Although Pfizer is in the healthcare industry, itscorporate leadership struggles with the samechallenges that face other large and small businessesin keeping employees and family membershealthy and productive. While managing tremendousinvestments in health, Pfizer sought to inform, motivate,and empower its employees to take the steps towardhealth improvement, sickness prevention, and diseasereduction that have been proven to positively affect thewell-being of employees and their families.

has succeeded in influencing employee understandingand action. In year 2 of this new employeedirectedhealth management initiative that began in2005, 

has exceeded initial benchmarksfor participation. Year 1 (June 2005 through June 2006)saw an 83% health questionnaire completion rate amongcolleagues, with 28% and 17% of those identified as beingeligible for 

programs,respectively, enrolling in these coaching programs.Measurable changes in employee health areevident, and indications point to improvements inhealthcare utilization, claims, cost, productivity, absenteeism,and presenteeism (the degree to which individualsare fully present and functioning while they are atwork).

was launched with defined goals forthe first 3 years. Year 1 included employee engagementthrough healthcare awareness and understanding. Year2 comprised behavior change, including exercise frequency,smoking reduction, medication adherence, andpreventive care. Year 3 involves utilization changes,such as patterns of hospital and emergency departmentuse and physician visits.

was its US employee base of 41 223 members and theirdependents, for a total of 105 479 covered lives.

Theemployee demographics are 54.6% men and 45.6%women, with a mean age of 40 years and just over 9years of Pfizer service. Factoring in dependents, themean age of the covered lives is 28.6 years, and themean family size is 2.56 members.

population includes employeesworking at all Pfizer sites, its sales force, as well asdependents. Major sites include the company's headquartersin New York City and Brooklyn, New York, aswell as sites with more than 500 employees inConnecticut, Michigan, Missouri, New Jersey, andCalifornia. When 

was launched in June2005, Pfizer offered 5 medical plan options, with mostcovered lives enrolling in self-insured plans.

program is multifaceted. Componentsinclude a health questionnaire, a Web portalwith access to health information, health coaching, andassistance with disease management. The program alsoprovides access to online health advisors, workplace-basedservices, and an electronic data warehouse torecord and benchmark progress.

participants. The level of involvement that an employeepursues is his or her choice. The first step is completing the120-item health questionnaire–a risk assessment tool.The questions address family disease history, exercise frequencyand fitness, results of recent disease screenings,habits related to eating and drinking, and biometric data,including body mass index, cholesterol and glucose levels,and questions that assess emotional health status.

The online questionnaire can be completed in lessthan 15 minutes by registering at a customized site poweredby 

The site offersa variety of resources on healthy lifestyles, behaviormodification, disease management, stress reduction,child-rearing, and other topics. A personalized datatrackingfeature lets participants benchmark their status. Participants can record the results of periodic biometricscreening to create a powerful, ongoing record oftheir progress over time.

To help colleagues complete the questionnaire, Pfizerheld health screenings at each location at the time the

program was launched. At the screenings,employees obtained their blood pressure, bodymass index, and cholesterol and glucose levels, whichthey could then use when responding to the questionnaire.The combination of responses to the health questionnaireand the biometric data from screenings yieldsa powerful snapshot of current health status.

Automatic data analysis scans the responses to thehealth risk assessment, including biometric data, toidentify participants for risk modification and diseasemanagement programs. These programs are offered by

Gordian Health Solutions provideslifestyle management programs primarily focused onreducing health risk factors, such as tobacco use, obesity,elevated stress, elevated blood pressure, and cholesterollevels. Matria Healthcare provides care counselingand disease management for persons diagnosed withtype 2 diabetes, asthma, coronary artery disease, andother chronic conditions. Employees participating in

who are identified for the coaching programsreceive a letter from Gordian Health Solutions(

),depending on which coaching partner is mostappropriate, informing them about their eligibility forthe program, providing self-enrollment information ifthey choose to enroll immediately, and letting themknow that they will also be receiving a telephone callregarding enrollment (

Coaching is provided telephonically by GordianHealth Solutions and Matria Healthcare. Throughout the

program, no data are identified to Pfizerby individual employee or dependent name. Rather,

executives receive only aggregate dataand population-based reports in accordance withhealthcare privacy laws. The entire 

programis adherent with the Health Insurance Portabilityand Accountability Act of 1996,

ensuring that personalhealth information is protected.

Participants also have access to a 24/7 telephone linestaffed by nurses. Professional nurses provide answersto healthcare questions and offer expert guidance onnavigating the healthcare system.

Awareness helps change behavior, and acquiringhealth information increases a person's pursuit ofhealthcare services. When a colleague in the 

program is identified as a candidate for coaching,the individual is invited to telephone a coach for moreinformation about risk factors and about coachingdetails, such as schedules, goals, and assessments. Theparticipant and coach jointly develop and execute acoaching and behavior change plan that might includeweight loss goals, an exercise regimen, suggested menus,and adherence with physician recommendations forglucose testing and other evaluations depending onidentified risks.

For Pfizer, the coaching programs are beginning tocreate a healthier, more productive workforce that isusing the right health resources at the right time. Pfizerbelieves that engagement in these programs will ultimatelylower the company's healthcare costs and resultin a positive return on investment. More than 13 000colleagues and dependents have enrolled in the coachingprograms, which represents about 25% of those identifiedas being eligible for the programs.

A strong indicator of future success is a program'sability to tailor its offerings. Questionnaire and screeningdata are used to fine-tune onsite 

programming.For example, data revealed that overallsmoking is less prevalent among Pfizer employees thanamong the population at large. Site-specific programsdeemphasized smoking cessation initiatives in favor ofother more relevant issues, such as fitness, nutrition,and weight management. At a manufacturing site implementingthe 

program, a high percentageof participants indicated poor diets and family historiesof heart disease. These factors were studied, and programofferings were adjusted accordingly.

Patient-centeredness is an important component ininitiatives to drive employee engagement in and responsibilityfor their healthcare, and sustained engagementis a function of culture change over time. During year 1,the primary 

goal was to encouragehealthcare engagement and understanding. This wasachieved in part by offering $100 gift cards to employeesand dependents who completed the health questionnaireand risk screening. The initial incentive alsoincluded a 20% discount on the employee-pay portion oftheir health insurance coverage. An expected target goalof 50% participation was exceeded by almost 30%.For the coaching programs, the initial target was a 20%enrollment rate for colleagues identified for coaching bythe end of year 1 and a 40% enrollment rate by the endof year 2. The number of participants who signed on forcoaching exceeded the year 1 expectations.

