The March issue of Health Affairs, released today, includes a variety of articles revolving around health and wellness, including an examination of mortality rates among American men and women by county. The issue also addresses whether physicians will see a return on investment from the adoption of electronic health records (EHRs), and it raises questions about cost savings from workplace wellness programs and the impact on less healthy workers.

Female mortality rates increased in 42.8 percent of counties in the United States during 1992–2006. Although mortality rates are falling in most counties in the United States, female mortality rates increased in 1,224 counties, compared to an increase in 108 counties for men, write David Kindig, professor emeritus of population health sciences at the University of Wisconsin–Madison, and Erika Cheng, a doctoral candidate there. Their study is the first to examine the relationship between socioeconomic and behavioral factors and mortality at the county level.

The authors found that for both men and women, factors associated with lower mortality included having a college degree, higher median household income, Hispanic ethnicity, and living in a higher population density area. For women, living in counties in the South and West was associated with a 6 percent higher mortality rate than living in the Northeast. Smoking rates were also a key factor in higher mortality rates. The researchers recommend targeted approaches that are suited to the unique needs of a county; they observe that investments in health care, public health, behavioral change, and social and physical environment will be needed to improve mortality rates.

In a related article, Jessica Ho of the University of Pennsylvania reports on her analysis that mortality under age 50 accounts for much of the fact that US life expectancy lags that of other high-income countries. She recommends focusing on prevention of the major causes of death in younger populations, such as unintentional injuries, including drug overdose; noncommunicable diseases; perinatal conditions; and homicide.

The average physician will lose $43,743 over five years after adopting electronic health records. Julia Adler-Milstein of the University of Michigan and coauthors used survey data from forty-nine community practices in a large EHR pilot in Massachusetts and projected that only 27 percent of practices would achieve a positive return on investment in five years; an additional 14 percent would be in the black assuming they received the $44,000 federal meaningful-use incentive. The biggest difference in which practices achieved a positive versus negative return stemmed from whether they used EHRs to increase revenue by seeing more patients or through improved billing. The incentives had a larger impact on practices with more than six physicians and those that provided primary care, compared to smaller and specialty practices.

The most common financial change was a reduction in the cost of paper medical records (seen by 55 percent of respondents), yet almost half of practices did not realize these savings because they continued to keep records on paper. The authors conclude that adoption of EHRs can have a positive financial effect on practices, yet the current incentives tend to favor larger practices. Meaningful-use incentives may therefore not be sufficient to entice practices of varying sizes and types to use EHRs without further guidance on how they can benefit from adoption.

Cost savings from workplace wellness incentives reflect cost shifting to unhealthy workers. The Affordable Care Act encourages workplace wellness programs, chiefly by promoting programs that reward employees for changing health-related behavior or improving measurable health outcomes. Recognizing the risk that unhealthy employees might be punished rather than helped by such programs, the act also forbids health-based discrimination, Jill Horwitz of the University of California, Los Angeles, and colleagues observe.

However, while there may be valid reasons beyond lowering costs to institute workplace wellness programs, there is little evidence that such programs can easily save costs through health improvement without being discriminatory, the authors warn. Savings to employers may come from cost shifting, with the most vulnerable employees — those from lower socioeconomic strata with the most health risks — probably bearing greater costs that in effect subsidize their healthier colleagues, say Horwitz and coauthors.

Another article relating to wellness programs examines the effectiveness of a program put in place by BJC HealthCare, a hospital system based in St. Louis, Missouri, that tied employees’ eligibility to participate in the system’s most generous health plan with participation in a wellness program. Gautam Gowrisankaran of the University of Arizona and coauthors report that the intervention, which began in 2005, was associated with a 41 percent decrease in hospitalizations for conditions targeted by the wellness program but with no significant decrease in other hospitalizations. The researchers found reductions in inpatient costs but similar increases in non-inpatient costs, resulting in no savings for the employer in the short term and underscoring that the ACA’s wellness program incentives are unlikely to greatly reduce health care spending over the short run.

Large variation in cesarean delivery rates. Katy Kozhimannil of the University of Minnesota and coauthors found that rates of cesarean deliveries varied tenfold across US hospitals, from 7.1 percent to 69.9 percent. Because Medicaid pays for nearly half of births in the United States, the government has strong incentive to decrease variation and improve quality in the use of these costly procedures. The authors recommend steps including better coordinating maternity care, collecting and measuring more data, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making.