US employers often provide benefits to their employees that pay a portion of the costs of medical services and prescriptions for employees and their dependents. Some US employers also provide a benefit, typically called sick leave, that replaces an employee’s salary during absences that result from illness (typically lasting less than 2 weeks) and may include paid personal time off. Some employers provide additional coverage to their employees for longer illnesses. Short-term disability usually pays 50% to 70% of salary for illnesses that last between 10 weeks and 26 weeks of duration.1 If the illness continues longer than 6 months, the employee begins using long-term disability, which can have various conditions for payout, diseases that are covered, and pre-existing conditions that are excluded.1 Medical costs and partial salary replacement (typically 66%-80%2) for workplace illnesses and accidents are provided through workers’ compensation coverage.
The 2020 Kaiser Family Foundation survey on employer health benefits provides an excellent overview of typical employer coverage for direct medical and prescription health insurance costs,3 but does not include any information on sick leave, short-term disability, long-term disability, or workers’ compensation. The Society for Human Resource Management 2019 health benefits survey provided statistics on the availability of short-term disability, long-term disability, and workers’ compensation benefits, but it did not include information on benefit use.4
Absences resulting from sick leave, short-term disability, long-term disability, and workers’ compensation can have a significant impact on business performance. Employers are increasing their attempts to manage these benefits and help employees improve their health. Several studies and initiatives5-9 have estimated the number of days of employee absences using subjective survey data or proxies based on the location of medical care (eg, office visits count as 1 half day of absence, emergency department visits count as 1 full day of absence, and hospitalizations count as 1 day of absence for each day in the hospital).5 Absence costs are often estimated in published research using the average salary in the United States rather than the actual amount paid to the employee for time missed because of their absence, and studies6,8 often assume that the percent of salary received is the same, regardless of benefit. These estimates often combine short-term and long-term disability benefits and may not include workers’ compensation. Some researchers develop extensive models of absence predictors and then multiply the estimated absence time by constant dollars and fixed salary-replacement percentages to estimate the absence costs across benefits and diseases.6,8
The US Healthy People 2030 initiative include several eye-related goals, including the reduction of vision loss from conditions such as diabetic retinopathy, glaucoma, cataracts, and age-related macular degeneration.7 Healthy People 2030 also contains 3 initiatives that may be related to workforce participation, including to reduce vision loss from refractive errors, to understand factors that impact the use of protective eyewear in occupational and recreational settings, and to understand the impact of screen time on eye development and vision loss.7
According to the Centers for Disease Control and Prevention (CDC), the prevalence of vision loss increases from 1.05 (confidence interval, 0.87-1.20) for patients aged 18 to 39 years to 1.21 (1.03-1.39) for patients aged 40 to 64 years.10 The prevalence dramatically increases to 6.46 (5.47-7.48) for those aged 65 to 84 years and to 20.65 (18.18-23.21) for those aged ≥85 years.10 Among the working age population, the prevalence rates were 0.18 for patients aged 18 to 39 years and 1.23 for those aged 40 to 64 years for age-related macular degeneration10; 1.2% to 6% for diabetic retinopathy (not restricted to those with diabetes), which rose to 48% for patients with diabetes; 2.1% to 25.5% for glaucoma; and 2.8% to 29.5% for cataracts,10 which is the most frequent worldwide cause of age-related loss of vision.11
