Tis a sordid profit that’s accompanied by the destruction of Health.

–Bernardino Ramazzini, Treatise on the Diseases of Tradesmen, 1705

By Karen O’Hara

A movement is afoot to get more occupational health programs and modestly sized companies to embrace workplace health and productivity management (HPM) initiatives that have been the domain of larger corporations.
When appropriately applied, proponents say HPM significantly expands the net cast by occupational medicine practitioners, who are population-health oriented.
The objective is to extend outreach from individual employees to groups of workers and to the community at large – somewhat analogous to the circles that radiate from a pebble dropped in a pond.

“I would hope an occupational medicine program would offer health and productivity management services to the employers they serve and to their community,” said Doug Benner, M.D., occupational health coordinator for Kaiser Permanente in Northern California, where he works closely with Kaiser’s group health plan. “Many people in our field feel you can’t do this just at the worksite. You have to make the whole community healthy. You can’t fix the employees if you have an unhealthy workplace or if the whole community is not health-focused.”

Pamela Hymel, M.D., M.P.H., president of the American College of Occupational and Environmental Medicine (ACOEM), corroborates Dr. Benner’s view.

“A healthy workplace, workforce, and community are vital to the long-term financial stability of the country,” she said. “The U.S. has far underestimated the impact of poor health in the workplace and on the economy. As we look at our gross domestic product and how much we spend on health care, it’s important for us to determine how we can provide greater efficiency and not have to treat so many chronic and end-stage diseases.

“We can’t just look at insurance coverage. We need to look at how we can increase the baseline health of the population. What better way is there to do that than through an occupational health professional who is in contact with employers and their employees more than 2,000 hours a year?”

HPM Underpinnings

As a discipline, occupational medicine appears to be fertilizing and watering its public health roots while supporting health and productivity management initiatives. ACOEM defines HPM as “a concept that directs corporate investment into interventions that improve employee health and business performance.” It also is described as the integrated management of health risks, chronic illness, and disability to reduce employees’ total health-related costs, including direct medical expenditures, unnecessary absence, and diminished performance at work (presenteeism).

“The survival of many American businesses in the global marketplace depends on shifting medicine’s singular focus of managing sickness to a much more encompassing view of managing health,” explains Dr. Dee Edington, director of the University of Michigan’s Health Management Research Center and a noted expert on the topic. “This is the total value of health and the value of total health management.”

Health management is “the big new idea” in business, according to Sean Sullivan, president and CEO of the Institute for Health and Productivity Management, Scottsdale, Ariz. Similar to other management concepts adopted by business leaders, health management needs to become a “vital strategic function that businesses must perform while continually assessing and improving it,” he said in a 2009 Change Agent Work Group (CAWG) report. “That’s the only way to succeed in a competitive marketplace where the performance of human capital is a differentiator.”

CAWG, funded by Pfizer Inc., is comprised of industry thought leaders – including Dr. Edington and Mr. Sullivan – who are collaborating to “accelerate improvement in American workforce health and productivity.” The CAWG report says organizations need to make employee health “an integral part of the vision and values of the organization” to achieve real HPM benefits, starting with data collection, demographic studies, and an understanding of behaviors that drive health status.

In survey research presented Feb. 8 by the Integrated Benefits Institute (IBI) at the 2010 IBI/National Business Group on Health Productivity Forum, HPM programs are characterized as critical to the vitality of U.S. businesses burdened by:

  1. declining employee health;
  2. pressures associated with lost work time;
  3. increasing health care costs;
  4. global competition; and
  5. the uncertainty of health reform.

IBI, based in San Francisco, Calif., is a non-profit resource for health and productivity research, measurement, and benchmarking. In its survey of 500 employers, 98 percent of respondents indicated their company has some form of HPM program – most frequently involving health promotion – and the majority said they plan to further expand HPM practices and resources. The research also shows that employers’ goals typically revolve around controlling medical costs and improving health-related productivity.

However, the HPM practices employers consider to be most important aren’t necessarily the ones that are adopted. And, one in three respondents reported their company does not measure absence and productivity outcomes, even though they believe health management interventions improve results, the study showed. Meanwhile, other IBI research suggests the dire straits the U.S. workforce is in when it comes to health. In an employee survey, nine out of 10 respondents reported having at least one chronic health problem; many reported suffering from a complex mix of socio-emotional, metabolic, and respiratory conditions.

