FAST TRACK ARTICLE
Evidence-Based Benefit Design: Toward a Sustainable Health
Care Future for Employers
William B. Bunn, III, MD, JD, MPH, Gregg M. Stave, MD, JD, MPH, Harris Allen, PhD,
and Ahmad B. Naim, MD
Abstract: Health care costs for employers are rising much faster than
inflation. The common approach to health benefit design of increasing cost
sharing has failed to contain costs. Some employers, however, have been
successful at mitigating the cost trend or actually reducing health care costs.
These employers have in common a dedication to data analysis, a search for
cost drivers, and a willingness to adjust their approach to health benefit
design to address these cost drivers. This approach has much in common
with the movement in clinical practice toward evidence-based medicine. We
propose that employers adopt a similar approach toward health benefits
termed evidence-based benefit design, which is based on a health and
productivity framework focused on direct and indirect costs. Evidence-
based benefit design incorporates the relevant literature and employer-
specific data that are integrated and regularly analyzed.
spending. In 2008, US employers spent nearly $600 billion for the
health insurance of their workers, an increase of just ?10% from
the previous year.1The growth in employer spending in 2009 will
likely result in a new round of concern as the percentage of the
gross domestic product devoted to health care continues to rise.2
This issue becomes especially important with continuing
doubts about the gains achieved with these ever increasing expen-
ditures. Although modest improvements have been realized in
certain areas, such as rates of smoking, cancer, cancer mortality,
and cardiovascular disease, the rates of obesity, diabetes, and
hypercholesterolemia have shown a marked deterioration and re-
sulted in substantial costs of health care cost increases.3For a
growing number of employers, these doubts extend to the invest-
ments they have recently made or are contemplating making in the
development, maintenance, or retention of health and wellness
programs for their employees.
Employers need to design better health benefits to improve
the health and productivity (H&P) of their workforces. Currently,
benefit decision-making at most employers is dominated by short-
term priorities and strategies such as cost sharing or cost minimiz-
ing, with insufficient attention to impact over the long term. This
article calls for a reshaping of this approach by incorporating: 1)
stewardship of the essential linkages between employee H&P; 2) a
framework driven by sustained, integrated, empirically based H&P
measurement and management; and 3) the application of evidence-
espite an array of efforts at cost control, US employers have
continued to average large annual increases in their health care
based benefit design (EBD) concepts to coverage issues and poli-
cies. These improvements must be rooted in a framework that
facilitates the examination of H&P outcomes and quality indicators
alongside trends in health care costs.
In addressing these themes, this article puts forward a ratio-
nale for why a H&P evidence-driven approach can enable employ-
ers to better meet their objectives for healthier employees, better
performing workers, and more sustainable health benefits program.
In the second article of this two-article series,4we focus on the case
study of a leading employer proponent of this approach to illustrate
how it can be implemented in the field.
FOUNDATIONS FOR A NEW APPROACH
The call for applying an evidence base with a H&P focus to
health benefits is rooted in: 1) recognition of the gains that a similar
focus has brought to decision-making in the clinical setting and 2)
awareness of the shortcomings that often characterize current ben-
efit decision-making at many employers.
Evidence-Based Medicine in the Clinical Setting
Since the early 1990s, several organizations, including the
Cochrane Collaboration Center for Evidence Based Medicine, the
NIH US Preventive Services Task Force, and the Agency for Health
care Research Quality, have performed and made available system-
atic reviews that aid the practice of evidence-based medicine
(EBM). In addition, professional organizations have developed
clinical practice guidelines that are supported by these systematic
reviews. To support guideline development, there has been increas-
ing emphasis on the rating of the quality and strength of evidence.5
Although the initial definition of EBM focused on individual
decision-making, David Eddy has elaborated his definition with a
broadened formulation that folds in two components: evidence-
based guidelines (applied to groups) and evidence-based individual
decision-making (applied to individual patients). Evidence-based
guidelines are predicated on four principles: 1) good evidence that
each test/procedure recommended is medically effective in reduc-
ing morbidity or mortality; 2) medical benefits must outweigh the
risks; 3) cost of tests/procedures must be reasonable compared with
expected benefits; and 4) recommended actions must be practical
and feasible. Evidence-based individual decision-making, on the
other hand, encompasses the following: 1) the conscientious/
explicit/judicious use of current best evidence in making decisions
about the care of individual patients and 2) the practice of EBM
means integrating individual clinical expertise with the best avail-
able external evidence from systematic research.6,7
For both components, the explicit objective is to advance the
functioning and well-being of individual patients by processes that
are trained on the care for their observable and diagnosable symp-
toms. For employers responsible for maintaining the fiscal sound-
ness of health care benefits, absent in this formulation is any
mention of macroconstraints that may limit the financial and non-
financial resources that can be brought to bear on this objective.
