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The Future of the Public’s Health in the 21st Century 6 Employers and Business The main function of American employers is the production and sale or direct provision of goods and services. Through these economic activities, employers provide jobs and incomes to America’s families. As noted in Chapter 2, employment and the workplace are important determinants of health that can generate protective health effects through income and social ties as well as adverse health effects (i.e., poor work conditions and job strain). This chapter provides information regarding the ways in which employers (both public and private), as actors in the public health system, can make important contributions to the health of the population through activities that are specifically directed toward health concerns. The chapter begins with a discussion of how American employers, as providers of health care benefits to their employees, contribute significantly to supporting the conditions for health of a large proportion of American workers and their dependents. The discussion then addresses the important role that employers play in ensuring quality and accountability for the health care services purchased by and for their employees. The chapter then discusses the rationale for employer investment in the health of employees and how sponsoring health promotion and disease prevention activities in the workplace and improving workplace conditions promote employee health. Finally, the chapter ends with a discussion of a range of health-promoting activities—lessening environmental pollution and involvement in civic activities in the community, for example—in which employers and the business sector at large can engage to help promote the health of the population.
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The Future of the Public’s Health in the 21st Century EMPLOYERS’ ROLE IN HEALTH INSURANCE COVERAGE Employers make a major contribution to population health and health security because of the important role they play in providing health insurance. Employers are primarily motivated to offer health insurance benefits to recruit and retain employees and to be competitive in the marketplace. Employees value health insurance and benefits and the opportunity to extend such coverage to their dependents. For a number of historical reasons, employment is the foundation of the private health insurance system in the United States. Ninety percent of persons under the age of 65 who are privately insured obtain their health insurance through employers. Voluntary employer-sponsored health insurance is offered to employees and their dependents as part of a typical compensation package. In 2002, 62 percent of all firms (including both public and private employers) offered health benefits to their employees, a decline from a high of 67 percent in 2000 (Kaiser Family Foundation, 2002). The percentage of firms offering health benefits varies by the size of the firm. For example, in 2002, 99 percent of firms with more than 200 workers offered health benefits to their employees, whereas less than 61 percent of small firms (those with 3 to 199 employees) offered such benefits (see Figure 6–1) (Kaiser Family Foundation, 2002). Small firms are less likely to offer health insurance for a number of reasons, including the increased cost of a comparable insurance package because of higher administrative costs, lower employee wages, and more part-time workers (Custer and Ketsche, 2000). Employees place a high value on health insurance. According to the Employee Benefit Research Institute and Mathew Greenwald & Associates, Inc.’s Value of Benefits Survey, 60 percent of employees rank health insurance as the most important benefit. Employees also report that benefits (e.g., health insurance and retirement plans) continue to be a very important factor in job selection (EBRI, 2002; Lave et al., 1999; Peele et al., 2000). Most employers (both private and public) believe that they play an important role in providing health insurance coverage and that they can provide better coverage than employees could buy on their own. However, changing economic pressures are causing employers, particularly private firms, to reconsider the nature of their health insurance offerings. Pressures resulting from the slowing of the U.S. economy, rising health care costs associated in part with increasingly looser forms of managed care, rising prescription drug prices, and employee demands are making it more difficult for small employers to offer insurance coverage and for large employers to maintain premiums at affordable levels (Custer and Ketsche, 2000; Lambrew, 2001; Kaiser Family Foundation, 2002). Data indicate that pre-
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The Future of the Public’s Health in the 21st Century FIGURE 6–1 Percentage of firms offering health benefits, by firm size, 1996– 2001. NOTE: Nationwide, there are an estimated 5,355,412 firms with 3 to 199 workers and 86,957 with 200 plus workers. Firms include both public and private employers. SOURCES: Kaiser Family Foundation (2000, 2001, 2002); KPMG (1996, 1998). miums have already begun to rise. Premiums for employer-based health insurance increased an average of 11 percent in 2001, the largest increase since 1992. Large employers faced, on average, a 10.2 percent increase in health insurance costs, whereas the smallest employers (those with three to nine employees) experienced an average increase in premiums of 16.5 percent (Kaiser Family Foundation, 2002). As their costs rise, many employers expect to ask employees to pay more for insurance in the years to come and to pay for a higher proportion of the costs of care in terms of higher deductibles or copayments when they actually use services. Increasing health insurance premiums influence whether an employee (as well as dependents) has coverage or joins the ranks of the uninsured. Employees typically pay between one-quarter and one-third of the total