During year 2, more engagement was required. Toachieve the maximum incentive (a $100 gift card and a20% health insurance discount), participants had toretake the health questionnaire, begin to compile theirelectronic personal health record, take an annual physical,enroll in the coaching program, participate in atleast 2 coaching sessions, and join a walking programoffered by 

As of November 20, 2006, 14 000 employeeshave registered in the walking program.

programhave been primarily devoted to increasing engagementrates and to promoting healthcare awareness, multipleindividual and family successes are evident. The following3 case studies are indicative of the programresults.

A research scientist had never given much thoughtto her health risk factors until she participated in a

screening. Despite a healthy lifestyle,genetics proved to be a contributor to her dangerouslyhigh blood pressure. Informed actions helped lower herblood pressure to acceptable levels. Now taking medication,exercising daily, and several pounds lighter, sheis convinced of the value of healthcare knowledge andvigilance.

challenges head-on,dropping 40 lb after identifying her risk factors anda family history of type 2 diabetes. She began taking thesmall steps that had eluded her in the past. In additionto healthy eating, she added moderate exercise to herlifestyle and found ways to remain active throughout herbusy day. Behavioral change has helped her find moreenergy for her son and for graduate school, in addition toher duties at work.

A senior manager of logistics is a 200-lb athlete over6 ft tall who was surprised to learn that his cholesterollevel was climbing silently but steadily. He likens hisGordian Health Solutions coach to a teacher or counselor.Almost a year after his health screening, hischolesterol level is below 200 mg/dL (<5.18 mmol/L). Hewatches his sugar intake, stays away from cheese, andcontinues to exercise regularly.

Company officials drew on the decade-long experienceof Pfizer Health Solutions (PHS), Pfizer's care managementprojects subsidiary, in creating 

.PHS is dedicated to improving health and healthcaredelivery through innovative programs that demonstratethe value of personalized, coordinated, and accessiblehealthcare services. Working in partnership with government,payers, and providers, PHS develops andimplements health improvement projects that focus onhelping individuals and populations living with, or whoare at risk for developing, chronic diseases. PHS programshave demonstrated that investments in healthcan result in better outcomes at lower costs.

, acollaboration between PHS and Florida's Agency forHealth Care Administration that emphasizes healthunderstanding and subsequent behavior change.Beginning in 2001, the program provides innovativepatient education and nursing care to high-riskMedicaid patients with asthma, high blood pressure,type 2 diabetes, and heart failure. The delivery vehicleis a statewide network of community hospitals, civicorganizations, and patient advocacy groups. During thefirst 3 years, the program helped the state save $97.4million through investments and medical cost reductions(as validated by Medical Scientists, Inc, Boston,Mass, an independent third-party evaluator and leaderin the use of predictive modeling software). In additionto improvements in clinical indicators, the program hasaffected utilization rates. Patients across all populationsare spending more time in their physicians' offices andless time in emergency departments and hospitals.

Articles

EMPLOYER CASE STUDIES

Engaging Employees in Health and Wellness: the Healthy Pfizer Program

To evaluate the effect of an educational interventionprogram on clinical outcomes and on compliance with medicaltherapy in patients with type 2 diabetes mellitus (DM), hypertension,or both.

Three hundred fifty-two patients were screened, and347 were randomized to the intervention group (education throughthe 

[KYH] program [n = 174]) or to the controlgroup (usual care [n = 173]). Evaluation of the effectiveness of theKYH program was based on the cohort of patients who were not atgoal at baseline (124 in the intervention group and 115 in the controlgroup). The primary research interests were to assess patientacceptance of the KYH materials and to compare the clinical outcomesof the intervention group with those of the control group.

After 6 months, significantly more patients in the interventiongroup than in the control group were at goal (44.2% vs29.2%, 

= .046). Among patients with hypertension, reductions inthe mean diastolic blood pressure were significantly greater in theintervention group compared with the control group at month 6(-6.7 vs -3.6 mm Hg, 

= .04). The groups did not differ significantlyon other primary end points (percentage of patients with DMwho were at goal, change from baseline glycosylated hemoglobinlevel, and change in Morisky score).

Participation in the KYH educational program duringa 6-month period improved clinical outcomes in patients withtype 2 DM or hypertension. The KYH materials were well receivedand were considered informative and easily comprehensible bypatients who completed the program.

Cardiovascular disease is the number one killer inthe United States.

According to the AmericanHeart Association,

cardiovascular disease is theunderlying cause of death in more than 910 000 adults,representing 37% of all deaths. Type 2 diabetes mellitus(DM) and hypertension are well-established risk factorsfor cardiovascular disease. An estimated 20 million persons(9.6% of adults) have DM, and 65 million persons(32.3%) have hypertension.

Uncontrolled DM underminesemployee productivity and increases the use ofhealthcare resources (eg, hospitalization and physicianvisits) for the management of associated amputations,blindness, kidney disease, and nerve damage.

The effectis compounded by restrictions on activities of daily livingand by a high incidence of depression.

Compared withtheir peers without DM, adults with DM are more likelyto earn less, be unemployed, have more absences fromwork, and be limited in the type and amount of workthey can perform.

By increasing the incidences of heartdisease, DM, stroke, kidney disease, depression, and lungdisease, uncontrolled hypertension also raises healthcareconsumption and costs, limits work, and contributesto coronary heart disease, the leading cause ofpremature permanent disability in the United States.

Despite medications to control both disorders, nonadherenceto protracted therapy has long been recognizedas a major barrier to the optimum care of chronicdiseases like DM and hypertension.

Adherence ratesof 50% to 75% of prescribed dosages may be typical.

Attempts to improve adherence have taken the form ofpatient education, written information, behavior modification,cash incentives, and directly observed therapy.

Because education remains a cornerstone ofoptimal therapy, nonadherence may reflect inadequateor inappropriate education. This failure cannot beattributed solely to the patients and may serve toremind healthcare professionals that patients mustunderstand why, how, and when to follow therapeuticrecommendations. This study was performed to determinethe effect of an education program (

[KYH]) on clinical outcomes and on compliancewith medical therapy among patients with DM, hypertension,or both in a large employer group.

the Joint National Committee on Prevention, Detection

Evaluation, and Treatment of High Blood Pressure

This 6-month randomized unblinded trial enrolled300 patients whose type 2 DM or hypertension wasuncontrolled according to criteria of the 

and the AmericanDiabetes Association (glycosylated hemoglobin [A1C]level, <7.0%).

