Journal of Community Health Vol. 1, No. 3, Spring 1976
HEALTH SERVICES, HEALTH STATUS, AND WORK LOSS Robert L. Robertson, Ph.D.
ABSTRACT: The number of workdays lost because of illness, coupled with records of health service utilization patterns, were studied to establish possible links between health status and different forms of p r e p a y m e n t coverage. The records of industrial workers at four branches of the same c o m p a n y were analyzed. Records of employees with broad-benefit coverage were compared with those who had lesscomprehensive indemnity coverage. A free choice of providers was available to the study population. Data for workers covered by the broader plans revealed fewer medical admissions to hospitals, more surgical admissions, and more o u t p a t i e n t physician visits. As hypothesized, their numbers of days absent from work were lower. Because few of these results were statistically significant, caution is necessary in their interpretation. Some aspects of the project warranting further consideration are discussed. Data suggest a positive correlation between breadth of health plan coverage and health status, with possible economic benefits to be derived from such coverage. The data also indicate the desirability of additional in~cestigations to be based on employers' and health plan records, that involve other types of populations and other benefit options. Recently medical
the
interests
of economists,
care specialists have converged
other
social scientists, and
in t h e a s s e s s m e n t o f o u t c o m e s
of
health care services. Despite this upsurge of interest-including cost-benefit studies of health programs-the results have been largely disappointing. In p a r t , t h i s is d u e t o a d i s p e r s a l o f l i m i t e d r e s e a r c h p e r s o n n e l a m o n g m a n y s u b j e c t s , in p a r t , t o a l a c k o f c o n s e n s u s o n t h e c o n c e p t a n d m e a s u r e m e n t o f "outcomes", a n d , in p a r t , t o t h e i n h e r e n t d i f f i c u l t y o f q u a n t i f y i n g t h e important effects of health care. I t is n o t h a r d t o d e f i n e o u t c o m e . I t is " t h e m e a s u r a b l e e f f e c t t h a t a h e a l t h c a r e s y s t e m , e i t h e r i n i t s e n t i r e t y o r in s e l e c t e d c o m p o n e n t s , h a s o n some aspect of health or well-being or on health care behavior .... ,1 Ideally, it s h o u l d b e r e l a t i v e l y e a s y t o i s o l a t e s u c h a r e s u l t , as i n d i c a t e d b y t h e following statement: If it were possible to eliminate those portions of the health impairment burden over which the health service system could have no control, the residual health impairment measure would reflect those
Dr. Robertson is Professor of Economics, Mount Holyoke College, South Hadley, Massachusetts 01075. Part of this work was done while the author was a Senior Associate at the Harvard Center for Community Health and Medical Care. Rashi Fein and John Rapoport reviewed an earlier draft; computational assistance was provided by Jardce Robertson. Robert Prouty, M.D., classified surgical procedures. The author particularly wishes to express gratitude to two persons whose efforts were essential to the study: Fremont C. Gault, retired Director of Employee Benefits, the Weyerhaeuser Company, and Sally Gunderson, medical records specialist. 175
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episodes which could presumptively, or hopefully, be affected by the health service program. 2
However, segregating the impact of medical care u p o n health status from the effects of such other important variables as nutrition, housing, and environmental hazards is n o t easy. a - 6 The field has not yet produced any regular data series that relate health inputs to outputs (in the way that educational inputs are related to earnings, as an estimate o f output), let alone one that ties inputs to health status indicators. Because clarification of key concepts in this area and an estimation of some of the effects of medical care w o u l d yield sufficient insights to policy m a k e r s - b o t h public and private (including governmental officials who allocate resources to health care and employers and p r e p a y m e n t plan officials who often influence health plan b e n e f i t s ) - w e feel such efforts b y researchers w o u l d be justified. The objectives of this paper are twofold: (a) to review some issues concerning measures of health status and to determine an acceptable outcome indicator; (b) to report the results of an empirical study concerning health services utilization and o u t c o m e in the form of reduced time lost from w o r k b y paper workers. These results are integrated with those from an unpublished report and from still another study population whose experience was the subject of earlier papers from this project. 7-9 The usefulness of the methods used in these investigations is considered in conclusion. No a t t e m p t is made here to survey the field of cost-benefit analysis as it relates to the health field 6-8' 10, 11 nor will we examine certain other areas of economic interest. The reader is referred to the references listed.6, 7, 12, 13 This discussion is limited to one of Fuchs' three outputs of health or medical c a r e - e f f e c t s on health status. 5 METHODS
Measures of Health Status Measures of health status and other indicators of outcomes have been explored extensively. 14-17 Still, issues remain to be resolved, and some concepts must be clarified and indicators selected before empirical work can begin. Most n o w agree that the broad definition of health of the World Health Organization fails to provide an operational concept; is a more acceptable approach is to designate one or more elements of health (or of its converse-illness) and measure them. Possible elements are suggested b y White's " 5 D's": death, disease, disability, discomfort, and discontent. 4 Each of these is influenced b y a complex of factors, with health care a significant set. Other measures have been discussed at length. 2' 19-28 The choice for this project is " w o r k loss", that is, days lost from w o r k due to sickness. Data axe available on this measure from the National
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177
Health Survey (for population aggregates). The measure has also been adopted or e n d o r s e d - n o t always to the exclusion of other o p t i o n s - b y several researchers, zT' 29-34 although it has its critics. 13 Our measure appears to meet most, if not all, of the specifications proposed by Shapiro for an end-result indicator and m a n y of the criteria for health status indices stated by other specialists, especially when the "social role" (i.e., customary social activities, including work) of the study group is clear. 17' 23, 3s, 36 This selection meets our need to quantify at least a part of the economic benefits of medical care for a specific employer that would be applicable to other employee populations and also satisfies Moriyama's pragmatic requirement that a measure "be useful for at least one stated purpose which is considered worthwhile", is We are omitting mortality effects of health services (or of their absence) and in addition are joining other writers in urging that someone else quantify the important but complex impact of medical care upon debility or productivity, s, 7, 37 Preliminary attempts at this have been made. 3s, 39 Data Sources
As we reviewed possible sources for data, we decided that the most accessible information of a usable quality on work loss would be that obtained from employer records. Health services data usually can be found elsewhere--for example, in health plan files. These when exploited can help to r e m e d y the situation described by Yett and associates that the uses of National Health Survey figures on work loss and other social role measures are limited "to broad regions and large SMSA's". 36 Our investigation used both specific e m p l o y e r and health plan data. The General Study Plan Four branches of the Weyerhaeuser Company's Pulp and Paperboard Division in the Pacific Northwest at Springfield, Oregon, and Longview, Cosmopolis, and Everett, Washington, were selected for study. Nearly 2,700 men for w h o m detailed one-year records on health services (medical care) utilization and work loss were available made up our study population. The general aim was to compare their experiences as subscribers to three health insurance plans. This enabled us to identify important differences in health service patterns and to estimate certain types of benefits of health plan coverage, as evidenced by less work loss. Hypotheses are detailed below, b u t the two-step reasoning underlying them is presented at this point. 1. The broader benefit provisions of two of the health plans would affect health service use, with benefit scope and utilization usually being correlated positively.
