Specialty drug use for autoimmune conditions varies by race and wage among employees with employer-sponsored health insurance.

BACKGROUND: The relationship between race and ethnicity, wage status, and specialty medication (SpRx) use among employees with autoimmune conditions (AICs) is poorly understood. Insight into sociodemographic variations in use of these medications can inform health equity improvement efforts. OBJECTIVE: To assess the association of race and ethnicity and wage status on SpRx use and adherence patterns among employees with AICs enrolled in employer-sponsored health insurance. METHODS: In this observational, retrospective cohort analysis, data were obtained from the IBM Watson MarketScan database for calendar year 2018. Employees were separated into race and ethnicity subgroups based on employer-provided data. Midyear employee wage data were used to allocate employees into the following annual income quartiles: $47,000 or less, $47,001-$71,000, $71,001-$106,000, and $106,001 or more. The lowest quartile was further divided into 2 groups ($35,000 or less and $35,001-$47,000) to better evaluate subgroup differences. Outcomes included monthly days SpRx-AIC supply, proportion of days covered (PDC), and medication discontinuation rates. Generalized linear regressions were used to assess differences while adjusting for patient and other characteristics. RESULTS: From a sample of more than 2,000,000 enrollees, race and ethnicity data were available for 617,117 (29.8%). Of those, 47,839 (7.8%) were identified as having an AIC of interest, with prevalence rates of AICs differing by race within wage categories. Among those with AICs, 5,358 (11.2%) had filled at least 1 SpRx-AIC prescription. Following adjustment, except for the highest wage category, prevalence of SpRx-AIC use was significantly less among Black and Hispanic subpopulations. Black patients had significantly lower SpRx-AIC use rates than White patients (≤$35,000: 4.9 vs 9.4%, >$35,000-$47,000: 5.5 vs 10.6%, >$47,000-$71,000: 8.5 vs 11.1%, and >$71,000-$106,000: 9.1 vs 12.7%; P <0.001 for all). For Hispanic patients, prevalence rates were significantly lower than White patients in 3 different wage categories (≤$35,000: 4.5 vs 9.4%, >$35,000-$47,000: 6.1 vs 10.6%, and >$71,000-$106,000: 8.6 vs 12.7%; P < 0.001). PDC and 90-day discontinuation rates did not differ among race and ethnicity groups within the respective wage bands. CONCLUSIONS: Race and ethnicity and wage-related disparities exist in SpRx use, but not PDC or discontinuation rates for treatment of AICs among non-White and low-income populations with employer-sponsored insurance, and may adversely impact clinical outcomes.

Addressing patients' unmet social needs: checklists are a means, trust is foundational.

Identifying and addressing unmet social needs without attention to other contributors to health inequities-such as medical mistrust-is unlikely to yield desired outcomes.

Why Don't Employees Participate in Well-being Programs? A Research-Informed Systems-Based Model.

OBJECTIVE: Employee nonparticipation in well-being programs is common, but not well understood. Development of a systems-based framework to characterize reasons for nonparticipation can inform efforts to enhance engagement. METHODS: Following literature review and building on previous research, a systems-based model was developed to contextualize participation barriers. RESULTS: Well-being program nonparticipation is more frequent among low-wage workers as well as minority subpopulations. Contributors include employer factors, such as inequitable benefits design, and employee factors, such as lack of perceived relevance, barriers to access, and lower prioritization of personal health needs. CONCLUSIONS: A systems-based approach to evaluating well-being program nonparticipation can help identify factors contributing to employee nonparticipation and lead to targeted policy and practice changes that encourage greater employee engagement.

Quantifying Value of Worksite Well-Being Programs With a Health Equity Lens: It's Time to Raise the Bar.

Calls to address workforce health inequities have been met with expanded well-being programming, without an assessment of programming relevance or evaluation of equity-related outcomes. The goal of this commentary is to summarize current practices and gaps in evaluation of well-being programs, provide evidence supporting the need for broader participation in well-being offerings, and make recommendations to incorporate health equity measures into planning and evaluation efforts conducted by both employers and vendors. Data sharing, expanded measurement, more rigorous evaluation methods, and alignment of goals are some of the recommendations to better address health inequities and differential participation among employees.

Increased dietary fiber is associated with weight loss among Full Plate Living program participants.