Current Decision-Making by Employers
Currently, most employers base their benefit decisions on
financial reporting that pays little attention to the impact of benefit
From the Health, Safety, Security and Productivity (Dr Bunn), Navistar, Inc,
Warrenville, Ill; Northwestern University School of Medicine (Dr Bunn),
Chicago, Ill; Division of Community and Family Medicine (Dr Stave), Duke
University Medical Center, Durham, NC; Harris Allen Group, LLC (Dr
Allen), Brookline, Mass; Health Economics and Outcomes Research (Dr
Naim), Centocor Ortho Biotech Services, LLC, Horsham, Pa.
Address correspondence to: Ahmad B. Naim, MD, Health Economics and
Outcomes Research, Centocor Ortho Biotech Services, LLC, 800 Ridgeview
Drive, Horsham, PA 19044; E-mail: email@example.com.
Copyright © 2010 by American College of Occupational and Environmental
JOEM•Volume 52, Number 10, October 2010
design on employee H&P. Health care costs are generally reported
by the insurer or the third party administrator as a cost per hospital
admission, office visit, procedure, or cost of specific drugs or
category of drugs for the previous year. The types of costs that are
analyzed for most payers are directed toward financial reporting.
Costs are projected in an actuarial fashion based on trends. Disease
trends and independent analysis of disease/illness are rarely per-
formed. Benefit design changes often fail to balance the need to
contain increasing costs with the impact on employee H&P. For
example, copays and coinsurance are usually applied in across-the-
board ways that make no differentiation as to appropriate manage-
ment, effective treatment, or functional status or quality-of-life
improvements or both.
The myopic emphasis on benchmarking, program partic-
ipation, and return-on-investment that has resulted has not been
successful in providing high-quality care at affordable costs.
These strategies have brought forth ineffective solutions such as
cost minimization and cost sharing that have had unintended
consequences of decreased access to care and medications. The
trend toward full-replacement consumer-driven health plans is
one such example. With these plans, employers are shifting costs
of up to 20% or more onto employees. The premise is that
empowered consumers will choose what is best for them. The
result, however, is leaving consumers with increased coinsur-
ance levels that can discourage the use of appropriate medical
DEVELOPING EVIDENCE-BASED BENEFIT DESIGN
The concepts of EBD build on the pioneering work in the
areas of coverage policies for investigational treatments,9inte-
grated data analysis and human capital management,10inte-
grated analysis of health and wellness,11and measurement of
presenteeism12,13among many others. This approach is predi-
cated on the idea that, by incorporating H&P into an evidence-
based evaluation model, a better understanding of health dete-
rioration and chronic care can be achieved along a continuum.
This, in turn, can serve to help employers generate and refine
strategies that facilitate healthy employees staying healthy and
afflicted employees managing chronic conditions in a well-
coordinated and efficient manner. Employers’ health benefit
designs need to support these strategies.
To achieve these objectives, these designs need to address
effectively a variety of nonfinancial drivers and challenges. These
factors are both external and internal to the company and include
the variety of demographic, historical, technological, and market-
place forces described in Table 1.
The dilemma for employer decision-makers, however, is that
benefits also need to be crafted in ways that contain total health care
costs.14Total in this regard encompasses two broad domains: direct
costs and indirect costs. Direct costs are the transaction costs that
result from an individual’s interface with the health care system.