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2. The utilization differences between worker groups would lead to a different health status among groups; generally, the broader benefit plan subscribers' service use patterns are associated with better health status, as measured by less work loss. Research methods are sketched very briefly here as they, like the reasoning behind the hypotheses, have been explained in two prior publications from the same project-these concerned a school-teacher population examined for virtually the same things in the same ways as the industrial workers.S, 9 We compared two study groups: differences between those groups' means (e.g., arithmetic mean days of work loss per year) were tested for statistical significance by t tests. Conventional measures of medical care utilization, like rates of hospital admission and of physician visits, were also compared. All male nonsupervisory employees of Weyerhaeuser's "paper" division in 1966 were covered in the study. The company provided the same income loss protection ("A and H" insurance) to everyone. Their general range of pay, occupation, size of community, and region of the United States were similar; except for variations in age, they comprise substantially comparable study groups. For our project the Weyerhaeuser Company provided information on employee characteristics and on income-loss protection claims for all branches. Data about absences were refined by the study staff until limited to those that were caused by nonoccupational sickness, as industrial illness is not likely to be correlated with health plan coverage. (Employees apparently were motivated to file for state workmen's compensation benefits when eligible, thus helping us to distinguish between the two types of absence.) All nonoccupational sickness episodes that exceeded three days in duration (physician-certified) were used to compile our work-loss figures. Because of a strong company-wide effort since 1964 in "policing" absenteeism through pressures on physicians and workers at all plants, it appears that comparable data existed across the company. An important feature of the study population is its division into three separate groups, according to prepaid health insurance coverage. Under a company-wide collective bargaining agreement applying in 1966, a plantwide choice of health plans was made: (a) Equitable Life Assurance Society of the United States-selected by the Longview and Cosmopolis branches; (b) Snohomish County Physicians Corporation (SCPC)--Everett; (c)Pacific Hospital Associations (PHA)-Springfield. Each of these plans had already been in effect for several years at its respective plant before the employees' 1966 selection time. The Equitable Company at that time underwrote a fairly comprehensive indemnity plan, administered by Weyerhaeuser, covering part or all of the costs of hospitalization, physician (both in and out of hospital), and ancillary services. Among its limitations were a "first call deductible" provision for sickness (but not injury) episodes, a maximum charge on visits and
Health Services, Health Status, and Work Loss
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an annual total physician reimbursement schedule, and a fee schedule for surgical charges. A major medical rider covered part of the additional expenses. The plans of SCPC and PHA were similar to each other. Each was written by a community-based organization with significant physician control. Each offered a very comprehensive benefit package, with few out-ofpocket costs to subscribers for services other than specific items, such as dental care and drugs. In all cases there was a free choice of providers within an area; none of the health programs was linked to a prepaid group practice with a closed panel of providers whose behavior would be affected by strong organizational norms and controls. Information on utilization of insured health services by the study population came from the files of the prepayment firms, except that the data for the Equitable plan were supplied by Weyerhaeuser. These records were very complete, except for the limitations in the Equitable records because of deductible physician visits and in SCPC on ancillary services, such as X-rays, which were provided out-of-hospital. Medical cases were distinguished from surgical ones in coding; obstetrical cases were irrelevant to data on the males. Hypotheses
Grouping the programs with similar coverage, we hypothesized that: 1. Everett-Springfield (E-S) workers will have a somewhat lower rate (arithmetic mean per year) of inpatient (hospital) admissions for medical cases than will the Longview-Cosmopolis (L-C) workers-due to the effects of outpatient care encouraged by the broader outpatient benefits with lower financial barriers of SCPC and PHA relative to Equitable. 2. The E-S workers will have a somewhat higher rate of inpatient admissions for surgical cases--due to the lower financial barriers of SCPC and PHA plans to such care, coupled with the absence of organizational controls over surgery. 3. E-S workers will have a slightly lower rate of inpatient days (medical and surgical total)--due to the positive effects on health status of probably earlier utilization of surgical procedures and outpatient visits under SCPC and PHA, not fully offset by higher surgical admission rates. 4. E-S workers will have a higher rate of outpatient physician visits for medical cases--due to broader coverage. (No clear basis exists for an hypothesis on outpatient visits for surgical needs.) 5. E-S workers will have a somewhat lower rate of work loss--due to the net effect on health status of greater (and probably more timely) outpatient service use and inpatient surgical care. (Weak effects are anticipated in the absence of financial and organizational controls on utilization.)
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For each variable, the annual arithmetic mean was c o m p u t e d for the two pairs of branches and also for each of the four branches separately. All data were adjusted to an annual basis to include persons who did not w o r k for a full year, e.g., a man w h o w o r k e d one-half of the study year and had five days of sickness absence then was charged with ten days of work loss. The effects of age-clearly correlated with health s t a t u s - w e r e handled b y presenting our means in t w o ways: (a) in specific age categories and (b) on an overall, age-adjusted (standardized) basis. For the latter, a variant of the "direct" m e t h o d was used, employing ten-year age intervals and the full paper-worker population as the standard. Although frequency distributions of absences were available, they were not analyzed here. 4° Health Services Hospital inpatient admissions for medical reasons were lower for the Everett-Springfield group, as hypothesized. The mean n u m b e r of annual medical admissions for the E-S workers was below that for the L-C workers in four of the five age groups, as well as on the overall (standardized) basis (see Table 1). Since our sample was small, the lack of statistical significance
TABLE 1 Mean Inpatient Medical Admissions per 1,000 Weyerhaeuser Company Paper Workers* by Age Categories in 1966 Longview-Cosmopolis (n = 1,639)
Everett-Springfield (n = 1,056)
t Value
15-24
18.5 (432)
12.4 (241)
-0.41
25-34
27.1 (443)
16.0 (312)
-0.90
35-44
27.2 (368)
32.3 (217)
0.31
45-54
83.0 (266)
77.8 (180)
-0.14
55-64
99.2 (130)
47.2 (106)
-1.48
Overall** (age-adjusted)
40.5
31.6
-0.97
Age Group
*Data supplied by the Weyerhaeuser Company and Snohomish County Physicians Corporation and Pacific Hospital Association. **Age adjustment is through the "direct" method of standardization.