Screening sessions took place atLockheed Martin's Georgia and Mississippi sites to identifythe targeted patient population. All patients had adiagnosis, were in treatment with primary care physicians,and were being followed up through LockheedMartin's tertiary prevention program, which assists withtreatment compliance. Before randomization, thosepatients who were not at goal had baseline evaluationsperformed by the study team regarding blood pressure,A1C level, or both to determine if they still met theinclusion criteria. A randomization sequence was computergenerated for each patient; once study eligibilitywas determined, patients received the next availablerandomization number. Approximately 150 patientseach were to be randomized to the intervention groupand to the control group. Eligible patients received aneducational intervention (intervention group) or usualcare (control group) during 6 months of follow-up. Nomedications were provided, and all participants in bothgroups were encouraged to see their physicians onenrollment. At the 3-month and 6-month follow-upvisits, blood pressure readings and A1C levels wererecorded by the study team. Before patient enrollment,the protocol was reviewed and approved by the WesternInstitutional Review Board, Olympia, Washington.Written informed consent was obtained before thescreening procedures were completed.

Eligible patients were at least 18 years old with anestablished diagnosis of type 2 DM, hypertension, orboth. Diabetes mellitus was defined as a random plasmaglucose level of 200 mg/dL or higher (<11.1 mmol/L)with clinical symptoms, a fasting plasma glucose level of126 mg/dL or higher (<7.0 mmol/L), or an A1C levelgreater than 7.0%. Hypertension was defined as a systolicblood pressure of 140 mm Hg or higher or a diastolicblood pressure (DBP) of 90 mm Hg or higher.Patients were required to speak English, not be pregnantor lactating, and be cognitively aware without a diagnosisof dementia or organic brain syndrome. Failure tomeet these criteria was reason for exclusion, as wererefusal to participate and absence of baseline values.The effectiveness of the intervention was based on evaluationsat baseline, at month 3, and at month 6.

The present study was modeled after the ongoingFlorida Health Literacy Study, which is using the KYHprogram in a community health center. The KYH programintegrates established culturally sensitive healtheducation practices for self-management of type 2 DMand hypertension with communication strategies andtechniques designed specifically for populations withlow functional health literacy. The KYH program in thepresent study provided 1 hour of education for patientswith hypertension and 3 hours of education for patientswith DM and was conducted by trained facilitators onLockheed Martin property. Participants were encouraged,but not required, to enroll in the on-site fitnesscenter, and any and all physical activity was promoted.Individual programs were not monitored. The programalso provided patients with diet and exercise regimensand with tools to track visits to their physicians.

The statistical analysis plan was finalized beforedatabase quality control and evaluability assessmentswere made and statistical analyses were conducted.The primary analysis cohort included all patients whowere not at goal for hypertension, DM, or both atbaseline and who had at least 1 postbaseline visit.Analyses were conducted at the month 3, month 6,and end point visits (end point was taken as the lastpostbaseline assessment for each patient). Secondaryanalyses were conducted on the subsets who had DMor hypertension. Participants with dual diagnoses wereincluded in both subsets. Categorical measures, suchas the number of patients at goal, were assessed usingthe general association variant of the Cochran-Mantel-Haenszel c

test. At each time point, analyses ofcovariance were applied to continuous measures, suchas the changes from baseline in blood pressure. To provideadditional statistical power, changes from baselinein A1C level and in systolic blood pressure and DBP atthe 3-month and 6-month evaluations were analyzedusing linear contrasts with repeated-measures random-effects models (PROC MIXED, SAS softwareversion 8; SAS Institute, Cary, NC). Descriptive statisticswere calculated for all primary and secondarymeasures at baseline, at 3 months, and at 6 months.All statistical tests were 2-sided, and significance wasset at 

= .05. Enrollment of approximately 150 patientswith uncontrolled disease per group was designed toprovide 80% power, with a type I error rate of .05, todetect a 16% between-group difference in the percentageof patients at goal. The calculation was based on anassumed 30% response rate in the control group (46%in the intervention group).

At baseline, 352 patients were screened for enrollment,and 347 were eligible for randomization. Of thosepatients not at goal, 124 were assigned tothe intervention group and 115 to thecontrol group (the efficacy-evaluablecohorts). Three patients were not evaluatedat any visits and were excluded fromthe analysis. The study groups werewell matched for demographics, workenvironment, general health, and responsesto baseline questions (

).Most patients in both groups werewhite or African American men. Theirage ranged from 22 to 80 years, andmost participants had at least somecollege or technical school education.Almost all patients worked full-time onthe first shift, with about 50% in manufacturing.Annual salaries averagedbetween $50 000 and $75 000. Approximately90% of both groups describedthemselves as nonsmokers.Participants generally reported thatthey were recreational exercisers whorated their health as good and had nohealth-related limitations in carryingout moderate activities or in climbingstairs. The Short Test of FunctionalHealth Literacy in Adults scores indicateda more than adequate literacylevel in 98.6% of patients.

At baseline, 24 patients (6.9%) had DMonly, 229 (66.0%) had hypertension only,and 91 (26.2%) had a dual diagnosis(

). Overall, 23.6% of the interventiongroup and 17.6% of the control groupleft the study prematurely, with 76.4% and82.4%, respectively, completing the study.Between 92.9% and 100.0% of patientswith DM tested their blood glucose levelregularly (5-6 days/wk) (

).Between 56.4% and 60.9% of patientswith hypertension tested their blood pressureregularly (5-6 times/mo). Morepatients with DM (85.7%-95.2%) took medication thanpatients with hypertension (67.4%-69.1%). Substantiallymore patients with DM (57.1%-81.0%) reported havingreceived education about their condition comparedwith patients with hypertension (13.0%-13.8%).

After randomization to the intervention group, thepercentage of patients in the efficacy-evaluable cohortwho reached goal was 30.0% at month 3, with afurther increase to 44.2% at month 6 (

). The proportion of the control group thatreached goal after randomization was greater atmonth 3 (33.3%), dropping to 29.2% at month 6. Thedifference in goal achievement between the groups wasstatistically significant in favor of the intervention atmonth 6 (

There were no statistically significant between-groupdifferences for changes in A1C level from baseline tomonth 3 or month 6 (Table 3). The repeated-measuresanalysis also showed no significant differences in thisvariable, primarily because of the small number of patientswith DM enrolled.