Introduction: Prior studies have demonstrated that an intake of foods rich in dietary fiber is associated with a favorable impact on health status and body weight. However, the association between fiber intake and weight loss has not been well-studied in employer settings. This research aimed to assess the relationship between dietary fiber and weight loss among individuals participating in the Full Plate Living (FPL) program. Methods: The 16-week plant-predominant fiber-rich eating program was delivered to 72 employers, primarily in the Southwest U.S., over 3 years (2017-2019). Participants received weekly video lessons, FPL materials, and additional online resources. A retrospective analysis of repeated measures was conducted using participant data obtained from 4,477 participants, of which 2,792 (62.5%) reduced body weight. Analysis of variance with post hoc analysis was used to assess the statistical significance of the changes between baseline and follow-up measures of dietary fiber intake in each of the food categories, specifically the relationship between changes in individual and combined (composite) daily servings of fruits, vegetables, whole grains, beans, and nuts on body weight measures among three groups at follow-up: those who lost, maintained, or gained weight. Multilevel modeling was used to test the hypothesis that increased intake of fiber was associated with greater weight loss. Results: The mean weight loss for the weight loss group was 3.28 kg. As compared to the two other groups, the intake of whole fiber-rich foods at follow-up was significantly higher among the weight loss group with fruits (2.45 servings), vegetables (2.99 servings), beans (1.03 servings), and total fiber composites (9.07 servings; P < 0.001). A significant increase in servings of grains was also noted (P < 0.05). Multilevel modeling demonstrated that a higher total fiber composite (Model 1), as well as higher intakes of either vegetables or fruits (Model 2), resulted in greater weight loss. Discussion: Our findings indicate that the FPL program can be a part of a lifestyle medicine approach to healthy eating and weight loss. Delivering the program in clinical, community, and workplace settings can increase its reach as an effective and low-cost offering.

Mental health diagnoses and services utilization vary by wage level.

OBJECTIVES: The relationship between employee wage status and mental health care utilization has not been characterized in large-scale analyses. This study assessed health care utilization and cost patterns for mental health diagnoses according to wage category among employees with health insurance. STUDY DESIGN: This was an observational, retrospective cohort study for the year 2017 among 2,386,844 adult full-time employees (254,851 with mental health disorders; subgroup of 125,247 with depression) enrolled in self-insured plans in the IBM Watson Health MarketScan research database. METHODS: Participants were stratified into annual wage categories: $34,000 or less; more than $34,000 to $45,000; more than $45,000 to $69,000; more than $69,000 to $103,000; and more than $103,000. Health care utilization and costs were analyzed via regression analyses. RESULTS: Prevalence of diagnosed mental health disorders was 10.7% (9.3% in the lowest-wage category); prevalence of depression was 5.2% (4.2% in the lowest-wage category). Severity of mental health, and specifically depression episodes, was greater in lower-wage categories. All-cause utilization of health care services was higher in patients with mental health diagnoses vs the total population. Among patients with mental health diagnoses, specifically depression, utilization was highest in the lowest- vs highest-wage category for hospital admissions, emergency department visits, and prescription drug supply (all P < .0001). All-cause health care costs were higher in the lowest- vs highest-wage category among patients with mental health diagnoses ($11,183 vs $10,519; P < .0001), specifically depression ($12,206 vs $11,272; P < .0001). CONCLUSIONS: Lower mental health condition prevalence and greater use of high-intensity health care resources highlight the need to more effectively identify and manage mental health conditions among lower-wage workers.

Health Benefits of a 16-Week Whole Food, High Fiber, Plant Predominant Diet among U.S. Employees.

PURPOSE: To assess improvements in eating behaviors and health measures among adults participating in a whole food plant predominant diet, Full Plate Living (FPL) program. DESIGN: Retrospective, post hoc analysis of self-reported 16-week pre-post participant data obtained over a 3 year program period (2017-19). SETTING: Wellness offering for employees in Southwest U.S. SUBJECTS: Of 6,820 enrollees, 4,477 completed the program, further segmented by generational cohorts. INTERVENTION: FPL program materials and weekly online video lessons. MEASURES: Baseline and follow-up measures included eating behaviors, self-perceived health status and energy, body weight, and confidence in healthy eating and weight loss. ANALYSIS: Paired t-tests were used to examine changes in eating behaviors and health measures. Mixed-effects models were used to examine whether changes among generational cohorts differed. RESULTS: Significant pre-post improvements were demonstrated for all measures, including servings of fruits (1.54 to 2.34), vegetables (2.05 to 2.87), beans (.63 to .99), and weight loss (3.5) (P < .001). Self-perceived health and energy values, and confidence in making healthy food choices and losing weight improved (P < .001). Improvements were observed across generational cohorts (P < .001). CONCLUSION: The FPL healthy eating approach has a beneficial impact on health measures across generational cohorts, and may be an effective addition to lifestyle medicine and corporate wellness offerings. Longer-term program evaluation is warranted.