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TABLE 2 Mean Inpatient Adminissions for Surgical Cases in 1966 per 1,000 Weyerhaeuser Company Paper Workers* t
Age Group
Longview-Cosmopolis
Everett-Springfield
Value
15-24
18.5
37.3
1.17
25--34
36.1
38.5
0.15
35-44
35.3
59.9
1.09
45--54
83.0
38.9
--1.06
55--64
61.1
141.5
1.36
Overall (age-adjusted)
41.5
52.1
0.91
*Sameas Table 1.
is understandable; large differences were not anticipated. (An unexpected result for this variable was revealed in the data for the individual branches. The behavior o f the Everett plant employees was distinctly different from that of the Springfield men, despite their seemingly similar health plans. Small numbers of hospitalizations influenced apparently by random events were involved, as suggested by zero values in certain age cells, but other factors such as personal, physical differences might have been at work.) The hypothesized excess of mean inpatient admissions for surgical cases at the E-S branches was borne out by our data for all but one age category (Table 2). These nonsignificant findings were not appreciably altered when examined by branch. As Table 3 indicates, the difference b e t w e e n the two means of total inpatient days spent by medical and surgical cases was, as predicted, lower for the E-S workers in most age categories. In fact, large differences, significant at the 5% level (in a single-tailed test), were found for one age group and in the overall figures. Individual branches' experiences were similar on the whole, but not in every instance. Although physician visits on an outpatient basis (in home, office, and elsewhere) showed the hypothesized higher values for E-S workers (see Table 4), these differences were not as great as anticipated. Moreover, our results were somewhat weakened by an u n d e r s t a t e m e n t of L-C figures, due to data deficiencies concerning deductible visits. Additional findings, difficult to interpret, revealed the Everett averages to be below (rather than above) the Longview ones for all ages. A few additional findings--not tabulated h e r e - w a r r a n t reporting. The E-S workers showed a shorter average duration of hospitalizations for
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TABLE 3 Mean Inpatient Days for Medical and Surgical Cases in 1966 per 1,000 Weyerhaeuser Company Paper Workers* t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
67.1
141.1
1.12
25-34
503.4
240.4
-0.87
35-44
356.0
373.3
0.08
45-54
1,369.8
461.1
-2.00"*
55-64
1,923.7
943.4
-1.24
630.4
342.7
-2.05"*
Overall (age-adjusted)
*Same as Table 1. **Difference is significant at the 0.05 level (one-tailed test),
most age groups, especially for surgical cases. The overall difference in length of stay is one factor in the appreciably smaller mean number of hospital days noted (Table 3). Such a finding implies clear savings for the subscribers to the SCPC and PHA plans in services used, over those persons covered by Equitable. These resource and cost savings are in addition to others for the Everett-Springfield workers in the form of significantly fewer total physician inpatient visits. One small offset to such economic advantages is the slight excess of total outpatient physician visits (medical plus surgical) apparently TABLE 4 Mean Outpatient Physician Contacts* for Medical Cases in 1966 per Weyerhaeuser Paper Worker** t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
1.16
1.48
0.93
25-34
1.55
1.58
0.11
35-44
1.58
1.72
0.53
45-54
2.42
2.71
0.62
55-64
3.24
2.73
-0.75
Overall (age-adjusted)
1.75
1.87
0.77
*Physician contacts in all locations for non-inpatients;excludes radiology. **Same as Table 1.
Health Services, Health Status, and Work Loss
183
incurred by the E-S workers, and another is the slightly higher annual premiums paid for SCPC and PHA coverage. 41 Work Loss As is customary in such situations, 8' so the time lost from work due to sickness was unevenly distributed among the workers at each plant, with a few employees accounting for much of the absence total. This pattern is accentuated by our lack of information on sicknesses of less than four days' duration. The hypothesis on comparative work loss-involving improved health status with broader plan benefits-was supported by our results. As shown in Table 5, the E-S mean was lower than the L-C mean overall and for all age categories except the oldest one. Incidentally, each branch pair showed the to-be-expected rise in absence with advancing age. None of these differences was statistically significant (with the highest t value being a modest 0.85). However, no major difference between the groups was anticipated and the assessment of chance versus true differences conveyed by a t test is unlikely to be definitive, considering our sample sizes. Findings were similar when the data for the four individual branches' means were compared. DISCUSSION The most important findings (although limited as to statistical significance) from this Weyerhaeuser study were the lower average work loss and TABLE 5 Mean Days of Work Loss* in 1966 per Weyerhaeuser Company Paper Worker** t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
0.50
0.28
0.78
25-34
0.78
0.57
0.69
35-44
0.88
0.57
0.73
45-54
3.85
2.56
0.85
55-64
6.05
7.91
-0.59
Overall (age-adjusted)
1.70
1.47
0.61
*"Mean Days of Work Loss" refers to annual average days (rounded) of absence from work due to sickness, excluding episodes of less than four days' duration. **Computed from data provided by the Weyerhaeuser Company.