The overall prevalence of visual impairment ranges from 0.27% to 7.5%.10 Despite ophthalmic conditions being common in the United States, there are limited data on the costs of work absence or lost time related to vision loss in the literature. A study by Yang and colleagues reported that in 2019 blindness- and vision loss–related disability-adjusted life-years (DALYs) worldwide resulted from cataracts in the majority of patients (29.6%), followed by refraction disorders (29.1%), near vision loss (21.7%), other vision loss (13.7%), glaucoma (3.3%), and age-related macular degeneration (2.5%).11 In another study, Marques and colleagues estimated that moderate and severe vision impairment or blindness in working-age persons resulted in an overall relative reduction in employment by 30.2%.6 Based on the Gross Domestic Product (GDP), they estimated that the global annual cost of potential productivity losses was $410.7 billion in 2018 US dollars (range, $322.1 billion-$518.7 billion), or 0.3% of the GDP.6
We identified studies in PubMed on panuveitis,5 dry eye,8 work-related eye injuries,12 and eye injuries in the military.13,14 Outside of the United States, ophthalmic studies were identified detailing the direct costs associated with the management of glaucoma via monotherapy in Egypt.15 Gordon and colleagues reported on vision loss in Canada as measured in DALYs and estimated the costs associated with productivity losses based on employment information compiled by Statistics Canada and on the economic theory of productivity loss.9
Our research focuses on the US Agency for Healthcare Research and Quality (AHRQ) ophthalmic condition category, which includes inflammation of the eye, infections of the eye (except from tuberculosis or sexually transmitted diseases), blindness and vision defects, cataracts, glaucoma, retinal detachment, eye defects, vascular occlusion, retinopathy, and “other eye disorders.”16 This retrospective research compares all-cause short- and long-term disability, workers’ compensation, sick leave, and the utilization of benefits, and explores changes in a variety of absence time and payment metrics from baseline (2001) through the end of the study period for eligible employees with an ophthalmic condition.
To better understand the impact of ophthalmic conditions on an employed population and on work absenteeism, data from the Workpartners (formerly known as Human Capital Management Solutions) Research Reference Database (RRDb) were analyzed. The RRDb is a proprietary database of deidentified employee medical and prescription claims that includes site-of-care data. Covered lives within the RRDb continue to grow as new employees and dependents are added. Recent publications report that the RRDb contains information on 3 million US employees and 1.6 million spouses and dependents from multiple insurers.17-19 Employers in the RRDb represent the retail, service, manufacturing, transportation, energy, technology, financial, and utilities industries.17-19
In addition to the medical and prescription data, the RRDb also has data on employees’ salaries, absence payments, and absence days (including sick leave, short- and long-term disability, and workers’ compensation claims) from January 2001 to the present. In our research, we found that during this period, 1.2 million employees in the database were eligible (had coverage) for short-term disability, 1.1 million for long-term disability, 1.4 million for workers’ compensation, 710,000 for sick leave, and 250,000 for vision benefits.
The RRDb has been used to support published research on the role of eye examinations in the early detection of diabetes20; diabetes, diabetic macular edema, and diabetic retinopathy in drivers and nondrivers21; multiple sclerosis17,22; complications associated with hepatitis C23; acromegaly24; and various other conditions.25-28
In a retrospective analysis of data from January 1, 2001, to December 31, 2019, we identified patients in the Workpartners RRDb based on claims with International Classification of Diseases (ICD)-9 or ICD-10 codes for the AHRQ ophthalmic condition category. All claims data were analyzed over fixed calendar-year time periods from 2001 to 2019.
The overall prevalence of ophthalmic conditions and the prevalence of the individual AHRQ-specific ophthalmic conditions for each year were calculated. For the annual prevalence, the Charlson Comorbidity Index (CCI) score was calculated as a measure of overall patient illness severity.29
Additional analyses were restricted to the overall AHRQ ophthalmic category. For each benefit, the population was restricted to those employees with eligibility for the benefit, and the percent of patients using the benefit was calculated. In addition, for short- and long-term disability and workers’ compensation, the mean days of leave and the median payment as a percent of salary were calculated. Because sick leave payments are equal to salary payments, the median sick leave payments as a percent of salary are not reported. The outcomes from 2002 to 2019 were compared with the baseline (ie, 2001).