“Employers – the largest purchasers of health care and dependent on a healthy and productive workforce – understand the essential need to promote health,” said Dr. Thomas Parry, IBI president and CEO. “Given that 55 percent of health care is funded through the workplace in the U.S. and that employers have an economic interest in health improvement of their workers, employers must remain a key part of the American health care landscape. “Additionally, most employees often spend more waking hours at work than anywhere else, providing a significant opportunity to positively influence the health of the U.S. workforce through their benefits, compensation, and working conditions.”

Aligning Interest

Employers’ current comprehension of the value of HPM is shaped by the gradual development and adoption of validated health risk assessment tools and data management systems that support sophisticated outcome analyses and reporting. HPM experts point to a growing body of scientific and economic evidence they believe can be effectively used by occupational health professionals to overcome objections from employers on tight budgets who are reticent to invest in wellness and other HPM-related services.

“Even in these challenging economic times, there are some very progressive employers who understand that their investment in a healthier workforce and a healthier workplace can help their bottom line,” said Dr. Benner, speaking at RYAN Associates’ 2009 national conference on Providing Healthcare Services to Employers. “There are studies to prove it, and you are going to find more and more interest in this area. It doesn’t matter how small your practice is, you can be involved.”

In an interview, Wayne Burton, M.D., retired corporate medical director at JPMorgan Chase (formerly BankOne), where he gained international recognition as an HMP innovator, said he has observed a “tremendous increase in interest” in HMP in the U.S. and globally in recent years. “There is a reasonable understanding now about how workforce health status relates to short-term disability, absenteeism and presenteeism,” he said. “This puts practicing occupational medicine physicians in a great, great position, especially if they have some way to capture data for (their client) companies.” Dr. Hymel agrees that occupational medicine physicians, in particular, can play an integral role in putting HPM initiatives into play on a broader scale. “They can translate what is happening in medicine to business and translate what is happening in business back to their colleagues in medicine – that is where we see the real leverage in occupational health,” said Dr. Hymel, corporate medical director for Cisco Systems, San Jose, Calif., and another prominent HPM proponent. “At ACOEM, we are focusing on how to help physicians build health and productivity into their practices.”

While assisting employers, Dr. Hymel also suggests that provider-based occupational health professionals position themselves to work closely with insurance brokers to ensure prevention programs are incorporated in benefits packages, particularly for smaller companies.

Expertise Needed

Historically, some occupational medicine clinicians have felt underappreciated for their routine contributions to sustaining workforce well-being. Now, with reform discussions focused on prevention and economically stressed companies looking for more comprehensive ways to manage workforce health, the pendulum seems to be swinging in their direction. Speaking at RYAN Associates’ national conference, Dr. Hymel said small to mid-sized companies that lack the resources of larger corporations represent the most promising venue for provider-based occupational health programs offering HMP expertise.

“Those of you who act as the primary occupational health consultants or health care providers for smaller companies are going to be key to this movement,” she said. “Many of you already provide outsourced services to employers.” Occupational medicine physicians have a valuable perspective in terms of their training, skill sets and vantage points, which encompass individual, public, private and population health delivery settings. “Certainly, we can engage the employer community by raising awareness of health and productivity initiatives and building partnerships and coalitions in our communities. Being able to build that bridge between private and public health, population health and individual expertise is something we all bring to the table,” Dr. Hymel said.

Applying Evidence

When introducing HPM concepts to a company, providers need to appreciate the chief financial officer’s (CFO) perspective, William Molmen, co-founder and general counsel at IBI advised occupational health program directors at RYAN Associates’ national conference. In surveys, IBI has learned that company CFOs would most likely use lost-productivity information to compare healthcare costs to intervention costs, design more effective benefit plans, and reduce absence, he said.
Dr. Burton said consulting physicians and nurses have the opportunity to supplement fee-for-service income when they function as consultants to the industry. But in order to do that, they must first demonstrate how their expertise will help the company save money and enhance workforce health.

While an occupational health program may not have fully converted to an electronic medical record system, clinicians can use the program’s billing system to capture, in general terms, the kinds of injuries and illnesses they treat on a company-by-company basis, he said. For example, an occupational medicine provider who keeps track of work-related injury and illness rates should be equipped to provide insights for employers on programs and services designed to decrease occurrences.

He encourages professionals working in provider-based settings to develop basic performance metrics, such as the number of injuries/visits per 100 employees, and use the data for benchmarking among similar industries.

“That may require the physician to receive some additional training on benefit and disability plan design and wellness programs,” said Dr. Burton, who recently joined the Center for Health Value Innovation’s Board of Strategic Advisors. He also recommends routinely conducting basic biometric screening (e.g., blood pressure, blood sugar, cholesterol) on employee populations. “Biometric screening provides an entree to the company,” Dr. Burton said, “and the information obtained is valuable in terms of identifying employees at risk, getting them into treatment, and avoiding injuries and disability.”