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the combination of the somewhat higher use of physicians' services out-ofhospital with the lower rate of medical hospital admissions and fewer days in-hospital for the workers at the Everett and Springfield plants. More surgical care, with an emphasis on those cases requiring shorter hospital stays and some probable benefits to health, was exhibited by the E-S pair. (A special sub-study of surgery at all branches was made, including classification by a physician of elective versus nonelective procedures. The results indicated a lower proportion of classifiable cases that were elective at E-S, including such procedures as vasectomies.) It appears, therefore, that the main impact of the broader financial protection of the E-S health plans came from inducing earlier surgical and medical care (hence, the comparatively short hospitalizations); the smaller volume of elective procedures there probably was a function of different physician treatment practices or of other variables not measured in the study. The principal findings suggest (albeit with limited statistical impact) that the E-S men's greater protection from the burden of medical expenses for certain health services affected the pattern of care they received and, with it, their health status as measured by time lost from work due to sickness. Admittedly, the evidence here is mixed on some points and limited by the partially erratic behavior of the Everett group regarding some utilization variables. This behavior may reflect a different incidence of disease hazards encountered. The fact that there was no information on very short absences should be recalled as a further caution. Economic benefits, through reduced time loss, and savings, because of fewer medical services consumed, do appear to accompany a better health status for employees at the two branches electing the broad communitybased prepayment programs rather than the more restrictive indemnity plan. These results, especially if supported by additional studies, should interest others who are concerned with health care, such as the promoters of health maintenance organizations. Conclusions based on the Weyerhaeuser study are reinforced by the results of two other components of the same long-term research project. For a population of about 3,000 public school teachers in a western city, their work-loss experience again suggested a gain in health status as a result of broader coverage, particularly when coupled with a prepaid group practice plan; this was more evident for the women than for the men. 8 The related medical care utilization data indicated greater outpatient medical contacts and savings in hospitalization and certain types of surgical care for the teachers covered by the comprehensive, prepaid group practice plan, compared with the group subscribing to a "free-choice" Blue Cross/Blue Shield type plan. 9 An unpublished study of a much smaller population of male bus drivers in the same city also displayed a clear advantage in terms of less work loss for the men covered by a prepaid group practice than for those with a broad-benefit, free-choice plan. (The bus drivers in the group practice plan
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had the same policy as the teachers.) These findings (all adjusted for age differences between comparison groups) are in the expected direction, but they do not allow us to separate the effects of prepaid group programswhose organizational and financial features probably are very i m p o r t a n t - f r o m the impact of broad-benefit coverage under any type of prepayment plan and provider arrangements, az The Weyerhaeuser research study, like the others, was based on the premise that case studies are necessary to establish clear linkages between health insurance scope, medical care use, and health status outcomes, for these links have not been well established by more aggregative analyses. By exploiting opportunities that are not usually available, we have been able to link data on work loss and related measures for a fairly large number of specific individuals. While this m e t h o d has parallels in the literature of industrial medicine, it adds another dimension to reports from some other fields in which results for national, regional, or other broad aggregates have been presented. 43 No single study can be equally applicable to all situations. However, the results for the paper workers and those for the school teachers (and, conceivably, bus drivers) appear pertinent to other employee populations covered by similar prepayment options. The benefits at Weyerhaeuser and for the other employers studied were broader than those enjoyed by most Americans at that time, particularly with respect to out-of-hospital physician coverage, a4 However, as coverage has generally expanded since the study period to approximate more closely that of the cases examined, the applicability of our results has also increased. The prime requisite for this kind of research is sound data, analyzed only so far as their nature permits, as For this reason, detailed f'des on work loss and utilization experiences of all employees were used. Age is the crucial sociodemographic characteristic of the men and was controlled for through a conventional age-adjustment (standardization) device and through agespecific analyses. Another variable that has been shown to be important to heaIth is the educational level. 46 Although not studied explicitly for the paper company's manual workers or for teachers, it is unlikely to confound any of our results, as the years of schooling probably vary within narrow limits in each population. Two other variables that were not considered, because of their correlation with age, were the length of employment by the company and the rate of earnings (which some have seen as important in other contexts), x3 A possible extension of this kind of work, when feasible, would be the comparison among health plan groups of "before-after" changes when employee benefit coverages have been expanded. For example, such a project would have been practicable at Weyerhaeuser after post-1966 plan changes. In summary, this paper tests several hypotheses concerning the effect
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of health plan coverage upon medical care use and health status, as measured by the number of days lost to work by sickness. Although the data are not statistically overwhelming, they appear to point quite consistently toward the expected relationships among variables and to suggest the feasibility and desirability of further investigations of this type. Important public and private policies might be influenced by the results of such extensions of applied community health research. REFERENCES 1. Densen PM, Lee SS, Kasey EH (eds): Discussion. In University Medical Programs: Evaluation. DHEW Pub. No. HSM 72-3010. Government Printing Office, 1972. Pp 113-116. 2. Houten DT, DuBois DM: A trial method for combined end result and process evaluation of health service systems. In Densen PM, Lee SS, Kasey EH (eds.): University Medical Programs: Evaluation. DHEW Pub. No. HSM 72-3010. Government Printing Office, 1972. Pp 55-74. 3. Gellman DD: The price of progress: Technology and the cost of medical care. Can Med Assoc J 104:401-406, 1971. 4. White KL: Evaluation of medical education and health care. In Lathem W, Newburg A (eds): Community Medicine. New York, Appleton-Century-Crofts, 1970. Pp 241-262. 5. Fuchs VR: The contribution of health services to the American economy. Milbank Mere Fund Q
44:65-103, 1966. 6. Fein R: On measuring economic benefits of health programs. In Medical History and Medical Care. London, Oxford University Press, 1971. Pp 181-217. 7. Robertson RL: Issues in measuring the economic effects of personal health services. Med Care 5:362-368, 1967. 8. Robertson RL: Economic effects of personal health services: Work loss in a public school teacher population. A m ] Public Health 61: 30--45, 1971. 9. Robertson RL: Comparative medical care use under prepaid group practice and free choice plans: A case study. Inquiry 9: 70-76, 1972. 10. Grosse RN: Cost-benefit analysis of health services. The Annals o f the American Academy o f Political and Social Science 399:89-99, 1972. 11. Menz FC: Economics of disease prevention: Infectious kidney disease. Inquiry 8:3-18, 1971. 12. Klarman HE: The Economics o f Health. New York, Columbia University Press, 1965. Pp 162-164. 13. Silver M: An economic analysis of variations in medical expenses and work-loss rates. In Klarman HE (ed): Empirical Studies in Health Economics. Baltimore, Johns Hopkins Press, 1970. Pp 121-140. 14. Sullivan DF: Conceptual Problems in Developing an Index o f Health. PHS Pub. No. 1000, Series 2, No. 17. Washington, DC, Public Health Service, 1965. 15. Sullivan DF: Disability Components for an Index o f Health. PHS Pub. No. 1000, Series 2, No. 42. Rockville, Md, Public Health Service, 1971. 16. Roemer MI: Evaluation of health service programs and levels of measurement. HSMHA Health Reports 86:839-848, 1971. 17. Goldsmith SB: The status of health status indicators. HSMHA Health Reports 87:212-220, 1972. 18. Moriyama IM: Problems in the measurement of health status. In Sheldon EB, Moore WE (eds): Indicators o f Social Change. New York, Russell Sage Foundation, 1968. Pp 573-600. 19. Sanders BS: Measuring community health levels. A m J Public Health 54:1063-1070, 1964. 20. Michael JM, et al: A basic information system for health planning. Public Health Rep 83:21-28, 1968. 21. Department of Health, Education, and Welfare: Toward a Social Report. Government Printing Office, 1969. 22. Taeuber KE: Review of Department of Health, Education, and Welfare: Toward a Social Report. ] Human Resources 5: 354-360, 1970. 23. Bickner RE: Measurements and indices of health. In Hopkins CE (ed): Methodology o f Identiflying, Measuring and Evaluating Outcomes o f Health Service Programs, Systems and Subsystems. Government Printing Office, 1969. Pp 133-149. 24. Lerner M: The level of physical health of the poverty population. Med Care 6:355-367, 1968.