The mean systolic blood pressure and DBP decreasedfrom baseline to the postbaselineevaluations in the interventiongroup and in the control group(Table 3). These decreases wereconsistently larger in the interventiongroup at month 3 and atmonth 6. The difference in DBPreduction at month 6 was significantlygreater in the interventiongroup (

= .04) based on a repeated-measures analysis.

In both groups, mean Moriskyscores indicated a shift towardhigher-level compliance behaviorat month 3 and month 6, althoughno statistically significantdifferences between the groupswere seen (Table 3).

The mean scores on theReadiness to Change Questionnaireincreased relative to baselinein both groups at month 3and month 6 (Table 3). The differencebetween the groups wasnot statistically significant.

In the intervention group,83.3% of patients with DM and86.6% of patients with hypertensionwere very satisfied with theKYH intervention program. Mostpatients, including those withthe highest levels of education,rated the program as 4 or 5 on a5-point scale. Most patients alsoexpressed appreciation thattheir company provided the program and indicated thatthey would attend similar learning programs coveringother diseases.

The groups did not differ significantly in thechange from baseline body mass index. By month 3according to a questionnaire on patient characteristics, 73.3% of the interventiongroup had seen theirphysicians since their lastvisit compared with 63.3%of the control group. Thisbehavior allowed moreintervention patients thancontrol patients to changetheir regular medication(47.8% vs 31.1%, 

Systematic interventionwith a program that integratesestablished culturallysensitive health educationpractices for self-managementcan help improve clinicaloutcomes in patients withtype 2 DM and hypertension. In this study, statisticallysignificant differences in the primary end points wereobserved after implementation of the KYH program.Significantly more patients in the intervention groupwere at goal after 6 months compared with the patientsin the control group (44.2% vs 29.2%, 

= .046).Although the mean blood pressure decreased in bothgroups, the intervention group demonstrated a significantlygreater mean reduction in DBP compared with thecontrol group at month 6 (-6.7 vs -3.6 mm Hg, 

= .04).No statistically significant between-group differences wereobserved on other primary end points (percentage ofpatients with DM who were at goal, change from baselineA1C level, and change in Morisky score).

The KYH program was well received by patientsassigned to the intervention group: 76.4% attended theeducational session and more than 80% reported beingsatisfied with the program, indicating acceptance of theprogram and its benefits. This comprehensive programwas designed to help patients with DM and hypertensiontake better care of themselves by educating them abouttheir medical condition, the importance of a healthfuldiet and exercise, the need to check blood glucose leveland blood pressure regularly and frequently, and thebenefits of discussing these issues with their physicians.At the conclusion of the program, almost all participantsfelt healthier and in better control of their health. Evenhighly educated participants accepted the comparativelylow educational level of the program materials.

The substantial blood pressure reductions in theintervention group likely reflect the effect of educationand the reinforcement of adherence.The educational focus on understandingall relevant risk factors used a structuredapproach that emphasized theimportance of lifestyle changes, followupwith physicians, regular blood pressuremonitoring, and adherence tostudy and nonstudy interventions,including medication use. The positivemessages of the KYH program empowerpatients to reduce their risks by makingfeasible changes. The finding of substantial,albeit smaller, reductions in bloodpressure in the control group suggeststhat enrollment in the study andincreased interaction with healthcareprofessionals may have improved theadherence to treatment. Supporting thishypothesis is the fact that adherence inthe control group improved as much asthat in the intervention group, an effectobserved in earlier clinical trials.

The absence of effect on A1C level in patients with DMmay have at least 2 explanations. First, the small numberof these patients may have limited the statistical power todetect differences during follow-up. Second, the patientswith DM in both study groups were at substantially higherlevels of awareness and functioning about their disorderon entry than the patients with hypertension. For example,many more patients with DM had already been educatedabout their disease, were monitoring glucose levelsregularly, and were taking appropriate medication.Patients with DM in the intervention group and in thecontrol group may have already been taking better care ofthemselves and had less room for improvement.

In conclusion, the primary efficacy analysis of thisstudy demonstrated that participation in the comprehensiveKYH program significantly improved attainmentof treatment goals, with a significant reduction in DBP inpatients with hypertension. The KYH materials werewell received and were considered informative and easilycomprehensible by the study participants.

Evaluation of the Know Your Health Program for Type 2 Diabetes Mellitus and Hypertension in a Large Employer Group

To evaluate a program to reduce musculoskeletal disability-related absenteeism at a North American manufacturing facility.

Staged communication and educational interventions targeting physicians to improve care of musculoskeletal conditions and reduce related absenteeism.

The program was implemented in three 1-year stages. The first stage required physicians to complete assessment forms for employees claiming disability because of musculoskeletal injuries. The second stage added physician education programs focusing on current clinical guidelines. The third stage incorporated local physician education about the facility's onsite physical therapy program. Annual number of work-related injuries, days lost per injury and per scheduled full-time-equivalent (FTE) employee, lightduty days per injury, average annual indemnity per FTE, indemnity per injury, medical costs per FTE, and medical costs per injury were examined to determine the program's effectiveness.

Overall productivity improved by a mean of 12.5 days per injured employee. Mean days lost per work-related injury decreased from 35.1 to 27.6. Number of light-duty days increased from 6.1 to 11.1 per work-related injury. Mean annual indemnity per work-related injury decreased from $9327 to $4493; mean annual medical costs per work-related injury decreased from $4848 to $2679. The annual incidence of musculoskeletal injuries declined by up to 50%.

This intervention was associated with reduced musculoskeletal disability-related absenteeism and increased productivity. The program reduced medical costs per work-related injury and improved the company's communications and relationship with local physicians.

Disability-related absences cost major corporations billions of dollars annually. On a typical day, 3% to 6% of any given workforce is likely to be absent as a result of unscheduled issues or disability claims. In 2004, American industries reported approximately 4 257 300 cases of nonfatal injuries and illnesses.

Of these cases, about 1 259 300 involved lost workdays, 525 390 related to musculoskeletal injuries (eg, sprains, strains, muscle tears), and 282 240 involving back injuries.

The causes, nature, treatment, and prevention of work-related musculoskeletal injuries were investigated in a North American facility with an unusually large number of musculoskeletal disability claims, lost workdays, and surgical referrals. Based on its findings, the company developed a 3-stage communication and educational intervention targeted at community physicians and employees. The program aimed to improve care received by injured employees and to reduce disability-related absenteeism, and was implemented in three 1- year stages. In this article, we describe the changes in related clinical and financial outcomes.

