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important as it is, may not be sufficient to address: high health care prices, inefficient and complex systems, and an outdated work environment ill designed to meet the pressing goals of better health care at lower cost.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.

Adolescents' leisure activities, parental monitoring and cigarette smoking--a cross-sectional study.

BACKGROUND: Adolescent participation in leisure activities is developmentally beneficial, but certain activities may increase health compromising behaviours, such as tobacco smoking. A limited range of leisure activities has been studied, with little research on out-of-school settings where parental supervision is a potential protective factor. Tobacco smoking is an important, potentially modifiable health determinant, so understanding associations between adolescent leisure activities, parental monitoring, demographic factors and daily smoking may inform preventive strategies. These associations are reported for a New Zealand adolescent sample. METHODS: Randomly selected schools (n = 145) participated in the 2006 Youth In-depth Survey, a national, biennial study of Year 10 students (predominantly 14-15 years). School classes were randomly selected and students completed a self-report questionnaire in class time. Adjustment for clustering at the school level was included in all analyses. Since parental monitoring and demographic variables potentially confound relations between adolescent leisure activities and smoking, variables were screened before multivariable modelling. Given prior indications of demographic differences, gender and ethnic specific regression models were built. RESULTS AND DISCUSSION: Overall, 8.5% of the 3,161 students were daily smokers, including more females (10.5%) than males (6.5%). In gender and ethnic specific multivariate analysis of associations with daily smoking (adjusted for age, school socioeconomic decile rating, leisure activities and ethnicity or gender, respectively), parental monitoring exhibited a consistently protective, dose response effect, although less strongly among Maori. Attending a place of worship and going to the movies were protective for non-Maori, as was watching sports, whereas playing team sport was protective for all, except males. Attending a skate park was a risk factor for females and Maori which demonstrated a strong dose response effect. CONCLUSIONS: There were significant differences in the risk of daily smoking across leisure activities by gender and ethnicity. This reinforces the need to be alert for, and respond to, gender and ethnic differences in the pattern of risk and protective factors. However, given the consistently protective, dose response effect of parental monitoring, our findings confirm that assisting oversight of adolescent leisure activities may be a key component in public health policy and prevention programmes.

US health care costs: the crushing burden.

This chapter provides an overview of health care costs in the United States, including trends, sources and uses of funds, employers' role, and factors driving costs. It also reviews what analysts believe are cost drivers especially compared to other countries that have significantly lower health care costs and, often, better health outcomes. Within the US, there are also important differences by geography, further demonstrating that higher US costs do not reflect higher quality and greater patient and physician satisfaction. In fact, the opposite is often the case.

Health care reform: perspectives from large employers.

Recently enacted health reform legislation will have mostly positive effects on large employers, as millions more Americans gain access to affordable insurance and, potentially, primary care. But the law will impose new administrative burdens and financing costs on employers, while raising concerns about provisions that could allow their lower-wage employees to obtain coverage through insurance exchanges. Given the need to restrain the rate of growth of health spending, the private sector, especially large employers, must collaborate with the public sector to drive delivery system reform. And every public program and exchange should appoint a chief value officer who reports quarterly on spending, cost drivers, and potential ways to contain costs.

Addressing obesity in the workplace: the role of employers.

CONTEXT: Employers have pursued many strategies over the years to control health care costs and improve care. Disappointed by efforts to manage costs through the use of insurance-related techniques (e.g., prior authorization, restricted provider networks), employers have also begun to try to manage health by addressing their employees' key lifestyle risks. Reducing obesity (along with tobacco use and inactivity) is a priority for employers seeking to lower the incidence and severity of chronic illness and the associated demand for health services. METHODS: This article describes the employer's perspective on the cost impact of obesity, discusses current practices in employer-sponsored wellness and weight management programs, provides examples from U.S. companies illustrating key points of employers' leverage and opportunities, and suggests policy directions to support the expansion of employers' initiatives, especially for smaller employers. FINDINGS: Researchers and policymakers often overlook the extensive efforts and considerable impact of employer-sponsored wellness and health improvement programs. Greater focus on opportunities in the workplace is merited, however, for the evidence base supporting the economic and health impacts of employer-sponsored health promotion and wellness is growing, although not as quickly as the experience base of large employers. CONCLUSIONS: Public and private employers can serve their own economic interests by addressing obesity. Health care organizations, particularly hospitals, as well as public employers can be important role models. Policy development is needed to accelerate change, especially for smaller employers (those with fewer than 500 employees), which represent the majority of U.S. employers and are far less likely to offer health promotion programs.

Tobacco education: have New Zealand primary schools done their homework?

OBJECTIVE: To describe the content, delivery and evaluation of tobacco-related (smoke-free) education to pre-teen students and to compare this education with current best practice. METHOD: Postal survey to staff of 136 New Zealand (NZ) schools with primary-aged children. RESULTS: More than 90% of schools offered some form of education about the harmful effects of tobacco use and many relied on external providers for this education. CONCLUSION: Although most schools offered some form of smoke-free education, there was a lack of rigorous program evaluation, particularly of programs provided by external agencies. IMPLICATIONS: Smoking remains a significant health problem in NZ and improving the quality of smoke-free education for pre-teen students, before most young people initiate smoking, would be a positive step towards better health.

Employment-based health benefits and public-sector coverage: opportunity for leadership.

In this commentary, Helen Darling, speaking from the large-employer perspective, responds to James Robinson's paper on the mature health insurance industry, which faces declining opportunities with employer-based health benefits and growing but less appealing public-sector opportunities for management and other services. The similar needs of public and private employers and payers provide an opportunity for leadership, accelerating innovation and using value-added services to improve safety, quality, and efficiency of health care for all.

Brief report: Disposable income, and spending on fast food, alcohol, cigarettes, and gambling by New Zealand secondary school students.

We describe self-reported sources of income and expenditure, and the association between part-time employment and spending on fast food, alcohol, cigarettes, and gambling for a sample of 3434 New Zealand (NZ) secondary school students (mean age 15.0 years). Disposable income was usually received from parents and guardians, but nearly 40% of students also reported receiving money from part-time employment. The proportion of students employed increased as socioeconomic rating increased, and was associated with increased purchasing of fast food and alcohol, and increased spending on cigarettes and gambling. Spending by youth has obvious public health implications, particularly when it is concentrated on products that have a negative health impact.

Is there a relation between school smoking policies and youth cigarette smoking knowledge and behaviors?

To comply with workplace legislation, New Zealand schools are required to have policies regarding tobacco smoking. Many schools also have policies to prevent tobacco use by students, including education programmes, cessation support and punishment for students found smoking. This paper investigated the associations between school policies and the prevalence of students' cigarette smoking. Furthermore, we investigated the association between school policy and students' tobacco purchasing behavior, knowledge of health effects from tobacco use and likelihood of influencing others not to smoke. Data were obtained from a self-report survey administered to 2,658 New Zealand secondary school students and staff from 63 schools selected using a multi-stage sampling procedure. Components of school policy were not significantly associated with smoking outcomes, health knowledge or health behavior, and weakly related to a punishment emphasis and students advising others to not smoke. Similarly, weak associations were found between not advising others to not smoke and policies with a punishment emphasis as well as smoke-free environments. The results suggest that having a school tobacco policy was unrelated to the prevalence of tobacco use among students, tobacco purchasing behavior and knowledge of the negative health effects of tobacco.

Healthcare cost crisis and quality gap: our national dilemma.

Actions needed to achieve affordable, high-quality health care: make the healthcare system transparent; standardize information and reporting on costs, quality, and patient safety; make sure consumers have a financial stake in care decisions.