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25. Auster R, Leveson I, Surachek D: The production of health, an exploratory study. J Human Resources 4:411-436, 1969. 26. Stewart CT: Allocation of resources to health. J Human Resources 6:103-122, 1971. 27. Shapiro S, Fink R, Rosenberg C: A program to measure the impact of multiphasic health testing on health differentials between poverty and nonpoverty groups. Med Care 10:207-214, 1972. 28. Kaplan RS, Lave LB, Leinhardt S: The efficacy of a comprehensive health care project-an empirical analysis. A m J Public Health 62: 924-930, 1972. 29. Department of Health, Education, and Welfare: Disability Days: United States-July 1 9 6 5 - J u n e 1966. PHS Pub. No. 1000, Series 10, No. 47. Washington, DC, Public Health Service, 1968. 30. Smith DJ: Absenteeism and "presenteeism" in industry. Arch Environ Health 21: 670-677, 1970. 31. Smith DJ: Absenteeism in industry. I l l M e d J 129:225-229, 1966. 32. Enterline PE: Social causes of sick absence. Arc Environ Health 12:467-472, 1966. 33. Wolfe H: A technique for assessing attrition, absenteeism and lateness among nursing personnel. Health Sero Res 2: 140-153, 1967. 34. McCaffree KM: The economic basis for the development of community health programs. Med Care 6: 286-299, 1968. 35. Shapiro S: End result measurements of quality of medical care. Milbank Mem Fund Q 45:7-30, 1967. 36. Yett DE, et al: Determination o f Economic Attributes o f Community Health Profiles and Health Indices. Los Angeles, University of Southern California, Human Resources Study Center, 1970. 37. Fein R: Health programs and economic development. In The Economics o f Health and Medical Care. Ann Arbor, University of Michigan, 1964. Pp. 271-282. 38. Weisbrod BA, Andreano RL, Baldwin RE, et al: Disease and Economic Development. Madison, University o f Wisconsin Press, 1973. 39. Leveson I, Ullman D, Wassail G: Effects of health on education and productivity. Inquiry 6:3-11, 1969. 40. Glasser JH: A stochastic model for industrial illness absenteeism. A m f Public Health 60: 1936-1444, 1970. 41. Gault FC (retired Director of Employee Benefits of the Weyerhaeuser Co.): Personal communication to the author, July 26, 1972. 42. Gerber A, Robertson RL: Letters to the Editor. A m f Public Health 61:901-903, 1971. 43. Newhouse JP: Determinants of days lost from work due to sickness. In Klarman HE (ed): Empirical Studies in Health Economics. Baltimore, Johns Hopkins Press, 1970. Pp 59-70. 44. Reed LS, Cart W: Private health insurance in the United States, 1967. Social Security Bulletin 32:4, 1969. 45. Leontief W: Theoretical assumptions and nonobserved facts. A m Econ Rev 61: 1-7, 1971. 46. Fuchs VR, Grossman M: The correlation between health and schooling. Unpublished, undated paper.
HEALTH SERVICES, HEALTH STATUS, AND WORK LOSS Robert L. Robertson, Ph.D.
ABSTRACT: The number of workdays lost because of illness, coupled with records of health service utilization patterns, were studied to establish possible links between health status and different forms of p r e p a y m e n t coverage. The records of industrial workers at four branches of the same c o m p a n y were analyzed. Records of employees with broad-benefit coverage were compared with those who had lesscomprehensive indemnity coverage. A free choice of providers was available to the study population. Data for workers covered by the broader plans revealed fewer medical admissions to hospitals, more surgical admissions, and more o u t p a t i e n t physician visits. As hypothesized, their numbers of days absent from work were lower. Because few of these results were statistically significant, caution is necessary in their interpretation. Some aspects of the project warranting further consideration are discussed. Data suggest a positive correlation between breadth of health plan coverage and health status, with possible economic benefits to be derived from such coverage. The data also indicate the desirability of additional in~cestigations to be based on employers' and health plan records, that involve other types of populations and other benefit options. Recently medical
the
interests
of economists,
care specialists have converged
other
social scientists, and
in t h e a s s e s s m e n t o f o u t c o m e s
of
health care services. Despite this upsurge of interest-including cost-benefit studies of health programs-the results have been largely disappointing. In p a r t , t h i s is d u e t o a d i s p e r s a l o f l i m i t e d r e s e a r c h p e r s o n n e l a m o n g m a n y s u b j e c t s , in p a r t , t o a l a c k o f c o n s e n s u s o n t h e c o n c e p t a n d m e a s u r e m e n t o f "outcomes", a n d , in p a r t , t o t h e i n h e r e n t d i f f i c u l t y o f q u a n t i f y i n g t h e important effects of health care. I t is n o t h a r d t o d e f i n e o u t c o m e . I t is " t h e m e a s u r a b l e e f f e c t t h a t a h e a l t h c a r e s y s t e m , e i t h e r i n i t s e n t i r e t y o r in s e l e c t e d c o m p o n e n t s , h a s o n some aspect of health or well-being or on health care behavior .... ,1 Ideally, it s h o u l d b e r e l a t i v e l y e a s y t o i s o l a t e s u c h a r e s u l t , as i n d i c a t e d b y t h e following statement: If it were possible to eliminate those portions of the health impairment burden over which the health service system could have no control, the residual health impairment measure would reflect those
Dr. Robertson is Professor of Economics, Mount Holyoke College, South Hadley, Massachusetts 01075. Part of this work was done while the author was a Senior Associate at the Harvard Center for Community Health and Medical Care. Rashi Fein and John Rapoport reviewed an earlier draft; computational assistance was provided by Jardce Robertson. Robert Prouty, M.D., classified surgical procedures. The author particularly wishes to express gratitude to two persons whose efforts were essential to the study: Fremont C. Gault, retired Director of Employee Benefits, the Weyerhaeuser Company, and Sally Gunderson, medical records specialist. 175
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episodes which could presumptively, or hopefully, be affected by the health service program. 2
However, segregating the impact of medical care u p o n health status from the effects of such other important variables as nutrition, housing, and environmental hazards is n o t easy. a - 6 The field has not yet produced any regular data series that relate health inputs to outputs (in the way that educational inputs are related to earnings, as an estimate o f output), let alone one that ties inputs to health status indicators. Because clarification of key concepts in this area and an estimation of some of the effects of medical care w o u l d yield sufficient insights to policy m a k e r s - b o t h public and private (including governmental officials who allocate resources to health care and employers and p r e p a y m e n t plan officials who often influence health plan b e n e f i t s ) - w e feel such efforts b y researchers w o u l d be justified. The objectives of this paper are twofold: (a) to review some issues concerning measures of health status and to determine an acceptable outcome indicator; (b) to report the results of an empirical study concerning health services utilization and o u t c o m e in the form of reduced time lost from w o r k b y paper workers. These results are integrated with those from an unpublished report and from still another study population whose experience was the subject of earlier papers from this project. 7-9 The usefulness of the methods used in these investigations is considered in conclusion. No a t t e m p t is made here to survey the field of cost-benefit analysis as it relates to the health field 6-8' 10, 11 nor will we examine certain other areas of economic interest. The reader is referred to the references listed.6, 7, 12, 13 This discussion is limited to one of Fuchs' three outputs of health or medical c a r e - e f f e c t s on health status. 5 METHODS
Measures of Health Status Measures of health status and other indicators of outcomes have been explored extensively. 14-17 Still, issues remain to be resolved, and some concepts must be clarified and indicators selected before empirical work can begin. Most n o w agree that the broad definition of health of the World Health Organization fails to provide an operational concept; is a more acceptable approach is to designate one or more elements of health (or of its converse-illness) and measure them. Possible elements are suggested b y White's " 5 D's": death, disease, disability, discomfort, and discontent. 4 Each of these is influenced b y a complex of factors, with health care a significant set. Other measures have been discussed at length. 2' 19-28 The choice for this project is " w o r k loss", that is, days lost from w o r k due to sickness. Data axe available on this measure from the National