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The Future of the Public’s Health in the 21st Century cost of the insurance premium, in addition to deductibles, copayments, and the costs of health services that are not covered or that are covered only in part. The proportion of employees who choose to participate in employer-sponsored health insurance is inversely related to the employee’s contribution to the cost. The expense and competing demands on family income are the main reasons individuals report for declining an offer of employment-based coverage (Cooper and Schone, 1997; Rowland et al., 1998; Hoffman and Schlobohm, 2000). Individuals who decline employer-based health insurance are typically covered through a spouse or some other type of coverage, and about 4 percent remain uninsured. The consequences of being uninsured are described in Chapter 5 and in past reports of the Institute of Medicine (IOM, 2001a, 2002). EMPLOYERS’ ROLE IN ASSURING HEALTH CARE QUALITY As purchasers for the health services of a large proportion of American families, the employer sector has an important role to play in ensuring the availability of high-quality health care services. Recent Institute of Medicine (IOM) reports have noted that the American health care delivery system is in need of fundamental change and that purchasers (employers and governmental agencies such as the Centers for Medicare and Medicaid Services) can play an important role in demanding health care services that are safe, effective, patient centered, timely, efficient, and equitable (IOM, 2001a). Over the years, many employers (both private and public) have been strong partners of health plans and other health care organizations in efforts to improve health care quality. They were active participants in the National Committee for Quality Assurance initiative to develop the Health Plan Employer Data and Information Set in the early 1990s. The data set attempts to standardize a process for assessing and comparing health plan performance so that purchasers and consumers have a better sense of the quality of services provided. Another partnership, the Washington Business Group on Health, has worked over the past 27 years with approximately 170 employer members to improve employee health and productivity through attention to employee mental health issues and clinical preventive service guidelines, among others. More recently, the Leapfrog Group, founded in 1999 and composed of growing numbers of Fortune 500 companies and other large health care purchasers, has joined forces to “trigger a giant leap forward in quality, customer service and affordability of health care.” The two-pronged strategy to achieve this goal involves educating the public about patient safety and defining a set of purchasing principles designed to promote safety and increase the value of health care. Other employer-based initiatives include
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The Future of the Public’s Health in the 21st Century the National Business Coalition on Health, a membership organization of nearly 85 employer-led coalitions representing more than 11,000 mid- and large-sized employers and approximately 21 million employees and their dependents. These coalitions have joined together to collectively purchase health care, to proactively challenge high costs and the inefficient delivery of health care, and to share information on quality. Through these efforts and others across the country, the business community can be proactive in shaping the health care delivery system and promoting quality. Illustrations of other employment-based efforts to improve health care quality include specific activities of the California Public Employees Retirement System (CalPERS) and the Minnesota Health Plan Initiative to Improve Health Care. Many employer groups are also involved in prevention activities sponsored by the Partnership for Prevention, a national nonprofit organization dedicated to increasing the resources for and knowledge about effective disease prevention and health promotion policies and practices. CalPERS is one of the oldest purchasing coalitions in the country, representing one-third of public agencies in California; it holds the purchasing power of more than 1 million people and $1.7 billion a year in premiums. CalPERS pioneered the use of patient satisfaction and medical quality reports to encourage the provision of high-quality medical care from its participating plans (CalPERS, 2002). The combination of consumerism and strong purchasing influence is working to help improve the quality of health care for CalPERS members. In another pioneering move to improve health care quality, five health plans (HealthPartners, Blue Cross and Blue Shield of Minnesota, Medica, PreferredOne, and UCare Minnesota) covering the majority of Minnesota residents came together to endorse evidence-based standard treatments and prevention procedures. This was the first time that the majority of health plans in a state have collaborated around setting and adopting evidence-based standards. Under the auspices of the Institute for Clinical System Improvements, a not-for-profit corporation, physicians and other health care professionals reviewed the scientific evidence and recommended the best course of action for 50 health problems such as urinary tract infection, hypertension, diabetes, and lower back pain. The health plans believe that use of the treatment guidelines is responsive to the health care quality concerns raised by IOM (2001b) and will lead to improved and more consistent care across the state (Freudenheim, 2001). Recognizing that employers often have a difficult time balancing decisions about which benefits to purchase for their employees, the Partnership for Prevention convened a 25-member advisory panel to provide guidance on the clinical and preventive services that provide the “best bang for the buck.” To begin, the panel—composed of public- and private-sector purchasers of care, health plan medical directors, state and local public health