International Truck and Engine Corporation (referred to hereafter as International) is the nation's largest manufacturer of medium-and heavy-duty trucks, school buses, and diesel engines, with facilities in more than 40 major locations. The company employs mostly blue-collar, hourly employees involved in manufacturing operations. International provides free outpatient medical services and support for employees through plant staff. In addition to traditional corporate managers, department and plant staff includes physicians, physical therapists, nurses, and case managers.

In late 2001, approximately 25% (≥200) of International's musculoskeletal disability claims, accounting for 65% of total workers' compensation costs company-wide, were coming from the Springfield, Ohio, manufacturing facility. At that time, Ohio state workers' compensation laws allowed employees to seek care at International or select their own treating physicians.

Workers' compensation records revealed that International's Springfield employees with musculoskeletal injuries were not always adequately diagnosed or treated by local primary care physicians (as determined by local orthopedic specialists). Although some employees were unnecessarily referred to orthopedic specialists, others were not referred when appropriate. Additionally, physicians frequently prescribed sedating, controlled-substance pain relievers (eg, opioids), which prevented a safe return to work and often kept employees from returning when their level of disability would have allowed a return to light duty. Company resources, including onsite physicians and physical therapists, were not being sufficiently utilized at the Springfield facility to maximize outcomes.

The literature on musculoskeletal disability management programs indicated that the incidence of workers' compensation claims often leveled off after implementation of a risk screening program that included employee education about work-related musculoskeletal pain.

 Furthermore, clinical practice guidelines for musculoskeletal injuries have been successfully applied in the workers' compensation setting.

Thus, it was hypothesized that physician education and use of established guidelines, along with improved communications with employees, might help reduce workers' disability costs and improve the care of injured employees at the Springfield site.

In 2002, the company developed the International Musculoskeletal Disability Management (IMDM) program, administered by its Medical Services Department located within the Springfield facility. Baseline data were obtained from workers' compensation records from the first quarter of 2000 through the fourth quarter of 2001. The IMDM program was implemented in 3 stages (

The Employee Status/Return to Work Report. 

This form (the ESRW Report) was given to all employees filing a claim for a musculoskeletal disability, and they, in turn, gave the form to their treating physician. The physician reported on the nature of the disability and current ability to perform body movements, such as bending, twisting, and repetitive hand use; safety-sensitive activities, such as operating motorized equipment; lifting and carrying; and pushing or pulling at specified weight limits, both above and below shoulder level. A new form was completed for each visit and returned to the Medical Services Department.

Evidence-based Medicine Diagnostic Training

The American Academy of Orthopedic Surgeons (AAOS) clinical guidelines

were selected and used as the basis for more than a dozen diagnostic training seminars presented by orthopedic specialists to local primary care physicians who currently or recently treated International employees. The seminars were funded by the company and a corporate sponsor.

Treating physicians were given the employee's job description, which helped them to assess conditions wherein the employee could return to work, either on a light-duty or unrestricted basis.

During stages 2 and 3, the AAOS practice guidelines specific to an employee's injury were given to treating physicians.

Physicians were informed about International's onsite physical therapy capabilities so that they might allow injured employees to return to work earlier, knowing they would be appropriately followed and their therapy sessions could be scheduled to accommodate work shifts.

Local physicians were encouraged to (1) complete the ESRW Report; (2) use the AAOS clinical practice guidelines; (3) use the company's onsite physical therapy services for employees with musculoskeletal conditions; and (4) prescribe appropriate medications to safeguard employees, particularly over-the-counter pain relievers, nonsteroidal anti-inflammatory drugs, or the cyclooxygenase-2 (COX-2) inhibitor celecoxib.

Four primary clinical end points were examined. The mean number of scheduled full-time-equivalent (FTE) employees was determined by dividing 37.5 hours per week into the total number of hours worked. The number of work-related injuries was taken from the monthly work loss injury report, and mean injury rate was determined by dividing the total number of injuries by the average number of employees during the stage. The number of days lost per work-related injury was computed by dividing the number of injuries into the total number of injury-related lost workdays. Finally, the number of days lost per scheduled FTE employee was computed as the number of lost workdays divided by the total number of scheduled FTE employees.

Four secondary-cost end points were examined. The average indemnity paid per FTE employee was computed as total facility indemnity costs divided by the total number of FTE employees. The average indemnity paid per work-related injury was computed as the total work-related indemnity cost divided by the total number of injuries. The average medical cost paid per FTE employee was calculated by dividing the total medical costs by the total number of FTE employees. The average medical cost per work-related injury (annually) was computed as total medical costs divided by the number of injuries.

Periodic updates were communicated to the plant management in Springfield and to senior company management. These updates made management aware of the need for continued adherence to the study interventions.

Average values of the clinical and financial outcome measures were compared before and after the program. Outcomes are reported as rates, so the change in total FTE employees does not affect the results, although the number of claims dropped in proportion to the decrease in FTE employees.

In 2001, the Springfield facility employed 3417 persons. The number of FTE employees at the facility decreased between 2001 and 2005 as a result of merging some operations into other locations and because a large number of employees retired. The number of employees at the study's end was 1366. The mean age of employees at the Springfield facility was 52.6 years, and mean tenure with the company was 23.2 years. Eighty-two percent of the employees at the facility were men.

Large reductions were observed in work-related injuries (75%), days lost per injury (21%), and days lost per FTE employee (50%). Overall productivity improved by an average of 12.5 days per injured employee after the program was implemented. The mean number of days lost per work-related injury decreased from 35.1 days to 27.6 days, or an improvement of 7.5 days per injury (

). Furthermore, the number of light-duty days increased per work-related injury, from 6.1 to 11.1, and use of the company's onsite physical therapy facilities increased by more than 50%.

Both mean indemnity and medical costs decreased per injured employee (

). The mean annual indemnity paid per work-related injury decreased by $4834 (from $9327 to $4493) and the mean annual medical costs paid per work-related injury decreased by $2169 (from $4848 to $2679). The greatest change from baseline was observed in the mean annual indemnity paid per FTE employee at the facility. Over the 3 stages of the study, this amount decreased from $590 to $178 per FTE employee.