Health Services, Health Status, and Work Loss
177
Health Survey (for population aggregates). The measure has also been adopted or e n d o r s e d - n o t always to the exclusion of other o p t i o n s - b y several researchers, zT' 29-34 although it has its critics. 13 Our measure appears to meet most, if not all, of the specifications proposed by Shapiro for an end-result indicator and m a n y of the criteria for health status indices stated by other specialists, especially when the "social role" (i.e., customary social activities, including work) of the study group is clear. 17' 23, 3s, 36 This selection meets our need to quantify at least a part of the economic benefits of medical care for a specific employer that would be applicable to other employee populations and also satisfies Moriyama's pragmatic requirement that a measure "be useful for at least one stated purpose which is considered worthwhile", is We are omitting mortality effects of health services (or of their absence) and in addition are joining other writers in urging that someone else quantify the important but complex impact of medical care upon debility or productivity, s, 7, 37 Preliminary attempts at this have been made. 3s, 39 Data Sources
As we reviewed possible sources for data, we decided that the most accessible information of a usable quality on work loss would be that obtained from employer records. Health services data usually can be found elsewhere--for example, in health plan files. These when exploited can help to r e m e d y the situation described by Yett and associates that the uses of National Health Survey figures on work loss and other social role measures are limited "to broad regions and large SMSA's". 36 Our investigation used both specific e m p l o y e r and health plan data. The General Study Plan Four branches of the Weyerhaeuser Company's Pulp and Paperboard Division in the Pacific Northwest at Springfield, Oregon, and Longview, Cosmopolis, and Everett, Washington, were selected for study. Nearly 2,700 men for w h o m detailed one-year records on health services (medical care) utilization and work loss were available made up our study population. The general aim was to compare their experiences as subscribers to three health insurance plans. This enabled us to identify important differences in health service patterns and to estimate certain types of benefits of health plan coverage, as evidenced by less work loss. Hypotheses are detailed below, b u t the two-step reasoning underlying them is presented at this point. 1. The broader benefit provisions of two of the health plans would affect health service use, with benefit scope and utilization usually being correlated positively.
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2. The utilization differences between worker groups would lead to a different health status among groups; generally, the broader benefit plan subscribers' service use patterns are associated with better health status, as measured by less work loss. Research methods are sketched very briefly here as they, like the reasoning behind the hypotheses, have been explained in two prior publications from the same project-these concerned a school-teacher population examined for virtually the same things in the same ways as the industrial workers.S, 9 We compared two study groups: differences between those groups' means (e.g., arithmetic mean days of work loss per year) were tested for statistical significance by t tests. Conventional measures of medical care utilization, like rates of hospital admission and of physician visits, were also compared. All male nonsupervisory employees of Weyerhaeuser's "paper" division in 1966 were covered in the study. The company provided the same income loss protection ("A and H" insurance) to everyone. Their general range of pay, occupation, size of community, and region of the United States were similar; except for variations in age, they comprise substantially comparable study groups. For our project the Weyerhaeuser Company provided information on employee characteristics and on income-loss protection claims for all branches. Data about absences were refined by the study staff until limited to those that were caused by nonoccupational sickness, as industrial illness is not likely to be correlated with health plan coverage. (Employees apparently were motivated to file for state workmen's compensation benefits when eligible, thus helping us to distinguish between the two types of absence.) All nonoccupational sickness episodes that exceeded three days in duration (physician-certified) were used to compile our work-loss figures. Because of a strong company-wide effort since 1964 in "policing" absenteeism through pressures on physicians and workers at all plants, it appears that comparable data existed across the company. An important feature of the study population is its division into three separate groups, according to prepaid health insurance coverage. Under a company-wide collective bargaining agreement applying in 1966, a plantwide choice of health plans was made: (a) Equitable Life Assurance Society of the United States-selected by the Longview and Cosmopolis branches; (b) Snohomish County Physicians Corporation (SCPC)--Everett; (c)Pacific Hospital Associations (PHA)-Springfield. Each of these plans had already been in effect for several years at its respective plant before the employees' 1966 selection time. The Equitable Company at that time underwrote a fairly comprehensive indemnity plan, administered by Weyerhaeuser, covering part or all of the costs of hospitalization, physician (both in and out of hospital), and ancillary services. Among its limitations were a "first call deductible" provision for sickness (but not injury) episodes, a maximum charge on visits and
Health Services, Health Status, and Work Loss
179
an annual total physician reimbursement schedule, and a fee schedule for surgical charges. A major medical rider covered part of the additional expenses. The plans of SCPC and PHA were similar to each other. Each was written by a community-based organization with significant physician control. Each offered a very comprehensive benefit package, with few out-ofpocket costs to subscribers for services other than specific items, such as dental care and drugs. In all cases there was a free choice of providers within an area; none of the health programs was linked to a prepaid group practice with a closed panel of providers whose behavior would be affected by strong organizational norms and controls. Information on utilization of insured health services by the study population came from the files of the prepayment firms, except that the data for the Equitable plan were supplied by Weyerhaeuser. These records were very complete, except for the limitations in the Equitable records because of deductible physician visits and in SCPC on ancillary services, such as X-rays, which were provided out-of-hospital. Medical cases were distinguished from surgical ones in coding; obstetrical cases were irrelevant to data on the males. Hypotheses
Grouping the programs with similar coverage, we hypothesized that: 1. Everett-Springfield (E-S) workers will have a somewhat lower rate (arithmetic mean per year) of inpatient (hospital) admissions for medical cases than will the Longview-Cosmopolis (L-C) workers-due to the effects of outpatient care encouraged by the broader outpatient benefits with lower financial barriers of SCPC and PHA relative to Equitable. 2. The E-S workers will have a somewhat higher rate of inpatient admissions for surgical cases--due to the lower financial barriers of SCPC and PHA plans to such care, coupled with the absence of organizational controls over surgery. 3. E-S workers will have a slightly lower rate of inpatient days (medical and surgical total)--due to the positive effects on health status of probably earlier utilization of surgical procedures and outpatient visits under SCPC and PHA, not fully offset by higher surgical admission rates. 4. E-S workers will have a higher rate of outpatient physician visits for medical cases--due to broader coverage. (No clear basis exists for an hypothesis on outpatient visits for surgical needs.) 5. E-S workers will have a somewhat lower rate of work loss--due to the net effect on health status of greater (and probably more timely) outpatient service use and inpatient surgical care. (Weak effects are anticipated in the absence of financial and organizational controls on utilization.)