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The Future of the Public’s Health in the 21st Century officials, clinicians, and consumer advocates—identified 30 clinical and preventive services and groups of services recommended by the U.S. Preventive Services Task Force (USPSTF)1 for average-risk patients (AHRQ, 2002). The relative value of these services was then assessed on the basis of two dimensions: health impact and value. Health impact refers to the portion of disease, injury, and premature death that would be prevented if the service was delivered—that is, the clinical preventive burden. The value of the service refers to cost-effectiveness, in which the net cost of the service is compared to its health impact. Cost-effectiveness provides a standard measure for comparing services’ return on investment (ROI). The results of the assessment identified 14 services that employers may want to purchase to improve the delivery of clinical preventive services (see Box 6–1). The Partnership for Prevention has disseminated its results to employers through its publication Prevention Priorities: Employers’ Guide to the Highest Value Preventive Health Services (Partnership for Prevention, 2001b). The committee acknowledges the crucial role that employers, particularly large employers, play in creating health security for millions of Americans as providers of employer-based health insurance coverage and purchasers of health care services. It also notes that, to the extent that the quality improvement activities lead to improvements in the processes of care, these improvements should benefit not only the employees of specific companies but all people who use the health care system. In recent years, however, the current role of employer-sponsored health has been challenged. Some of the criticism points out that employers are under no legal mandate to offer health insurance and that the employer is an unstable source of insurance for some employees, particularly those who work for small firms or firms that hire a disproportionate number of low-income employees (Long and Marquis, 2001). Other criticism is directed at the employer’s “role” per se (Reinhardt, 1999). A number of critics have argued that the employer should be removed from these decisions and that the employee, not the employer, should make decisions about what type of insurance to hold (Gavora, 1997; American Medical Association, 1999; Health Policy Consensus Group, 1999). In addition, critics point out that although employees ultimately bear the cost of insurance through lower wages, they are not aware of the trade-offs that are being made between wages and benefits and are demanding more benefits (or resisting cost containment) because such benefits are viewed as being “free” (Pauly, 1986, 1 The USPSTF is a panel of independent experts in prevention and primary care tasked with identifying a core set of clinical preventive services known to improve health. The USPSTF recommendations are published in the Guide to Clinical Preventive Services, 2nd edition (U.S. Preventive Services Task Force, 1996), and most recent updated recommendations are available at www.ahrq.gov/clinic/uspstfix.htm.
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The Future of the Public’s Health in the 21st Century BOX 6–1 Priorities for Employers: Recommended Clinical Preventive Services with High Health Impact and Value Vaccinate children: DTP/DTaP, MMR, oral polio/IPV, Hib, Hep B, varicella. Assess adults for tobacco use and provide tobacco cessation counseling. Screen adults aged ≥65 years for vision impairment. Assess adolescents for drinking and drug use and counsel them on abstinence from alcohol and drug use. Assess adolescents for tobacco use and provide an antitobacco message or advice to quit. Screen sexually active women aged ≥18 years for cervical cancer. Screen all persons aged ≥50 years for colon cancer (FOBT or sigmoidoscopy). Screen newborns for hemoglobinopathies, PKU, and congenital hypothyroidism. Screen all persons for hypertension. Vaccinate adults aged ≥65 years against influenza. Screen sexually active women aged 15 to 24 for chlamydia. Screen men aged 35 to 65 and women aged 45 to 65 for high blood cholesterol levels. Screen for problem drinking among adults and provide brief counseling. Vaccinate adults aged ≥65 against pneumococcal disease. NOTE: DTP/DtaP = diphtheria, tetanus, pertussis/diphtheria, tetanus, acellular pertussis; FOBT = fecal occult blood testing; Hep B = hepatitis B; Hib =Haemophilus influenzae type b; IPV = poliovirus vaccine, inactivated; MMR = measles, mumps, rubella; PKU = phenylketonuria. SOURCE: Partnership for Prevention (2001a). 1997). Furthermore, critics point out that employer-sponsored health insurance distorts the labor market by favoring large businesses over small ones, encourages employers to outsource certain workers, and affects workers’ decisions about work and retirement (Congressional Budget Office, 1994; Gruber and Madrian, 1996). These critics recommend changes in tax policy so that tax incentives for the purchase of health insurance would not favor employer-sponsored coverage (Pauly, 1986; Congressional Budget Office, 1994; Gruber and Madrian, 1996; Gavora, 1997; American Medical Association, 1999; Health Policy Consensus Group, 1999). Until reforms are enacted to assure access to affordable health insurance for all Americans, the committee urges employers to continue to provide and improve health insurance coverage for their employees. Employers should endorse the purchase of evidence-based benefits and work diligently to ensure the quality of the services that they purchase. The committee recommends that the federal government develop programs to assist small employers and employers with low-wage workers to purchase health insurance at reasonable rates.