All absences were aggregated based on the year that the leave began. Long-term disability and workers’ compensation payments included lump-sum distributions, and disability and workers’ compensation leaves potentially extended beyond the year that they were initiated. Workplace accidents were paid under the workers’ compensation benefit. Workers’ compensation claims without an absence from work (medical-only claims) were excluded from the study.
The prevalence of ophthalmic conditions (Figure 1) averaged 10.2% over the study period, with the highest prevalence in 2002 and the lowest prevalence in 2004. At baseline, 9.6% of the total patients had an ophthalmic condition. Among specific ophthalmic conditions, the highest prevalence was for glaucoma (4.47% in 2002) and cataracts and “other eye disorders” were the least prevalent conditions.
The average patients’ overall severity for all ophthalmic conditions combined, as measured by the annual CCI score, increased over the study period from 0.33 to 0.58 (Figure 2). Retinal detachments decreased from a high average CCI score of 1.12 in 2003 to a low average CCI score of 0.73 in 2016, and then increased slightly at the end of the study period.
At baseline (2001; Table 1), in the eligible employees who were using the various benefits, sick leave was the most used benefit (57.4%), followed by short-term disability (6.4%), workers’ compensation (0.9%), and long-term disability (0.2%). The annual percentages of employees using each of the different absence benefits relative to the baseline are shown in Figure 3. From 2002 through 2019, as a percent of baseline, the use of short-term disability was 96.9% to 139.5%, long-term disability was 132% to 277.9%, workers’ compensation was 46.7% to 144.9%, and sick leave was 59.3% to 132.9%.
At baseline (2001; Table 1), the average days of leave for the various benefits were the highest for long-term disability, at 191.9 days, followed by workers’ compensation (57 days), short-term disability (38.7 days), and sick leave (5.9 days). The annual days of leave relative to the baseline by benefit are shown in Figure 4. During the 18-year period (2002-2019) as a percent of baseline, the relative mean days of short-term disability leaves were 110.7% to 307.8%, of long-term disability days were 77.9% to 121.1%, of workers’ compensation days were 76.3% to 464.9%, and of sick leave days were 77.3% to 212%.
At baseline (2001), the sick leave payments were equal to salary; for the other benefits, the median payments as a percent of salary were highest for short-term disability (70.4%), followed by workers’ compensation (66.7%) and long-term disability (22.8%) at baseline (Table 1). Compared with baseline, the range of relative median payments as a percent of salary is shown in Figure 5. From 2002 to 2019 as a percent of baseline, the median payments were 64% to 140.7% for short-term disability, 98.2% to 262.7% for long-term disability, and 87.3% to 158.8% for workers’ compensation. Because sick leave payments are equal to salary, they have been omitted.
Although many studies use real-world data, few studies in the literature use real-world, person-specific absence cost and lost time data from comprehensive employee benefits and payroll systems.8,20-28 Many published studies focus only on disability data or use proxies or survey data to estimate lost time.5,7-9,12,30-32 Survey data are subject to recall bias and may report absences that did not occur during work hours. Furthermore, published research often applies a constant payment for absences across benefits, which the results of our study show is inaccurate. Few studies cover multiple benefits. Some studies focus only on short-term disability or combine short-term and long-term disability while excluding workers’ compensation.5,6,13,30-32 Some studies report on workplace injuries in the general population or in patients in the military, but they do not include data on workers’ compensation benefits.12-14
Healthy People 2030 included a number of ophthalmic-related goals; however, these objectives focused on the overall US population and were not limited to the employed population.7 Furthermore, some studies tend to focus on specific ophthalmic conditions only.5,8,15,33 Aligned with the Healthy People 2030 goals,7 Forrest and Cali used survey data in their study,12 and the 2 military data studies that focused on eye injuries were convenience samples in specialized populations.13,14 Lau and colleagues reported that patients lost an average of 21.6 days of work after a severe eye injury; however, these absence days were not based on workers’ compensation data.14
Since its inception in 2001, the Workpartners RRDb has consistently published data from all 4 absence benefits using real-world data based on claims and payroll data.21-28 In the present study, the annual cohort inclusion, prevalence of ophthalmic conditions, and CCI scores were based on medical claims, and the remaining outcomes were based on employee absence benefits. Our research shows that the overall annual prevalence of ophthalmic conditions among commercially insured employees is 6.8% to 12.5%. This differs from the CDC’s general population estimates of working-age individuals,10,34 which were based on the NHIS survey that reported 27.9% of the US noninstitutionalized civilian population, including those with Medicaid coverage, as having self-reported vision or eye problems.35
The years with the highest use of benefits varied by the benefits themselves. The use of benefits among eligible employees differed, with sick leave and short-term disability being the highest-use benefit in 2013, long-term disability being the highest in 2017, and workers’ compensation being the highest in 2003. The days of leave were highest in 2017 for sick leave, in 2005 for long-term disability and workers’ compensation, and in 2019 for short-term disability. The highest median payments as a percent of salary occurred in 2006 for short-term disability, in 2004 for long-term disability, and in 2003 for workers’ compensation.