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For each variable, the annual arithmetic mean was c o m p u t e d for the two pairs of branches and also for each of the four branches separately. All data were adjusted to an annual basis to include persons who did not w o r k for a full year, e.g., a man w h o w o r k e d one-half of the study year and had five days of sickness absence then was charged with ten days of work loss. The effects of age-clearly correlated with health s t a t u s - w e r e handled b y presenting our means in t w o ways: (a) in specific age categories and (b) on an overall, age-adjusted (standardized) basis. For the latter, a variant of the "direct" m e t h o d was used, employing ten-year age intervals and the full paper-worker population as the standard. Although frequency distributions of absences were available, they were not analyzed here. 4° Health Services Hospital inpatient admissions for medical reasons were lower for the Everett-Springfield group, as hypothesized. The mean n u m b e r of annual medical admissions for the E-S workers was below that for the L-C workers in four of the five age groups, as well as on the overall (standardized) basis (see Table 1). Since our sample was small, the lack of statistical significance
TABLE 1 Mean Inpatient Medical Admissions per 1,000 Weyerhaeuser Company Paper Workers* by Age Categories in 1966 Longview-Cosmopolis (n = 1,639)
Everett-Springfield (n = 1,056)
t Value
15-24
18.5 (432)
12.4 (241)
-0.41
25-34
27.1 (443)
16.0 (312)
-0.90
35-44
27.2 (368)
32.3 (217)
0.31
45-54
83.0 (266)
77.8 (180)
-0.14
55-64
99.2 (130)
47.2 (106)
-1.48
Overall** (age-adjusted)
40.5
31.6
-0.97
Age Group
*Data supplied by the Weyerhaeuser Company and Snohomish County Physicians Corporation and Pacific Hospital Association. **Age adjustment is through the "direct" method of standardization.
Health Services, Health Status, and Work Loss
181
TABLE 2 Mean Inpatient Adminissions for Surgical Cases in 1966 per 1,000 Weyerhaeuser Company Paper Workers* t
Age Group
Longview-Cosmopolis
Everett-Springfield
Value
15-24
18.5
37.3
1.17
25--34
36.1
38.5
0.15
35-44
35.3
59.9
1.09
45--54
83.0
38.9
--1.06
55--64
61.1
141.5
1.36
Overall (age-adjusted)
41.5
52.1
0.91
*Sameas Table 1.
is understandable; large differences were not anticipated. (An unexpected result for this variable was revealed in the data for the individual branches. The behavior o f the Everett plant employees was distinctly different from that of the Springfield men, despite their seemingly similar health plans. Small numbers of hospitalizations influenced apparently by random events were involved, as suggested by zero values in certain age cells, but other factors such as personal, physical differences might have been at work.) The hypothesized excess of mean inpatient admissions for surgical cases at the E-S branches was borne out by our data for all but one age category (Table 2). These nonsignificant findings were not appreciably altered when examined by branch. As Table 3 indicates, the difference b e t w e e n the two means of total inpatient days spent by medical and surgical cases was, as predicted, lower for the E-S workers in most age categories. In fact, large differences, significant at the 5% level (in a single-tailed test), were found for one age group and in the overall figures. Individual branches' experiences were similar on the whole, but not in every instance. Although physician visits on an outpatient basis (in home, office, and elsewhere) showed the hypothesized higher values for E-S workers (see Table 4), these differences were not as great as anticipated. Moreover, our results were somewhat weakened by an u n d e r s t a t e m e n t of L-C figures, due to data deficiencies concerning deductible visits. Additional findings, difficult to interpret, revealed the Everett averages to be below (rather than above) the Longview ones for all ages. A few additional findings--not tabulated h e r e - w a r r a n t reporting. The E-S workers showed a shorter average duration of hospitalizations for
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TABLE 3 Mean Inpatient Days for Medical and Surgical Cases in 1966 per 1,000 Weyerhaeuser Company Paper Workers* t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
67.1
141.1
1.12
25-34
503.4
240.4
-0.87
35-44
356.0
373.3
0.08
45-54
1,369.8
461.1
-2.00"*
55-64
1,923.7
943.4
-1.24
630.4
342.7
-2.05"*
Overall (age-adjusted)
*Same as Table 1. **Difference is significant at the 0.05 level (one-tailed test),
most age groups, especially for surgical cases. The overall difference in length of stay is one factor in the appreciably smaller mean number of hospital days noted (Table 3). Such a finding implies clear savings for the subscribers to the SCPC and PHA plans in services used, over those persons covered by Equitable. These resource and cost savings are in addition to others for the Everett-Springfield workers in the form of significantly fewer total physician inpatient visits. One small offset to such economic advantages is the slight excess of total outpatient physician visits (medical plus surgical) apparently TABLE 4 Mean Outpatient Physician Contacts* for Medical Cases in 1966 per Weyerhaeuser Paper Worker** t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
1.16
1.48
0.93
25-34
1.55
1.58
0.11
35-44
1.58
1.72
0.53
45-54
2.42
2.71
0.62
55-64
3.24
2.73
-0.75
Overall (age-adjusted)
1.75
1.87
0.77
*Physician contacts in all locations for non-inpatients;excludes radiology. **Same as Table 1.
