivity loss performed well in a series of concurrent and predictive validitiy tests
• Self-reports helped to differentiate known groups, even when administrative data on adverse events were used.

Four peer-reviewed articles on this workt appeared in the September, 2003 Journal of Occupational & Environmental Medicine.  Another four articles have appeared in sequential issues of Health and Productivity Management. 

Community Health & Work Environment

Sponsored by an employer coalition and pharmaceutical companies, this community initiative ranked the burden of specific medical conditions on employee health and productivity.  Known as the Healthy People/Productive Community Survey,  this engagement implemented a first-of-its-kind two-wave, two-year survey process (a general population survey and 17 condition-specific surveys) on 20,000 employees from 9 major corporations in the Tampa Bay, Florida area..

Key findings:

• The top ranking diseases in terms of prevalence were ranked as follows:  allergies (26%), hypertension (17%), neck/shoulder problems (15%), arthritis (14%), lower back problems (13%), and depression (10%).
• For these diseases, the average loss in presenteeism & absenteeism ranged from 3.1 for allergies to 4.9 days for depression over a 20 workday period.
• The exception was hypertension:  its relatively modest per person impact caused it drop for this top list
• Overall, the 17 disease conditions were linked to a productivity loss of over $7.25 million per 100 employees per year.
• The presence of obesity worsened the productivity loss impact across all 17 conditions.

A copy of the article summarizing this work can be obtained by contacting us.

Health Plan Performance over Time

With three major Fortune 500 employers, we conducted a national two-year, two-wave survey on employee/enrollee satisfaction with health plans. The data from nearly 12,000 employees was used to rank 23 major plans located in five major markets across the U.S.

The three employer clients used the results to assess corporate health care strategy and to initiate and monitor continuous qualitiy improvement with each of these plans.   The National Committee for Quality Assurance used the survey as a model for the Consumer Survey included in iits HEDIS system for measuring health plan performance.

Reprints of the several articles appearing on this work in Health Affairs, theInternational Journal for Health Care Quality, Managed Care Quarterly and other peer-reviewed venues are available on request..

Enrollee Satisfaction with Adult and Pediatric Care 
and Plan Performance

With a major Midwest health plan, we conducted annual, statewide, enrollee surveys to compare 80+ primary care clinics over a three-year period.  Each year’s survey was used by senior management to gauge plan-wide performance relative to corporate goals developed from the previous year’s survey.

Longitudinal Evaluation 
of a Corporate Health Care Delivery System

We conducted five annual surveys over a seven-year period to monitor the impact of a family health center (FHC) for a corporation in a southeastern city. We found that the FHC’s value to employees solidified during the study period, despite a period of continued and divergent change among the four health plans with which it interfaced.

Assessment of effectiveness of new medical device

Working with seven hospitals and a health plan, we conducted complex data collection on 800 coronary stent patients. This process involved development and administration of two patient surveys as well as abstraction of medical records. Results were used to promote new areas for plan/hospital collaboration.

Health Plan Benefit and Strategy Consulting

As part of a multidisciplinary team of actuaries and clinicians, we reviewed health benefits provided to state employees and retirees for a state agency in the northeast. This review used focus groups and a large survey to employees and retirees to help formulate and test recommendations made to the agency. The results helped to finalize the recommendations.