In the United States, health plans often focus on components they can control and manage, such as the direct costs of prescription drugs and medical care.27,36,37 Indirect costs and lost time are part of the employers’ costs, and if health plans do not cover therapies that allow people to be productive at work, the employers may seek to change the health plans that they offer.38 Coverage decisions for the treatment of ophthalmic and other conditions should go beyond direct medical and prescription drug costs to also consider the impact on employees’ absence and productivity and the impact on caregivers who are caring for their spouses with these conditions.19
This study’s strengths include the use of real-world, objective data from employers’ disability and workers’ compensation claims and payroll systems, and being conducted using a diverse, commercial workplace–centric database, which includes patients throughout the United States. The Workpartners RRDb also includes job-related information (salary, exempt status, and part- or full-time status) and self-reported racial information that are not contained in other databases. The employers in the database represent a wide range of industries.
This study has several limitations. These administrative claims data are derived from employees with commercial health insurance over the study period and may not be generalizable to patients who do not have employer-sponsored health insurance or who are unemployed.
The study did not assess the individual conditions, the impact of treatment on patient quality of life, direct healthcare costs, or employee productivity, and did not ascertain disease control in the patients.
Although comparisons with baseline allow for a level of control, the study did not include specific control groups. The Workpartners RRDb provided a convenience-based sample, and the population expanded or contracted by employers joining or leaving the database. Although the study was conducted over a 19-year period, each year and condition was a different cohort.
Finally, the cost data associated with paid leaves are, in general, not typically distributed and may benefit from a regression-based approach. Table 2 outlines the study’s strengths and limitations.
In this real-world study, the overall severity of illness in the patient population with eye conditions increased during the study period. The use of short-term disability, long-term disability, workers’ compensation, or sick leave benefits by these employees in a given year varied greatly. In addition, these employees had widely varying days of leave and payments as a percent of salary over time, which also varied by benefit type. Using a constant cost or salary replacement factor over time, or for all benefits, is not accurate or appropriate in health benefit absence research. Every effort should be made to use estimates from research based on actual person-level or claim-level absence and payment data from employers’ disability, workers’ compensation, and payroll data systems.
Future research should consider examining specific ophthalmic conditions, using control cohorts (employees without the ophthalmic conditions), adjusting the inclusion and exclusion criteria to require multiple medical or prescription claims, and using 2-part regression models to control for employees’ job-related information (eg, salary, full- or part-time status) to estimate their absences and costs, which might allow the impact to be projected to the employed population of the United States.
Author Disclosure Statement
Mr Brook and Dr Kleinman conduct research with UPMC Management Services d/b/a/ Workpartners, the owner of the Workpartners RRDb; and Mr Beren is an employee of UPMC Management Services d/b/a/ Workpartners.