Policy changes are needed to further reduce perioperative opioid use.

Opioid prescriptions in the perioperative setting are a known risk factor for long-term opioid use and misuse. Recent initiatives in the United States to address the issue have focused on judicious prescribing patterns and quality measurement to minimize opioid dispensing. However, policy gaps have limited the effectiveness of current interventions. Expanded policy considerations are warranted, including patient-focused opioid risk screening and preferences for nonopioid pain management, with broader plan coverage for multimodal opioid-sparing pain management (OSPM). Additionally, formalized clinician education regarding specific nonopioid pain management alternatives may increase utilization, as will incorporation into perioperative OSPM clinical pathways. It is also important for patients to have access to the option for multimodal OSPM in the perioperative setting without financial disincentives, which may arise in surgery-specific bundled payment models. Finally, expansion of research activities regarding clinical and cost-efficacy outcomes may help to advance use of these options, laying the groundwork for development of a broader set of quality measures reflecting utilization and outcomes of multimodal OSPM in the perioperative setting.

Employee Sources of Stress and Their Associations With Absenteeism: Differences by Wage Category.

OBJECTIVE: The aim of this study was to examine the association between sources of stress and self-reported illness- or injury-related absenteeism (SRIRA) across three wage categories among participants in an employee health and well-being program. METHODS: In multivariate analyses, linear regression models were analyzed separately by wage bands (low, <$46,100; moderate, $46,100 to $62,800; high, >$62,800). RESULTS: In the low-wage category, child care concerns are positively associated ( b = 0.5, P = ≤0.05), whereas illness or injury of a loved one is negatively associated ( b = -0.6, P = 0.05) with SRIRA. Personal illness/injury is positively associated with SRIRA across all wage bands (in ascending order of wage bands: b = 4.2, P < 0.001; b = 4.4, P < 0.001; b = 4.1, P < 0.001). CONCLUSION: Results provide evidence that employees in different wage categories experience different home-based stressors, which may impact SRIRA. Employers collecting SRIRA data may be better able to respond to the needs of employees in different wage categories.

Specialty drug and health care utilization vary by wage level in employer-sponsored health plans.