They are captured in claims for group health, medical, pharmacy,
behavioral health, and the medical component of workers’ com-
pensation and disability activity.
Indirect costs, on the other hand, are the costs that
employers incur with respect to lost productivity as a function of
the health of their workers. They encompass an array of com-
ponents that are both measurable and evidentiary in nature,
including the following:
Y Presenteeism is the extent to which an employee can meet their
day-to-day job responsibilities.
Y Accidents, injuries, and illnesses employees incur while at work
that restrict their continued performance on the job.
Y Job substitution or replacement or the costs incurred when job
positions need to be refilled because of an employee’s departure
or going onto disability.
Y Absenteeism or the time employees miss from work because of
routine factors such as short duration sickness or illness, vacation
or holidays, or family leave.
Y Workers compensation and short- and long-term disability,
which includes lost compensation and medical care incurred
when employees take extended leave from the job to recover
from accidents, illnesses, or injuries.
Y Return to work or the pace with which employees return to their
job from extended absence.
Y Caregiver costs are the burden and responsibilities of providing
care for a family members.
Recent studies have documented the role that ill health, disease,
and disability play in these indirect costs borne by employers. As one
example, Goetzel et al recently reported combined direct and indirect
of 10 chronic conditions. Costs associated with health, absenteeism,
presenteeism, and short-term disability for hypertension were $392 per
eligible employee per year, followed by heart disease ($368), depres-
sion and other mental illnesses ($348), and arthritis ($327). Indirect
costs were greater than direct costs in most cases and represented as
much as ?60% of all costs for the 10 conditions.15
Currently, benefit design for most employers is driven pri-
marily by short-term fluctuations in direct costs, particularly group
health.16As an alternative to this practice, the use of evidence
evaluation has shown promise in the context of initial efforts such
as the drug effectiveness review program and subsequent reviews
of these efforts, although they focused on direct costs only.17,18
Among other aspects, an emphasis on evidence has also illuminated
the need to keep the long-term consequences on health in view.19
Yet, from the employer’s perspective, a more effective approach
will arise when evidence analysis is focused more broadly on total
costs, health, wellness, and productivity in both the short and the
long term. Given the complexities of health care data and the varied
possibilities in analytical design, an integrated data framework
needs to be developed so that employers can use to develop their
specific EBD strategies.
INFUSING EBD INTO HEALTH BENEFIT DESIGN
The following attributes present a basic framework on which
employers can build EBD studies:
Any approach at generating employer-related evidence has
to be defined by parameters that have a wide understanding and
applicability. This includes determining the burden of illness, direct
and indirect costs, assessing worker productivity, presenteeism and
absenteeism, and examining the disability and worker compensa-
tion profiles. This also includes EBD studies that are disease or
condition specific and studies that drive at specific management
criteria designed to have a direct beneficial effect on health and
quality of care or address business practices or both that may have
a less immediate bearing on health.20
EBD requires a high level of rigor and objectivity. This can
be achieved by using real-world longitudinal studies based on
employer-specific data designed to create a continuous quality
improvement framework that will enable employer decision-mak-
ers to monitor change over time and implement the most cost-
effective approaches using EBD. Furthermore, credibility is main-
tained by using employer-centric data that are key to acceptability
and adoption of these EBD metrics.
© 2010 American College of Occupational and Environmental Medicine
Bunn et alJOEM•Volume 52, Number 10, October 2010
To create a standard set of EBD metrics, employers should
collaborate with academic experts and mutually agree on objec-
tivity and transparency and provide guidance while maintaining
confidentiality standards. EBD strategies should be peer re-
viewed and supported by thought leaders in their respective
arenas of expertise.
The empirical framework serving as the foundation for EBD
requires the routine monitoring of data on the sources of direct and
indirect costs. The more that this monitoring can encompass all of
these sources and convert the magnitude of the losses observed into
credible estimates of lost dollars, the better the framework.