Health Services, Health Status, and Work Loss
183
incurred by the E-S workers, and another is the slightly higher annual premiums paid for SCPC and PHA coverage. 41 Work Loss As is customary in such situations, 8' so the time lost from work due to sickness was unevenly distributed among the workers at each plant, with a few employees accounting for much of the absence total. This pattern is accentuated by our lack of information on sicknesses of less than four days' duration. The hypothesis on comparative work loss-involving improved health status with broader plan benefits-was supported by our results. As shown in Table 5, the E-S mean was lower than the L-C mean overall and for all age categories except the oldest one. Incidentally, each branch pair showed the to-be-expected rise in absence with advancing age. None of these differences was statistically significant (with the highest t value being a modest 0.85). However, no major difference between the groups was anticipated and the assessment of chance versus true differences conveyed by a t test is unlikely to be definitive, considering our sample sizes. Findings were similar when the data for the four individual branches' means were compared. DISCUSSION The most important findings (although limited as to statistical significance) from this Weyerhaeuser study were the lower average work loss and TABLE 5 Mean Days of Work Loss* in 1966 per Weyerhaeuser Company Paper Worker** t
Age Group
Longview-Cosmopolis Everett-Springfield Value
15-24
0.50
0.28
0.78
25-34
0.78
0.57
0.69
35-44
0.88
0.57
0.73
45-54
3.85
2.56
0.85
55-64
6.05
7.91
-0.59
Overall (age-adjusted)
1.70
1.47
0.61
*"Mean Days of Work Loss" refers to annual average days (rounded) of absence from work due to sickness, excluding episodes of less than four days' duration. **Computed from data provided by the Weyerhaeuser Company.
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the combination of the somewhat higher use of physicians' services out-ofhospital with the lower rate of medical hospital admissions and fewer days in-hospital for the workers at the Everett and Springfield plants. More surgical care, with an emphasis on those cases requiring shorter hospital stays and some probable benefits to health, was exhibited by the E-S pair. (A special sub-study of surgery at all branches was made, including classification by a physician of elective versus nonelective procedures. The results indicated a lower proportion of classifiable cases that were elective at E-S, including such procedures as vasectomies.) It appears, therefore, that the main impact of the broader financial protection of the E-S health plans came from inducing earlier surgical and medical care (hence, the comparatively short hospitalizations); the smaller volume of elective procedures there probably was a function of different physician treatment practices or of other variables not measured in the study. The principal findings suggest (albeit with limited statistical impact) that the E-S men's greater protection from the burden of medical expenses for certain health services affected the pattern of care they received and, with it, their health status as measured by time lost from work due to sickness. Admittedly, the evidence here is mixed on some points and limited by the partially erratic behavior of the Everett group regarding some utilization variables. This behavior may reflect a different incidence of disease hazards encountered. The fact that there was no information on very short absences should be recalled as a further caution. Economic benefits, through reduced time loss, and savings, because of fewer medical services consumed, do appear to accompany a better health status for employees at the two branches electing the broad communitybased prepayment programs rather than the more restrictive indemnity plan. These results, especially if supported by additional studies, should interest others who are concerned with health care, such as the promoters of health maintenance organizations. Conclusions based on the Weyerhaeuser study are reinforced by the results of two other components of the same long-term research project. For a population of about 3,000 public school teachers in a western city, their work-loss experience again suggested a gain in health status as a result of broader coverage, particularly when coupled with a prepaid group practice plan; this was more evident for the women than for the men. 8 The related medical care utilization data indicated greater outpatient medical contacts and savings in hospitalization and certain types of surgical care for the teachers covered by the comprehensive, prepaid group practice plan, compared with the group subscribing to a "free-choice" Blue Cross/Blue Shield type plan. 9 An unpublished study of a much smaller population of male bus drivers in the same city also displayed a clear advantage in terms of less work loss for the men covered by a prepaid group practice than for those with a broad-benefit, free-choice plan. (The bus drivers in the group practice plan
Health Services, Health Status, and Work Loss
185
had the same policy as the teachers.) These findings (all adjusted for age differences between comparison groups) are in the expected direction, but they do not allow us to separate the effects of prepaid group programswhose organizational and financial features probably are very i m p o r t a n t - f r o m the impact of broad-benefit coverage under any type of prepayment plan and provider arrangements, az The Weyerhaeuser research study, like the others, was based on the premise that case studies are necessary to establish clear linkages between health insurance scope, medical care use, and health status outcomes, for these links have not been well established by more aggregative analyses. By exploiting opportunities that are not usually available, we have been able to link data on work loss and related measures for a fairly large number of specific individuals. While this m e t h o d has parallels in the literature of industrial medicine, it adds another dimension to reports from some other fields in which results for national, regional, or other broad aggregates have been presented. 43 No single study can be equally applicable to all situations. However, the results for the paper workers and those for the school teachers (and, conceivably, bus drivers) appear pertinent to other employee populations covered by similar prepayment options. The benefits at Weyerhaeuser and for the other employers studied were broader than those enjoyed by most Americans at that time, particularly with respect to out-of-hospital physician coverage, a4 However, as coverage has generally expanded since the study period to approximate more closely that of the cases examined, the applicability of our results has also increased. The prime requisite for this kind of research is sound data, analyzed only so far as their nature permits, as For this reason, detailed f'des on work loss and utilization experiences of all employees were used. Age is the crucial sociodemographic characteristic of the men and was controlled for through a conventional age-adjustment (standardization) device and through agespecific analyses. Another variable that has been shown to be important to heaIth is the educational level. 46 Although not studied explicitly for the paper company's manual workers or for teachers, it is unlikely to confound any of our results, as the years of schooling probably vary within narrow limits in each population. Two other variables that were not considered, because of their correlation with age, were the length of employment by the company and the rate of earnings (which some have seen as important in other contexts), x3 A possible extension of this kind of work, when feasible, would be the comparison among health plan groups of "before-after" changes when employee benefit coverages have been expanded. For example, such a project would have been practicable at Weyerhaeuser after post-1966 plan changes. In summary, this paper tests several hypotheses concerning the effect
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of health plan coverage upon medical care use and health status, as measured by the number of days lost to work by sickness. Although the data are not statistically overwhelming, they appear to point quite consistently toward the expected relationships among variables and to suggest the feasibility and desirability of further investigations of this type. Important public and private policies might be influenced by the results of such extensions of applied community health research. REFERENCES 1. Densen PM, Lee SS, Kasey EH (eds): Discussion. In University Medical Programs: Evaluation. DHEW Pub. No. HSM 72-3010. Government Printing Office, 1972. Pp 113-116. 2. Houten DT, DuBois DM: A trial method for combined end result and process evaluation of health service systems. In Densen PM, Lee SS, Kasey EH (eds.): University Medical Programs: Evaluation. DHEW Pub. No. HSM 72-3010. Government Printing Office, 1972. Pp 55-74. 3. Gellman DD: The price of progress: Technology and the cost of medical care. Can Med Assoc J 104:401-406, 1971. 4. White KL: Evaluation of medical education and health care. In Lathem W, Newburg A (eds): Community Medicine. New York, Appleton-Century-Crofts, 1970. Pp 241-262. 5. Fuchs VR: The contribution of health services to the American economy. Milbank Mere Fund Q
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