Similarly, Change Agent Work Group members advise employers to conduct a basic analysis of demographics, risk factors, and disease burden (the impact of health problems measured by indicators such as financial costs, mortality, and morbidity) before implementing specific healthcare strategies to address those problems. In his 2009 book, “Zero Trends: Health as a Serious Economic Strategy,” Dr. Edington of the University of Michigan addresses how shifts in workplace culture can help reduce healthcare and disability costs while improving employee health and productivity.

“I have learned over the last several years that if we are going to have a meaningful impact on employee health management, we’ve got to start by changing the culture of the organization – and that process begins with the CEO setting forth his or her vision for employee health and well-being,” Dr. Edington said. “Once that vision is established, you align your company’s strategic priorities with that vision.”

In his book, Dr. Edington describes five pillars of effective HPM programs:

  1. Senior leaders crafting a corporate vision for health and well-being.
  2. Operations leaders align and communicate the workplace environment with the vision.
  3. Creating a sense of self-leadership.
  4. Rewarding healthy behaviors.
  5. Using quality assurance to measure progress toward desired outcomes and shape future strategies.

Occupational medicine providers also may pattern their practices after the Wellness Council of America’s patented Well Workplace model, which is based on seven benchmarks:

  1. Capturing and sustaining CEO support.
  2. Creating cohesive wellness teams.
  3. Collecting data to drive health efforts. Suggested tools include corporate culture audits, health risk appraisals, and employee interest surveys.
  4. Carefully crafting an operating plan for organizational health and wellness.
  5. Choosing appropriate interventions, such as tobacco cessation, fitness, weight management, self-care, and stress reduction programs.
  6. Creating a supportive environment, including policies, worksite modifications, and employee rewards/incentives.
  7. Carefully evaluating outcomes. Evaluation targets include participant rates and satisfaction scores, behavior modification, and cost containment.

Levels of Intervention

According to Dr. Hymel, the integration of occupational health, preventive medicine, and primary care services for workers and their families is a significant related trend. She supports the incorporation of strategies that maximize primary, secondary, and tertiary prevention both within and outside of the workplace.

“There is considerable potential for occupational health programs to provide onsite services that overlap into primary care,” she said.

In recent years, businesses with comprehensive HPM programs have emphasized the return on investment associated with tertiary prevention, mainly chronic disease management. While there is real value associated with that approach, Dr. Hymel said she would like to see more attention paid to primary and secondary prevention to address health risks that cause illness.

Although scientific and economic studies demonstrate the cost-effectiveness of early intervention, many business models fail to factor in primary prevention (e.g., health promotion and education, immunizations) and secondary prevention (e.g., early detection, health risk reduction, and biometric testing). In addition, she said, lifestyle factors comprise the greatest percentage of mortality risks. While heredity, environment, and access to basic health care services also are influencing factors, health can be improved by changing behaviors such as not smoking, eating a balanced diet, and getting regular exercise.

In an analysis of 10 health problems associated with lost work time, as identified through an HPM questionnaire, for every $1 spent on worker medical or pharmacy costs, $2 to $4 were expended on health-related diminished or lost productivity, Ronald Loeppke, M.D., Dr. Hymel, and colleagues reported in a study published in the Journal of Occupational and Environmental Medicine. The objective of the study was to assess the magnitude of health-related lost productivity relative to medical and pharmacy costs for four employers and the business implications of a full-cost approach to managing health. There were two primary findings: 1) Health-related productivity costs were more than four times greater than medical and pharmacy costs. 2) The full cost of poor health is driven by different health conditions other than those driving medical and pharmacy costs alone.

The researchers concluded that integrated population health and productivity management should be built on a foundation of integrated population health and productivity measurement. “Therefore, employers would reveal a blueprint for action for their integrated health and productivity enhancement strategies by measuring the full health and productivity costs related to the burdens of illness and health risk in their population,” they said.

Meanwhile, speaking of nourishing public health roots, in the 1700s, Bernardino Ramazzini, the “father of occupational medicine,” wrote about the benefits of exercise for decreasing the afflictions of clerks with repetitive motion injuries.

“He knew this over 300 years ago and eloquently described it,” Dr. Burton said. “Occupational medicine physicians on the front lines can advise companies, especially the small to mid-sized ones, about how to take remedial action.”

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