The most commonly occurring musculoskeletal injuries at the Springfield facility both before and after the program began were to the shoulder, wrist, hand, and lower back (

). After taking into account the reduction in the number of employees at the Springfield facility compared with baseline, the overall incidence of musculoskeletal injuries declined from baseline to end of study by as much as 50%. The greatest reduction occurred in the number of back injuries reported per year.

In the IMDM program, International identified shortcomings in its musculoskeletal disability management procedures and implemented solutions that were both clinically and financially effective. Although International decided to enact these procedures in 3 stages, a company wanting to duplicate this program could implement all 3 stages simultaneously or at an accelerated rate compared with this program.

In the Springfield facility, 50.9 hours go into building 1 truck. The IMDM program increased productivity by a mean of 12.5 days per injury. Based on a 37.5-hour workweek, multiplying this number by 7.5 hours per day and by the 54 employees injured during stage 3 reveals a gain of 5062 man-hours, which translates into 99 more trucks built per year. Also, given that replacement employees cost between $24.18 and $45.30 per hour, a gain of 5062 man-hours saves between $122 399 and $229 309 annually.

The large percentage of reductions in work-related injuries, days lost per injury, and days lost per FTE employee noted in this study compare favorably with disability management programs evaluated by Doheny,

 who reported a 20% reduction in the length of long-term absences, and by Skisak and colleagues,

who reported 9% to 23% reductions in total absences, a 20% reduction in absences lasting 4 or more days, and a 28% reduction in extended absences. Because physicians in this study initially often kept employees out of work until they were fully recovered, the number of annual light-duty days increased substantially after the study interventions were implemented. This increase is likely attributable to efforts to educate physicians about injured employees' tasks, their option to return to work on a light-duty basis, and the company's onsite physical therapy facilities. Goetzel and colleagues noted that when indirect costs associated with absenteeism, such as overtime premiums and cost of replacement workers, are examined, the health and productivity cost burden increases substantially.

 However, we did not collect these data, so no comparison between prestudy and poststudy indirect costs could be made. Although preliminary information on pain medications prescribed to workers with musculoskeletal injuries during this study is anecdotal, the use of controlled substances decreased at the Springfield facility. Conversely, the use of the COX-2 inhibitor celecoxib and other nonsteroidal anti-inflammatory drugs increased.

The success of the IMDM program was related to several factors. First, International took a systems perspective, not a defective-component perspective, focusing on improving organizational factors rather than individual employee factors.

The involvement of senior management throughout the program helped to ensure corporate responsibility for the program. Additionally, local healthcare providers were presented with a unified plan for managing musculoskeletal injuries and using in-house resources more effectively.

Program implementation appears to be associated with increased productivity and averted costs. The data collected from the ESRW Report provided ongoing feedback and established a means of accountability and evaluation of the program and its components, including return on investment. Although implementation costs (eg, physician education programs, printing of guidelines, letter mailings) for the IMDM program were minimal, the program has been successful in reducing workers' compensation costs by more than $1500 annually per FTE employee at this facility.

Goetzel and colleagues listed 10 best practices found in several successful health and productivity management plans.

The IMDM program followed each of these practices. Its goals were aligned with those of the company, and each component was interdisciplinary, involving people from several different departments. This helped to ensure adequate input for decision making and lent broad-based support. A program "champion" (the Medical Services Department) was identified and became the driving force behind the IMDM initiative. More important, senior management was involved in the design, implementation, and evaluation of each component and was committed to the success of the program, which emphasized improvements in injured employees' care and quality of life, not just reductions in healthcare costs. Communication was consistent throughout the organization and the community of local healthcare providers. In addition to ideas from its own plan design group, the IMDM program incorporated ideas from the literature, thus benefiting from lessons learned in similar efforts.

This was an observational study, and it is possible that the extra care and attention given to injured employees may have influenced their progress and return to full productivity. These employees may have experienced an effect similar to the Hawthorne effect, wherein the awareness of being studied changes observed behaviors. International hoped that employees would see the program as a genuine attempt to improve their welfare and job satisfaction. Their awareness of the program, however, may have influenced their behavior.

This program was implemented in a small community, with all employees working in 1 centralized location (Springfield). In this setting, it was easier to identify most of the physicians treating musculoskeletal-injured employees of the company. Replicating the program in its entirety might not be possible in larger communities, particularly the physician training seminars.

The interpretation of results of this study is limited by lack of a control group, which could not be used because International has no other facility in Ohio. Because workers' compensation regulations vary across states, using an out-of-state facility as a control group would not have been feasible. Additionally, a control group within the Springfield facility could not be designated because of union guidelines, wherein activities must be rolled out evenly across all employees. As a result, it was not plausible to rule out the possibility that some of this study's findings were attributable to causes other than the implementation of the musculoskeletal disability management program. The program appeared to increase productivity and decrease healthcare costs, although it was not possible to determine whether any 1 part of a stage had more of an effect than other parts. Also, because the program was rolled out in 3 stages, it was not possible to determine whether the perceived improvements of each stage were in addition to the effects of previous initiatives, or if the effects of previous initiatives would have continued to result in improvement without the new processes being enacted.

Claims-based absences account for about 1 of every 2 lost workdays and for about 1 of every 5 absences.

This study did not address other sources of absenteeism. Finally, because it often takes an extended period of time before all costs associated with a claim have been incurred and submitted for reimbursement, it is possible that not all costs associated with the most recently filed claims were captured in this analysis.

Impact of a Musculoskeletal Disability Management Program on Medical Costs and Productivity in a Large Manufacturing Company

Most employers are responding to rapidly growinghealthcare costs by asking workers to pay moreof the premium and by increasing prices (eg,deductibles and copayments) workers face at the pointof care. In 1999, for example, 84% of people covered byemployer-sponsored health insurance had a physiciancopayment of $10 or less, whereas 72% had physiciancopayments of $15 or more in 2005.

Likewise, copaymentsfor prescription drugs on the second (preferredbranded) and third (nonpreferred branded) tiers havealmost doubled between 2000 and 2005, rising from $13to $25 and from $17 to $33, respectively. The objectiveof these changes is to encourage employees and theirdependents to compare the benefits of medical carewith the cost, to discourage the use of low-value medicalservices, and thereby to slow down the growth rate ofhealth insurance premiums.

It is clear that increasing employee cost sharingachieves its primary objective of reducing costs.

Forpeople with certain health conditions, however, increasingemployee cost sharing may have unintended consequences.Several recent studies show that patients withhigh blood pressure, elevated cholesterol levels, or diabetesmellitus (DM) are less likely to adhere to medicaltherapy when drug copayments rise.