BACKGROUND: Expenditures on specialty medications for autoimmune conditions (SpRx-AIC) have increased considerably in recent years, raising affordability concerns for employers and other plan sponsors and resulting in greater patient cost-sharing. Among those commercially insured, prior studies have shown differential patterns of health care utilization in association with wage, though no data are available for SpRx-AIC. Notably, out-of-pocket costs associated with SpRx-AIC have been shown to impact medication adherence, particularly for low-income households. OBJECTIVE: To assess the association of wage status on SpRx-AIC and health care services use and cost among employees with employer-sponsored health insurance. METHODS: Employee health care claims and wage data were obtained from the IBM Watson MarketScan database for calendar year 2018. Midyear employee wage data were used as a basis for allocating employees into annual income quartiles: $47,000 or less, $47,001-$71,000, $71,001-$106,000, and $106,001 or more. The lowest quartile was further divided into 2 groups ($35,000 or less and $35,001-$47,000) to better evaluate subgroup differences at lower wage levels. Outcomes included monthly days supply of SpRx-AIC, medication discontinuation rates (medication cessation for ≥ 90 days), proportion of days covered (PDC), medical services utilization rates per 1,000, and allowed payment amounts. Generalized linear regressions were used to assess differences while adjusting for patient characteristics, including age, gender, plan type, region, median household income, deductible amount, comorbidity index, and psychiatric diagnostic scores. RESULTS: From a sample of more than 2 million enrollees, 148,761 (7.2%) were identified as having an autoimmune disorder of interest. Of those, 17,096 (11.5%) had filled at least one SpRx-AIC prescription. Following adjustment, SpRx-AIC use was significantly less among the lowest wage group compared with the highest wage group (10.1% vs 11.7%; P < 0.0001). Days supply was significantly lower in the lowest wage group (244.4 vs 258.0; P < 0.001), as was PDC (0.74 vs 0.76; P < 0.001). In the lowest wage group, medical services utilization was significantly higher for inpatient admissions (0.08 vs 0.05; P = 0.002) and emergency department visits (0.52 vs 0.16; P < 0.0001). There were no significant differences among wage groups in SpRx-AIC discontinuation, outpatient services use, or health care costs. CONCLUSIONS: Low-wage employees with autoimmune conditions are significantly less likely to use an SpRx-AIC and have a lower monthly supply and PDC when SpRx-AIC was used. They are more likely to be admitted to the hospital and have more emergency department visits. These findings raise concerns about employer benefit design inequities for SpRx-AIC access and the resulting potential adverse impact on health care costs and employee functional status. DISCLOSURES: National Pharmaceutical Council, Genentech, and TrialCard provided funding support for this study, with funding administered by the National Alliance of Healthcare Purchaser Coalitions. Genentech and TrialCard provided comments regarding the final manuscript draft; National Pharmaceutical Council employees were actively engaged in study design, analysis and interpretation of results, and manuscript preparation. Dr Sherman is a consultant to National Alliance of Healthcare Purchaser Coalitions. Mr Sils and Ms Westrich were employees of the National Pharmaceutical Council at time of study. Ms Kamen is an employee of IBM Watson Health.

Impact of a Thought Process Coaching Offering on Habitual Patterns of Thinking and Behavior: A Preliminary Report.

OBJECTIVE: Individual's thought processes shape reactions to life circumstances, impacting motivation, well-being, and work performance. We examined the ability of a novel assessment and short-term coaching tool (Px-12) to favorably change thought processes. METHODS: We used a convenience sample from 2013 to 2015 of 119 employees who completed the Px-12 before and after receiving personalized coaching to assess the effects of coaching on changes in thought process scores. RESULTS: Significant favorable changes were observed in all 10 thought process scores. coaching produced significantly greater favorable changes than the thought processes for which coaching was not provided. There was no significant effect of time between coaching and follow-up assessment on attenuation of the observed improvements. CONCLUSIONS: While preliminary, these findings indicate that improving intrinsic thought processes may be a useful addition to health promotion and well-being offerings.

For the Commercially Insured, Equitable Health Benefits Begin With Equitable Health Insurance Design.

Equitable health benefit design is central to addressing the health inequities of individuals with commercial health insurance in the United States. To do so, employers and other plan sponsors must take action to identify and address unmet health and well-being priorities among racialized groups and low-income workers. These historically underrepresented subpopulations will also benefit from more equitable approaches to healthcare benefits design that recognize and meaningfully address access and affordability concerns. Targeted appropriately, these actions have the potential to foster greater employee engagement and productivity, leading to enhanced business performance.

Unique Barriers to Workplace Health Promotion Programs by Wage Category: A Qualitative Assessment of Secondary Data.

PURPOSE: To understand barriers around accessing or using workplace health promotion (WHP) programs among workers in different wage categories. APPROACH: We conducted qualitative analysis of responses to three open-ended questions about WHP program participation, collected as part of an existing WHP program evaluation. Setting: A large mid-western university. PARTICIPANTS: Of the 20,000 employees emailed an online survey, 3,212 responded (16.1%). The sample was mostly female (75%), white (79%), and comprised of staff members (84%). The average age was 44 years and 67% had annual incomes <$75,001. METHOD: We used NVivo-12 Plus and two coders to apply Grounded Theory on the open-ended questions and identify emergent themes. RESULTS: Although most respondents were happy with the program, differences across wage categories emerged around time, financial incentives, commute, workload, and organizational policies/support. Employees at all wage levels were enthusiastic about creating a culture of health but needed different cultural supports to do so. For instance, higher-wage workers needed to overcome self-made time constraints, while lower-wage workers needed supervisor support to overcome coverage constraints that prevented participation. CONCLUSION: The unique participation challenges experienced by employees in different wage categories provide justification for WHP programs that can better accommodate the participation barriers of all employees. While some programs may simply require more flexible offerings, supervisors may need to be trained to support and foster healthy environments.