- Heathfield SM. See the essentials about long-term and short-term disability insurance. www.thebalancemoney.com/what-is-long-term-disability-insurance-1918178#toc-how-employers-should-offer-long-term-disability-insurance-for-employees. Accessed August 18, 2023.
- Hunt HA. Is compensation for workplace injuries adequate? Employ Res. 2002;9:1.
- Kaiser Family Foundation. Kaiser Family Foundation Employer Health Benefits 2020 Annual Survey. October 2020. http://files.kff.org/attachment/Report-Employer-Health-Benefits-2020-Annual-Survey.pdf. Accessed August 3, 2023.
- Society for Human Resource Management. Healthcare and Health Services: SHRM Employee Benefits 2019. June 2019. www.shrm.org/hr-today/trends-and-forecasting/research-and-surveys/Documents/SHRM%20Employee%20Benefits%202019%20Healthcare%20and%20Health%20Services.pdf. Accessed May 14, 2021.
- Thorne JE, Skup M, Tundia N, et al. Direct and indirect resource use, healthcare costs and work force absence in patients with non-infectious intermediate, posterior or panuveitis. Acta Ophthalmol. 2016;94:e331-e339.
- Marques AP, Ramke J, Cairns J, et al. Global economic productivity losses from vision impairment and blindness. EClinicalMedicine. 2021;35:100852.
- Office of Disease Prevention and Health Promotion; Department of Health & Human Services. Healthy People 2030: sensory or communication disorders. https://health.gov/healthypeople/objectives-and-data/browse-objectives/sensory-or-communication-disorders. Accessed October 10, 2021.
- Yu J, Asche CV, Fairchild CJ. The economic burden of dry eye disease in the United States: a decision tree analysis. Cornea. 2011;30:379-387.
- Gordon KD, Cruess AF, Bellan L, et al. The cost of vision loss in Canada. 1. Methodology. Can J Ophthalmol. 2011;46:310-314.
- Centers for Disease Control and Prevention Vision and Eye Health Surveillance System. Prevalence estimates—vision loss and blindness. www.cdc.gov/visionhealth/vehss/estimates/vision-loss-prevalence.html. Accessed August 21, 2023.
- Yang X, Chen H, Zhang T, et al. Global, regional, and national burden of blindness and vision loss due to common eye diseases along with its attributable risk factors from 1990 to 2019: a systematic analysis from the Global Burden of Disease Study 2019. Aging (Albany NY). 2021;13:19614-19642.
- Forrest KYZ, Cali JM. Epidemiology of lifetime work-related eye injuries in the U.S. population associated with one or more lost days of work. Ophthalmic Epidemiol. 2009;16:156-162.
- Buckingham RS, Whitwell KJ, Lee RB. Cost analysis of military eye injuries in fiscal years 1988-1998. Mil Med. 2005;170:196-200.
- Lau JJS, Thach AB, Burden JH, et al. Eye injuries in the U.S. armed forces. Mil Med. 2000;165:683-686.
- El-Khamery AAE, Mohamed AI, Swify HEH, Mohamed AI. Cost-effectiveness of glaucoma management with monotherapy medications in Egypt. J Adv Pharm Technol Res. 2017;8:25-28.
- Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. Clinical Classification Software Documentation. Report #2004-02. June 16, 2004. https://hcup-us.ahrq.gov/reports/methods/2004CCSUserGuideFinal.pdf. Accessed August 21, 2023.
- Hendin B, Brook RA, Beren IA, et al. The clinical and economic impact of employees who are care partners of patients with multiple sclerosis by disease severity. J Health Econ Outcomes Res. 2023;10:91-101.
- Brook RA, Beren IA, Kleinman NL. Employer paid sick leave, disability, and workers’ compensation trends for employees with cancer conditions in the United States. J Oncol Res Ther. 2022;7:10142.
- Brook RA, Beren IA, Kleinman NL. Employer paid sick leave, disability, and workers’ compensation trends for employees whose spouses have cancer conditions in the United States. J Oncol Res Ther. 2022;7:10143.
