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Lost in Translation: Healthcare Utilization by Low-Income Workers Receiving Employer-Sponsored Health Insurance
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Lost in Translation: Healthcare Utilization by Low-Income Workers Receiving Employer-Sponsored Health Insurance

Bruce W. Sherman, MD; Wendy D. Lynch, PhD; and Carol Addy, MD, MMSc
An opportunity exists to better understand healthcare utilization patterns by low-income workers, which may contribute significantly to employer healthcare cost trend and lost workforce productivity.
Based on available information, healthcare utilization patterns of low-income workers appear significantly different than those of their higher-paid counterparts. Employers, especially those in industries with higher proportions of low-income employees, may want to better understand the impact of low-income workers on organizational healthcare and productivity costs, and incorporate relevant findings in their benefits strategy.

Although employers may have other available markers for SES, their ready access to wage data makes inclusion of this information in claims data analysis a reasonable first step in facilitating a greater understanding of previously unappreciated disparities in health benefits utilization and costs. Wage data may be a poor indication of household income for dual-career families or for individuals with multiple jobs, but inclusion of these data into employer claims can help to inform benefits strategy.

As such, earnings data should be included in employer benefits enrollee files for integration with medical and pharmacy claims data, either by the health plan or third-party data warehouse. Analysis should include population health profiles of the respective subpopulations, including condition prevalence, as well as healthcare utilization and costs, and compliance with evidence-based treatment as part of the mix. The resulting data can be used to incorporate refinements in employer benefits strategy.

Strategy development should take into consideration the value of improving health literacy and healthcare consumerism engagement relative to that provided by incremental changes in wage-based benefit contributions. Wage-based premiums or deductibles may be a reasonable tactical consideration, but, as noted, critical evaluation of the impact of this approach on low-income employee behaviors is lacking. Furthermore, this approach may be cost-prohibitive for employers—particularly those in retail or service industries—having a substantial population of low-income employees. To this end, to inform strategy development, employers should consider evaluating employee choice of benefit design options, healthcare utilization patterns, and overall healthcare costs for low-income earners in comparison to their higher-earning counterparts.

Lastly, employers may want to capitalize on existing employee benefits survey data to better understand the health benefits preferences of low wage earners in comparison to their more highly paid counterparts.


Until more data are available, it is admittedly difficult to determine an optimal approach; further research is clearly warranted. Recognizing and addressing, in the broadest sense, the health needs of this sub-population may ultimately generate greater employee engagement and productivity—a benefit to employers, employees, and the customers they serve.

Author Affiliations: Department of Medicine, Case Western Reserve University School of Medicine (BWS), Cleveland, OH; Buck Consultants, A Xerox Company (BWS), Cleveland, OH; Employers Health Coalition, Inc (BWS), Canton, OH; Lynch Consulting, Ltd (WDL), Steamboat Springs, CO; HMR Weight Management Services Corp (CA), Boston, MA.

Source of Funding: None.

Author Disclosures: Dr Sherman is consultant for Takeda, Sanofi, and AstraZeneca; and is the medical director, population health management for Buck Consultants RightOpt private health insurance exchange. He has previously received lecture fees for speaking at the invitation of a commercial sponsor (Merck and Abbvie), though non-product–related, and has attended conferences by the Integrated Benefits Institute, HERO, NBCH, and NBGH. Dr Lynch is a board member of MGC Diagnostics, and a consultant for meQuilibrium and UPMC; she has received honoraria from UPMC and lecture fees paid by meQuilibrium for IBI and NBGH; she also received payment for involvement in the writing and literature review for this manuscript. Dr Addy reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (BWS, WDL, CA); analysis and interpretation of data (BWS); drafting of the manuscript (BWS, WDL, CA); critical revision of the manuscript for important intellectual content (BWS, WDL, CA); administrative, technical, or logistic support (BWS).

Address correspondence to: Bruce Sherman, MD, 3175 Belvoir Blvd, Shaker Heights, OH 44122. E-mail:

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