Supporting Employee Health at Work: How Perceptions Differ Across Wage Category.

PURPOSE: This study examines the association between sources of stress and perceptions of organizational and supervisor support for health and well-being. DESIGN: Retrospective, cross-sectional analysis. SETTING: Large university in the mid-western United States. SAMPLE: This study focused on university employees with complete data for all variables (organizational support/N = 19,536; supervisor support/N = 20,287). MEASURES: 2019 socioeconomic and demographic characteristics, count of chronic conditions, sources of stress and perceptions of organizational and supervisor support. ANALYSIS: For the multivariate analyzes, linear regression models were analyzed separately by wage bands (low ≤$46,100; middle >$46,100-$62,800; high >$62,800). RESULTS: For all employees, workplace stressors, including problematic relationships at work and heavy job responsibilities, were negatively associated with perceptions of supervisor and organizational support. In comparison, the most salient home-based stressors were negatively associated with perceptions of supervisor support for the lowest-wage band (the death of a loved one, b = -0.13) and middle-wage band (personal illness or injury, b = -0.09), while the one for the highest-wage band (illness or injury of a loved one, b = 0.07) was positively associated with perceptions of supervisor support. CONCLUSION: Stressful job responsibilities and work relationships are associated with lower perceptions of supervisor and organizational support for health and well-being across all wage bands. Favorable perceived support for personal stressors only among high wage earning employees may suggest a need for improved equity of perceived support for these stressors among lower wage workers.

Agritourism and Kidding Season: A Large Outbreak of Human Shiga Toxin-Producing Escherichia coli O157 (STEC O157) Infections Linked to a Goat Dairy Farm-Connecticut, 2016.

The objective of this study was to determine sources of Shiga toxin-producing Escherichia coli O157 (STEC O157) infection among visitors to Farm X and develop public health recommendations. A case-control study was conducted. Case-patients were defined as the first ill child (aged <18 years) in the household with laboratory-confirmed STEC O157, or physician-diagnosed hemolytic uremic syndrome with laboratory confirmation by serology, who visited Farm X in the 10 days prior to illness. Controls were selected from Farm X visitors aged <18 years, without symptoms during the same time period as case-patients. Environment and animal fecal samples collected from Farm X were cultured; isolates from Farm X were compared with patient isolates using whole genome sequencing (WGS). Case-patients were more likely than controls to have sat on hay bales at the doe barn (adjusted odds ratio: 4.55; 95% confidence interval: 1.41-16.13). No handwashing stations were available; limited hand sanitizer was provided. Overall, 37% (29 of 78) of animal and environmental samples collected were positive for STEC; of these, 62% (18 of 29) yielded STEC O157 highly related by WGS to patient isolates. STEC O157 environmental contamination and fecal shedding by goats at Farm X was extensive. Farms should provide handwashing stations with soap, running water, and disposable towels. Access to animal areas, including animal pens and enclosures, should be limited for young children who are at risk for severe outcomes from STEC O157 infection. National recommendations should be adopted to reduce disease transmission.

An Ecological Study of a Universal Employee Depression Awareness and Stigma Reduction Intervention: "Right Direction".

Objective: Right Direction (RD) was a component of a universal employee wellness program implemented in 2014 at Kent State University (KSU) to increase employees' awareness of depression, reduce mental health stigma, and encourage help-seeking behaviors to promote mental health. We explored changes in mental health care utilization before and after implementation of RD. Methods: KSU Human Resources census and service use data were used to identify the study cohort and examine the study objectives. A pre-post design was used to explore changes in mental health utilization among KSU employees before and after RD. Three post-intervention periods were examined. A generalized linear mixed model approach was used for logistic regression analysis between each outcome of interest and intervention period, adjusted by age and sex. Logit differences were calculated for post-intervention periods compared to the pre-intervention period. Results: Compared to the pre-intervention period, the predicted proportion of employees seeking treatment for depression and anxiety increased in the first post-intervention period (OR = 2.14, 95% Confidence Interval [CI] = 1.37-3.34), then declined. Outpatient psychiatric treatment utilization increased significantly in the first two post-intervention periods (OR =1.89, 95% CI = 1.23-2.89; OR = 1.75, 95% CI = 1.11-2.76). No difference was noted in inpatient psychiatric treatment utilization across post-intervention periods. Unlike prescription for anxiolytic prescriptions, receipt of antidepressant prescriptions increased in the second (OR = 2.25, 95% CI = 1.56-3.27) and third (OR = 2.16, 95% CI = 1.46-3.20) post-intervention periods. Conclusions: Effects of RD may be realized over the long-term with follow-up enhancements such as workshops/informational sessions on mindfulness, stress management, resiliency training, and self-acceptance.