Drivers and Challenges for Managing Health Benefit Costs
Driver Description Consequence
Insurer-dictated health plans With the exception of large self-insured employers who have
implemented value-based benefit design strategies, the
majority of employers rely on insurers and other service
providers to manage their benefits. These approaches often
are “one size fits all” and based on the false promise of
short-term cost-minimization systems.
The US health care system thrives on innovations and new
developments in biotechnology, medical devices, and
imaging that have improved understanding of disease and
quality of life and have often lengthened it.
The net result often shifts the costs to a later time
when both the disease/condition and costs are
potentially much higher.
Sustainable innovations Yet, these developments have also driven up
overall costs. The numerous services cropping
up in the marketplace to help manage these
high costs have often followed the well-
established cost-minimization culture.
However, the measurement approaches of these
organizations often do not address indirect
costs and related issues that employers need to
Benefit decisions and related policymaking often
take place in a vacuum that fails to integrate
employer-specific data to understand cost
drivers and does not “connect the dots” to the
organizational bottom line.
Such nontransparent systems limit access to data
and thereby inhibit the development of
comprehensive H&P evidence. They also
hamper capacity for informed negotiations in
Although all employers have an interest in the
productivity of their workforce, US employers
face unique challenges of providing
comprehensive health care benefits.
Limited H&P research Various commercial, public, and quasi-government agencies
such as NQF, NCQA, and AHRQ provide valuable tools
to generate evidence and monitor services for improved
quality and accessible health care.
Although there is much clinical evidence to inform
therapeutic decisions, there is little information available
that delineates the financial and nonfinancial resources that
need to be managed by employers as the stewards of these
The nontransparent, uncoordinated, inefficient, and
fragmented health care systems contribute to rising health
care costs and low quality of care.
Lack of employer-centric data
Lack of transparency
Competitive advantageIn today’s flat business world, US companies compete in an
intensely competitive global marketplace. Most European
and Asian economies have universal health care systems
that do not directly burden the employer to provide health
Often springing from societal needs and governmental
priorities, funded or unfunded mandates are also
challenging to implement for employers.
Government mandates Can often result in an additional restrictions and
hurdles that H&P activities must negotiate.
Competitiveness and profitabilityFundamental to any business is the capacity to sustain and
grow market share.
High health care costs trends and the enormous
resources dedicated to provision of health
benefits are hampering the ability to compete.
Because—all else equal—average direct medical
costs increase with age, employers increasingly
have to find ways to better manage direct cost
trends so as to capitalize on the advantages that
older employees often bring to productivity and
performance by virtue of their longer company
The increasing burden of illness is continuing to
put cost pressures on employers.
Aging workforceNumerous studies have outlined this growing challenge for
US companies. This is particularly the case for certain
industries, such as aviation, aerospace, heavy
manufacturing, and chemicals, as these rely on a technical
and highly trained workforce.
Proliferating chronic diseasePoor health habits and an aging workforce have resulted in
an increased prevalence of chronic diseases. Increased life
expectancy can translate into retirees living longer with
multiple chronic conditions.
With recent increases of cost sharing in health plans, there is
an emergent concern that talented professionals (especially
ones with chronic conditions or dependent with special
needs or both) will make job selections based on health
Talent recruitment and retentionThe link between health benefits and an
employer’s capacity to attract and retain top
talent has become an important ingredient for
maintaining a competitive edge.
NFQ indicates National Quality Forum; NCQA, National Committee for Quality Assurance; AHRQ, Agency for Healthcare Quality and Research.
© 2010 American College of Occupational and Environmental Medicine
JOEM•Volume 52, Number 10, October 2010 Evidence-Based Benefit Design
The data will be best positioned for the kinds of ongoing
scrutiny needed for effective EBD if they are maintained in inte-
grated databases that link the various types of data together with
identifiers at the individual level. The value of data integration is
that cost drivers can be identified across categories. These data need
to be obtained and handled with processes that provide adequate
safeguards for protecting employee privacy and confidentiality.