If the health ofnonadherent patients worsens such that they requireadditional medical services, then reducing drug copaymentsmay actually increase total medical expenditures.Furthermore, if one defines health costs broadly toinclude health-related absenteeism and reduced on-the-jobproductivity (often referred to as presenteeism) dueto a health condition, direct medical costs may actuallyrepresent a small proportion of total health-relatedcosts.

At least 20 employers, including Pitney Bowes Incand the University of Michigan, are adopting a contrarianapproach.

Rather than increasing copayments forall drug classes, these employers are selectively reducingcopayments for conditions such as diabetes, asthma,and hypertension in which the clinical evidence suggeststhere is a strong connection between adherenceto drug therapy and health. Unfortunately, there is nosingle study that performs a complete analysis of thefinancial effect of changing DM drug copayments onadherence, medical expenditures, absenteeism, and on-the-job productivity from the perspective of an employer,to my knowledge. The objective of this article is toperform such an analysis for DM by constructing afinancial model that links together results from severaldifferent published studies. The Diabetes OutcomesAnalyzer model, which is a disease-specific applicationof a general model proposed recently by Nicholson etal,

focuses on DM because there are more studiesexamining the key links required for the financialmodel than for other diseases and because it is a fairlycommon and expensive condition.

Although this financial model can help employersdesign health benefits, one must be careful when interpretingthe results. The model uses mean values (eg, thepercentage change in pharmaceutical expendituresassociated with a $1 change in the drug copayment)across several different studies and then links these valuestogether to estimate the financial effect of drugcopayments on total health-related costs. For pragmaticreasons, I assume that the employee populations andthe examined interventions are similar to one anotherand are representative of employers nationally.

The baseline situation for an employer with 5000workers is given in 

The analysisfocuses on workers only. Dependents and retirees couldbe incorporated, although the employer would not benefitfrom any changes in absenteeism or presenteeism.Each data element is described in column 1, the meanvalue based on the literature is given in column 2, andthe sources or assumptions are reported in column 3.Using the National Health and Nutrition ExaminationSurvey, Cowie et al

reported the percentages of USemployees between 1999 and 2002 by sex and by agecategory (20-39 years vs 40-64 years), as well as the percentagesof employees (men and women combined) inthese age categories who were diagnosed as having DM.Based on these data, an estimated 6.6% of the employedpopulation has DM, or 332 workers for a typical employerwith 5000 workers.

The patient populations, interventions, and resultsfrom several key studies are summarized in 

Two studies examined the medication adherencerates for patients with DM. Among a population of137 300 nonelderly employees and dependents insuredby a manufacturing firm, Sokol et al

found that 55% ofthe patients with DM adhered to their medication regimen.A patient was considered adherent if he or shereceived a supply of drugs for at least 80% of the year.Dor and Encinosa

reported that 58% of patients withDM adhered to their physicians' recommended drugtreatment among a population of 27 100 workers andretirees who received employer-based health insurancefrom 9 large firms. In the latter study, a patient was consideredadherent if he or she had a full 3-month supplyof drugs following the expiration of his or her first DMprescription, among patients who filled at least 1 DMprescription between June 1999 and September 2000. Iaveraged these 2 results and assumed that, before anydrug copayments were changed, 56.5% of employeeswith DM adhered to their physicians' recommendeddrug therapy. For an employed population of 5000, thisimplies that 144 workers are not adherent among 332workers with DM.

The model assumes that an employer's pharmaceuticaland nonpharmaceutical expenses per employee withDM are $3922 and $10 776, respectively. These are themean amounts reported by Sokol et al

Garrett and Bluml studied a population of256 patients with DM in Asheville, NC, who were coveredby employer-sponsored health insurance (Table2). The spending amounts reported in these 2 studieswere adjusted from the period examined (1999 forSokol et al

) to 2006values by using the overall US growth rate of pharmaceuticaland nonpharmaceutical expenses. Specifically,I applied a 12.5% annual growth rate for pharmaceuticalexpenses between 1999 (the date of the study by Sokolet al

) and 2004; I applied a 9.1% annual growth rate fornonpharmaceutical expenses during the same period.The growth rates from 2004 (the date of the study byGarrett and Bluml

) to 2006 (8.2% for pharmaceuticalexpenses and 7.9% for nonpharmaceutical expenses) arethe actual growth rates in the United States between2003 and 2004.

Eight studies examined how often workers with DMwere absent because of their health condition. Althoughthe questions differed somewhat across the studies, thedata were self-reported by surveyed employees, andemployees were usually asked to distinguish health-relatedabsences from overall absences. The numbers ofannual self-reported absence days ranged from 1.2 daysto 12.6 days across the 8 studies, with a mean of 4.4days. Goetzel et al

summarized 4 of these studies: theMedstat MarketScan Health and Productivity Managementdatabase that contained absenteeism informationon 375 000 employees between 1997 and 1999 at 6 largecorporations, the Employers Health Coalition, Inc,

thatsurveyed 10 000 employees at 8 large employers in 1998and 1999, the Work Productivity Short Inventory(Ozminkowski et al

) that evaluated 619 employees at alarge telecommunications company, and the Bank OneWorker Productivity Index (Burton et al

) that collecteddata from 1000 Bank One customer service operators inIllinois in 1995. To arrive at the overall mean of 4.4 daysper year, the data from these 4 studies were combinedwith the data from 4 other studies on how frequentlyemployees with DM were absent: Collins et al

surveyed6000 employees at Dow Chemical Company in 2004,Cranor et al

examined164 patients with DM covered by employer-sponsoredhealth insurance in Asheville, Wang et al

examined anemployer-based population, and Egede et al

examinedpatients with DM in the general population.

To estimate the annual cost associated with DM-relatedabsences, I multiplied the mean daily wage of anemployee in the United States by 4.4 days. This is a reasonableassumption if workers are paid according to themean value they provide a firm and if an absence resultsin 1 day's worth of output not being produced. Pauly etal

showed that the minimum cost of an absence is anemployee's daily wage if labor markets are competitive,so this assumption is conservative. Pauly et al argue thatif it is difficult to substitute for an absent worker if theworker operates as part of a team or if the worker's outputcannot be postponed without some penalty (eg, lostsales), the true cost of an absence will exceed the worker'sdaily wage. With a mean annual salary of $41 414,fringe benefits that represent 28.6% of the salary, and240 work days per year, the estimated annual cost to anemployer of 4.4 absences is $980. The mean salary dataare from the Bureau of Labor Statistics, and the fringebenefit data as a percentage of salary are from the USDepartment of Labor. In the short run, an employercould capture the financial benefits of improvements ina worker's health-related productivity. However,employees who are absent less frequently due toimproved health should capture the benefits in the formof higher wages if other potential employers observeimproved productivity.