Impact of Medication Adherence on Healthcare Resource Utilization, Work Loss, and Associated Costs in a Privately Insured Employed Population Treated With Adalimumab in the United States.

OBJECTIVE: The aim of this study was to evaluate the impact of adherence to adalimumab on all-cause work loss, healthcare resource utilization (HRU), and direct medical and indirect costs over 2 years using real-world data. METHODS: This was a retrospective cohort study using a large, United States administrative claims database. Adult patients treated with adalimumab were grouped into adherent and non-adherent cohorts and followed for up to 2 years. Outcomes were compared between cohorts. RESULTS: Over 2 years, adherent patients had $10,214 lower per patient medical and indirect costs compared to non-adherent patients, resulting from lower HRU, fewer days of absenteeism, and lower rates of work loss events. CONCLUSION: Patient and societal benefits of adherence to adalimumab are significant over 2 years. These findings highlight the importance of policies aimed at improving adherence to self-administrated medications.

Social Determinants of Health Challenges Are Prevalent Among Commercially Insured Populations.

OBJECTIVES: To evaluate the prevalence of social determinants of health (SDoH) factors in a large commercially-insured population and to characterize the prevalence of common conditions (eg, diabetes, behavioral health issues) and addressable health services utilization concerns (eg, lack of preventive care) for which employers offer no- and low-cost benefit programs. METHODS: We identified groups with SDoH challenges within a commercially-insured population of 5.1 M through administrative data and self-report. Using medical claims and health assessment data, we identified populations with SDoH needs who had common conditions for which employers often provide no- or low-cost benefit programs (ie, diabetes, behavioral health conditions, high-risk pregnancy, overweight/obesity). Additionally, we sought populations with common addressable health services utilization concerns such as avoidable emergency room visits, lack of preventive care services, or non-adherence to medications. We used univariate analyses to describe the prevalence of SDoH risks in the population of interest. RESULTS: Twenty-seven percent of this commercially-insured population live in a zip code where the median income is at or below 200% of the Federal Poverty Line. Respondents identified cost (55%) and family, school, or work responsibilities (26%) as key barriers to care. ER overutilization rates are higher in lower income zip codes than wealthier zip codes (34% vs 9%) as is the prevalence of diabetes, overweight/obesity, and behavioral issues, and decreased use of preventive services. Fifteen percent of the study population live in a low-access food area. There is considerable variability in access to employer-sponsored resources to address these needs (70% of employers provide behavioral health programs; 63% provide telehealth programs, but only 1% offer healthy food programs and less than 0.5% offer either child care or transportation support programs). CONCLUSIONS: Commercially insured populations could benefit from employer-sponsored programs or benefits that address key SDoH barriers such as financial support, healthy food programs, child-care, and transportation.

Management of individuals with multiple chronic conditions: a continuing challenge.

Individuals with multiple chronic conditions (MCCs) represent a growing proportion of the adult population in the United States, particularly among lower-income individuals and people of color. Despite ongoing efforts to characterize this population and develop approaches for effective management, individuals with MCCs continue to contribute substantially to health care expenditures. Based on a review of recent literature, several identified barriers limit the effectiveness of care for patients with MCCs. Health care delivery system structural limitations, evidence-based care concerns, patient-clinician relationship constraints, and barriers to inclusion of patient-centered priorities may singly or in combination negatively affect outcomes for individuals with MCCs. The COVID-19 pandemic has shed further light on inequities contributing to suboptimal MCC patient management. Awareness of the prevalence and demographic attributes of patients with MCCs and the identified barriers to care may help improve patient engagement and treatment outcomes for this high-cost population. This paper provides recommendations for enhancing MCC patient care outcomes in the current and post-COVID-19 health care delivery settings.