In the pursuit of comprehensiveness, however, employers will
Invariably, a variety of logistical and resource-intensive hurdles will
need to be overcome before a fully functioning integrated database
spanning all of the relevant sources can be made operational—a task
the long term for many employers. Although keeping this long-range
objective in view, employers can realize much value in starting with
wherever they are with regard to culling together, analyzing, and
reporting the data available. The important thing is initiate and/or
continue with the processes needed to accumulate evidence for EBD
design and not to allow the integrated database ideal forestall the
progress that is possible in the short term.
Each employer has unique and specific needs for which they
need actionable strategies for the greatest return-on-investment. An
EBD-based system provides for such an actionable plan by generating
real-time data and allows for the development of standardized report-
ing structures. Such standard reports can be used to change corporate
policies and health plan design, improve disease management systems,
delivered in real-time will improve quality of care and enhance access
to products and services in a timely and appropriate manner.
With these prerequisites in mind, Fig. 1 offers a depiction of the
approach needed for EBD decision-making. This representation seeks
to lay out the sequence that starts with the development of an inte-
grated database incorporating all available data for the assessment of
all eligible individuals in the covered population regardless of clinical
to be undertaken and completed to reach the end goal of actionable
EBD. Specifically, integrated databases need to be developed that link
the data at the individual level; direct and indirect costs need to be
computed in ways that that differentiate health and from nonhealth
direct and indirect costs; and disease-specific profiles need to be
described and predicted in well-controlled analyses if the best infor-
mation base for EBD decisions is to be achieved. The result will be
information that can be incorporated into corporate policies, health and
wellness programs, condition-specific programs, and the cost-sharing
elements of group health benefits.
PRECEPTS OF EBD
EBD is intended to improve the H&P of an employed popula-
tion just as the goal of clinical EBM is intended to improve the health
and functioning of patients. EBD seeks to direct through the structure
of benefits the application of the available financial and nonfinancial
resources to support those interventions and initiatives that will pro-
duce health or productivity enhancement or both.
Integral to this process is what we term the “appropriate”
paradigm: appropriate patient, appropriate time, appropriate care,
and appropriate value. Appropriate patient strategies include iden-
tification and screening processes to manage the health status and
health risk of employees and beneficiaries. These should not be
limited to the sick or to high-risk people or to both and must include
the healthy and low to medium risk individuals as well.
The initiative or intervention supported by EBD should be of
sufficient intensity to significantly increase the likelihood that the
desired changes in behavior will occur. Although many design or
policy changes will have no immediate costs, for those that do
involve additional spending, the time frame to evaluate the return
on this investment should allow for an appropriate time frame,
depending on the specific intervention.
For organizations that are too small or not fully prepared to
integrate and analyze their own data, they can take advantage of the
EBD approaches developed by others and apply findings to their
populations. This process is similar to the approach that a physician
uses in applying evidence-based guidelines to an individual patient.
For example, Pitney Bowes analyzed their employee health data and
determined that costs for employees with diabetes, asthma, and hyper-
tension were high, and medication use was lower than desired. After
reducing copayments for these medicines, total health care costs fell
15% to 20% below the benchmark costs for these disease states, driven
by reductions in emergency department visits and hospitalizations.21,22
Employers could evaluate the literature and determine whether this
approach would be applicable for their population.
To support this approach, there is a need to build out the
evidence database through publication of positive and negative
studies on all aspects of benefit design. These studies will be most
actionable if they are predicated on measures that include both
leading and lagging indicators. Leading indicators refer to future
developments and drivers/causes and encompass metrics such as
the rates of successful completion of training programs, employee
attitudes with respect to safety and health issues, and health risk
appraisals scores that are predictive of morbidity and mortality.
Lagging indicators refer to past developments and effects/results
that reflect the history and outcomes of certain actions and pro-
cesses. They encompass metrics such as incident frequency rates of
Occupational Safety and Health Administration-reportable events,
measures focusing on the causes of lost work time, and utilization
and cost rates tracking health care consumption.