- Schaneman J, Kagey A, Soltesz S, Stone J. The role of comprehensive eye exams in the early detection of diabetes and other chronic diseases in an employed population. Popul Health Manag. 2010;13:195-199.
- Brook RA, Kleinman NL, Patel S, et al. United States comparative costs and absenteeism of diabetic ophthalmic conditions. Postgrad Med. 2015;127:455-462.
- Hersh CM, Brook RA, Beren IA, et al. The implications of suboptimal year-1 outcomes with disease-modifying therapy in employees with multiple sclerosis. J Med Econ. 2021;24:479-486.
- Baran RW, Samp JC, Walker DR, et al. Costs and absence of HCV-infected employees by disease stage. J Med Econ. 2015;18:691-703.
- Yuen KCJ, Munoz KA, Brook RA, et al. Health benefit costs and absenteeism among employed patients with acromegaly. Endocr Pract. 2021;27:1034-1039.
- Kleinman NL, Schaneman JL, Lynch WD. The association of insulin medication possession ratio, use of insulin glargine, and health benefit costs in employees and spouses with type 2 diabetes. J Occup Environ Med. 2008;50:1386-1393.
- Brook RA, Wahlqvist P, Kleinman NL, et al. Cost of gastro-oesophageal reflux disease to the employer: a perspective from the United States. Aliment Pharmacol Ther. 2007;26:889-898.
- Brook RA, Rajagopalan K, Smeeding JE. Healthcare costs and absenteeism among caregivers of adults with partial-onset seizures: analysis of claims from an employer database. Am Health Drug Benefits. 2018;11(8):396-403.
- Brook RA, Kleinman NL. Human capital costs and absenteeism among employees with various conditions. In: Rizzo MF, Gallo A, eds. Human Capital and Resources: Developments, Management and Strategies. Hauppauge, NY: Nova Science Publishers; 2012:33-60.
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- Goetzel RZ, Long SR, Ozminkowski RJ, et al. Health, absence, disability, and presenteeism cost estimates of certain physical and mental health conditions affecting U.S. employers. J Occup Environ Med. 2004;46:398-412.
- Peterson C, Xu L, Barnett SBL. Average lost work productivity due to non-fatal injuries by type in the USA. Inj Prev. 2021;27:111-117.
- Orbai AM, Reddy SM, Dennis N, et al. Work absenteeism and disability associated with psoriasis and psoriatic arthritis in the USA-a retrospective study of claims data from 2009 to 2020. Clin Rheumatol. 2021;40:4933-4932.
- Klein BEK, Klein R, Linton KLP, et al. Prevalence of age-related lens opacities in a population. The Beaver Dam Eye Study. Ophthalmology. 1992;99:546-552.
- Flaxman AD, Wittenborn JS, Robalik T, et al; for the Vision and Eye Health Surveillance System study group. Prevalence of visual acuity loss or blindness in the US: a Bayesian meta-analysis. JAMA Ophthalmol. 2021;139:717-723.
- Saydah SH, Gerzoff RB, Saaddine JB, et al. Eye care among US adults at high risk for vision loss in the United States in 2002 and 2017. JAMA Ophthalmol. 2020;138:479-489.
- Syed EU. Will we ever bend the cost curve in healthcare? Am Health Drug Benefits. 2019;12(4):186-187.
- Willey VJ, Kong S, Wu B, et al. Estimating the real-world cost of diabetes mellitus in the United States during an 8-year period using 2 cost methodologies. Am Health Drug Benefits. 2018;11(6):310-318.
- Health Care Cost Institute. 2017 Health Care Cost and Utilization Report. February 2019. https://healthcostinstitute.org/images/easyblog_articles/276/HCCI-2017-Health-Care-Cost-and-Utilization-Report-02.12.19.pdf. Accessed August 21, 2023.