Although some employers consider the financialeffect of reduced absenteeism when deciding whether toinvest in the health of their workers, most employersare skeptical about whether to include presenteeismimprovements in such calculations.

In this model, Ireport the benefits associated with improved on-the-jobproductivity separately so that an employer can includeor omit them as he or she sees fit. Most of the researchto date on impaired presenteeism is based on informationcollected from workers regarding their perceptionof how often health impairs their productivity and of themagnitude of the impairment on their usual productivity.

Three studies summarized by Goetzel et al,

which were already described in the absenteeism analysis,also examined presenteeism among workers whohave DM. Workers reported that their productivity duringthe 4 weeks before the survey was 11.4% lower, onaverage, than their usual level because of their healthcondition. If this productivity decrement occurred persistentlythroughout the year, the productivity losswould amount to $6138 based on the mean annualsalary (with benefits) in the United States.

Based on this set of assumptions, the total health-relatedcost per worker with DM is $21 749 per year(Table 1). About two thirds of these costs are directmedical expenditures and one third are indirect productivity-related costs. For a firm with 5000 workers, thetotal health-related costs for all workers with DM areestimated to be $7.2 million per year.

Are health-related costs likely to increase or decreaseif an employer cuts the copayment for DM drugs? Mostemployers have instituted a 3-tier drug copayment system.As summarized in 

, the mean copaymentfor generic drugs in employer-sponsored health planswas $10 in 2005, while the mean copayments for preferredand nonpreferred branded drugs were $22 and$35, respectively.

Nationally, 53% of all prescriptionswere for generic drugs in 2004.

No information wasavailable regarding the percentage of prescriptions thatwere for preferred versus nonpreferred branded drugs.For purposes of calculating a mean baseline drug copaymentper prescription, I assume that 40% of prescriptionsare for preferred branded drugs and that 7% are fornonpreferred branded drugs. This implies that employeespaid a mean of $16.55 per prescription at the pointof care in 2005.

In this article, I simulate the effect if an employerwere to put all DM drugs on the first tier. That is,employees would pay the $10 generic copayment for allDM drugs, even for branded drugs. Therefore, for anemployee with DM, the mean copayment would bereduced by $6.55, from $16.55 to $10. The model isflexible enough so that an employer could simulate anypossible copayment structure, such as eliminatingcopayments for DM drugs or raising all copayments tothe nonpreferred branded amount.

The first outcome of interest is whether medicationadherence rates would improve as a result of the $6.55reduction in the mean drug copayment. As summarizedin Table 2, Dor and Encinosa

found that a $4 increasein drug copayments is predicted to reduce drug adherencerates by 3.4 percentage points, or 9%, amongemployees who have DM. As in other investigations, Iassume that the measured relationship between changesin copayments and adherence, medical spending, absenteeism,and presenteeism are symmetric. For example,if copayments were reduced by $4 per prescriptioninstead of increased by $4, I assume that adherencerates in the sample described by Dor and Encinosawould have increased by 9%. Furthermore, the measuredrelationships are assumed to be linear. In themodel, the relationship between copayments and adherencein the study by Dor and Encinosa is calibrated tothe magnitude of the simulated copayment change.Therefore, a $6.55 reduction in the mean copaymentwould be expected to improve adherence by 14.7%([-$6.55/$4] [-9%] = 14.7%). The model predicts that209 of 332 workers with DM would adhere to their recommendeddrug treatment under the lower copaymentdesign, an increase of 21 workers.

I adopt a similar approach to predict the effect oflower copayments on pharmaceutical and nonpharmaceuticalspending. Three of the studies summarized inTable 2 examined the relationship between copaymentsand pharmaceutical spending for patients with DM.Goldman et al

reported that doubling the copayment,which represents an increase of $9.39 in the meancopayment in their sample, was associated with a 23%reduction in spending on DM drugs; Garrett and Bluml

found that a $14.40 reduction in copayments was associatedwith a 27.3% increase in pharmaceutical spendingfor employees with DM; and Dor and Encinosa

predictedthat a $4 increase in copayments would reduce pharmaceuticalspending among patients with DM by 4.9%.Garrett and Bluml

also examined a situation in whichemployers in Asheville entirely eliminated the copaymentsfor DM drugs. Because the study did not indicatehow large the copayments were before the change, Iassume for purposes of calibrating the model that thecopayments were equal to $14.40, the national mean in2004.

Based on these 3 studies, the simulated $6.55decrease in the mean drug copayment is predicted toincrease pharmaceutical spending for employees withDM by 12.2%, on average, or $477 per worker per year.The spending before and after the simulated reductionin drug copayments is summarized in Table 3.Dor and Encinosa

alsoexamined the relationship between copayments andnonprescription drug spending, as summarized inTable 2. They found evidence of cost offsets: reducingthe price of pharmaceuticals via the copayment wasassociated with reductions in nonpharmaceuticalexpenses among employees who have DM, and increasingdrug copayments had the opposite effect on nonpharmaceuticalcosts. Specifically, Dor and Encinosafound that a $4 increase in copayments was associatedwith a 6.4% increase in nonpharmaceutical spendingamong persons with DM, and Garrett and Bluml foundthat a $14.40 reduction in copayments was associatedwith a 14.4% decrease in nonpharmaceutical spending.

Dor and Encinosa did not directly examine the effect ofdrug copayments on nonpharmaceutical expenses.Instead, they applied their results on the relationshipbetween copayments and adherence to the findings byWagner et al

December 2006 - Special Issue

Engaging Employees in Health and Wellness: the Healthy Pfizer Program

Evaluation of the Know Your Health Program for Type 2 Diabetes Mellitus and Hypertension in a Large Employer Group

Impact of a Musculoskeletal Disability Management Program on Medical Costs and Productivity in a Large Manufacturing Company

The Effect of Cost Sharing on Employees With Diabetes

Impact of Statin Copayments on Adherence and Medical Care Utilization and Expenditures

Innovations to Preserve Quality and Contain Cost

Value-based Insurance Design: Aligning Incentives to Bridge the Divide Between Quality Improvement and Cost Containment