For most employers, the current approach to health benefit
design focuses on short-term direct medical costs, which present an
incomplete picture of an organization’s investment in health. The
predominant approach is to increase cost-sharing every year. This
approach has not been effective at controlling these costs and may
be counter productive because it may result in a lower use of
desirable preventive and therapeutic medications and care, does not
take a longer-term view, and does not address indirect costs. The
failure to address indirect costs is a significant concern as indirect
costs often exceed direct costs and may actually be a driver of direct
costs (eg, proof of continuing disability may require continuing
medical evaluation, testing, therapy, and procedures). In fact, the
best clinical quality approach may not reduce direct or indirect
FIGURE 1. Process for developing EBD.
© 2010 American College of Occupational and Environmental Medicine
Bunn et alJOEM•Volume 52, Number 10, October 2010
costs especially when absenteeism and presenteeism are not inte- Download full-text
grated into the evidence-based analysis.
In contrast, companies that have taken an integrated evi-
dence-based approach to health benefit design have shown savings
in direct and indirect costs. These organizations also report a greater
sense of employee engagement.23The integrated approach requires
the collection and analysis of all data relevant to the calculation of
direct and indirect costs, usually in an integrated data warehouse.
Just as EBM needs to be individualized, evidence-based
health benefit design is not a “one size fits all” approach. The design
may vary for different populations. It requires an analysis of
integrated data so that the organization can understand direct and
indirect cost drivers. Similar to the approach of EBM, this approach
also requires a review of the relevant literature to assist in evalu-
ating potential benefit design or policy changes. This evidence-
based approach is also applicable to the full range of decision-
making for workplace policies and programs with respect to the
management of workforce H&P.
Analysis focused on total H&P costs is appropriate for all
health systems, not just for the United States. Even when health
care is supported through taxation and government systems, the
indirect costs of poor health and inappropriate or delayed care can
limit the productivity of workers and the businesses that hire them.
The resulting inefficiency reduces profits and associated taxes
collected, with the net result that less money is available for health
care. Therefore, investment in health-related productivity, using an
evidence-based design, is important regardless of how health care is
funded. For payors more generally, a strategy based on short-term
costs and cost shifting has not and will not be successful. The best
practice approach currently incorporates evidence-based decision
analysis and incorporates some measure of indirect cost.
As the drive for H&P EBD moves to the mainstream, it can
and methods will similarly grow. When empirically derived data serve
to shape and guide decision-making, the more demonstrably similar
the protocols and procedures are that are used to target, collect,
analyze, and report these data, the more reliable and credible the
comparisons that are made based on these data become. The drive
ease of use of the very information base that employers are seeking to
establish to improve their benefit design purchasing decisions.
For a model, the process will likely be akin to that which led to
the development of the National Committee for Quality Assurance’s
Healthcare Effectiveness Data and Information Set (HEDIS).24Spear-
headed by employer demand for an improved information base for
comparing and purchasing health plans, the inherent value that
HEDIS has shown vis-a `-vis these objectives has led to the dramatic
growth in its widespread adoption as the industry standard. This
growth has evolved from its trial use by just a few health plans in
its infancy in the early 1990s to its utilization by ?90% of all
American health plans today to measure important dimensions of
care and service.
Similar pressures emanating from within the employer com-
munity will quite likely lead to a drive for the identification and
development of measures and procedures for targeting, collecting,
analyzing, and reporting H&P data for informing benefit design
decision-making. As with HEDIS, it will likely not be a one size fits
all approach but rather one whose information base walks the fine
line between maximizing comparability across various benefit de-
sign options, on one hand, and the need to accommodate the
individual circumstances of the benefit design options on the other.
Employers will increasingly likely come to recognize that success-
fully negotiating this challenge will enable them to achieve their
objective of maximizing the congruence between their health ben-
efit design and their organizational bottom-line.
This study was funded by an unrestricted educational grant
provided by Centocor Ortho Biotech, Inc. The authors are solely
responsible for all findings and conclusions presented in this
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© 2010 American College of Occupational and Environmental Medicine
JOEM•Volume 52, Number 10, October 2010Evidence-Based Benefit Design