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The Future of the Public’s Health in the 21st Century EMPLOYER INTEREST IN PROMOTING THE HEALTH OF EMPLOYEES: A RATIONALE FOR CORPORATE INVESTMENT IN HEALTH Employers should be concerned about the health and well-being of their employees for a number of reasons. Healthy employees consume fewer benefits in the form of benefit payments for medical care, short- and long-term disability, and workers’ compensation. Furthermore, healthy employees are more productive than their nonhealthy counterparts because they are absent less often and are more focused on their tasks while at work. Through health insurance premiums and self-insured plans, employers pay large sums of money for the treatment of diseases and disorders, many of which are lifestyle related and often preventable. The leading causes of death in the United States are heart disease, followed by cancer, stroke, chronic lower respiratory disease, accidents, diabetes, pneumonia/influenza, Alzheimer’s disease, nephritis, nephritic syndrome and nephrosis, and septicemia (NCHS, 2002). A significant proportion of some of these diseases and disorders can be attributed to lifestyle habits and behaviors. For example, one study suggests that about 57 percent of heart disease deaths, 37 percent of cancer cases, 50 percent of strokes, 60 percent of accidents, 23 percent of pneumonias, 34 percent of diabetes cases, 60 percent of suicides, and 70 percent of chronic liver disease and cirrhosis cases are related to habits and behavior (NCHS, 1999). In the case of cancer and cardiovascular disease, seven modifiable risk factors account for 23 and 65 percent of the cases of morbidity, respectively (Amler and Dull, 1987). More than 10,000 peer-reviewed articles in scientific journals show a clear causal relationship between specific modifiable risk factors and adverse health consequences. The following modifiable risk factors increase rates of mortality, morbidity, disability, and, in many cases, productivity loss: tobacco use, alcohol and drug use, sedentary behavior, poor nutrition, being overweight, having elevated serum cholesterol levels and high blood pressure, exhibiting high levels of stress and hostility, a lack of social support networks, and having unsafe sex. About half of all deaths in the United States are attributable to nine modifiable risk factors, including tobacco use (Box 6–2), diet and activity patterns, alcohol use (Box 6–3), firearm use, sexual behavior, motor vehicle accidents, and illicit drug use (McGinnis and Foege, 1993). Tobacco use alone caused approximately 440,000 premature deaths annually from 1995 to 1999 (CDC, 2002). A number of studies have presented information on the distribution of illnesses in different companies. In a comprehensive study of Fortune 500 companies, coronary artery disease was the most costly disease for employers and represented 6.72 percent of total payments (Goetzel et al., 2000). The annual mean payment for claims related to coronary artery disease was $4,639 per patient and more than double the average payment of $2,230
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The Future of the Public’s Health in the 21st Century BOX 6–2 Smoke-Free Policies in the Workplace Tobacco use is the number one cause of preventable disease and death in the United States (DHHS, 2000). Private-sector restrictions on smoking in the workplace are effective strategies that can make a difference for a significant number of employees. A comprehensive review of workplace smoking policies from the National Cancer Institute’s tobacco use supplement to the Current Population Survey found that slightly more than 80 percent of workers are covered by an official workplace smoking policy; however, less than half are protected by smoking policies that prohibit smoking in both the work area and the public or common areas of the workplace (smoke-free policy). Furthermore, the study found that those workers who work indoors—an estimated 58 million Americans, 40 million of whom are nonsmokers—are not protected by a smoke-free workplace policy. These data suggest that access to smoke-free workplace environments could be improved (Gerlach et al., 1997). BOX 6–3 Creating Work Environments That Discourage Alcohol Misuse Drinking while at work and heavy drinking outside of work are a real headache for employers. Alcohol-related performance problems include absenteeism, tardiness, feeling ill at work, and sleeping. Alcohol misuse can undercut productivity (quality and quantity) and can aggravate problems between coworkers (Bernstein and Mahoney, 1989; Ames et al., 1997; Mangione et al., 1999). Health care costs for employees with alcohol problems are typically double those for other employees (Schneider Institute for Health Policy, 2001). Moreover, workers who drink even relatively small amounts of alcohol can raise the risk of alcohol-related death and injury in occupational accidents, especially if they drink before operating a vehicle (Partnership for Prevention, 2001a). In 1994, more than 8 percent of full-time workers (more than 6.5 million employees) engaged in heavy drinking, defined as five or more drinks on 5 or more days in the past 30 days. To stem the cost of lost productivity, work-site accidents, and excess health care because of alcohol and drug use, employers can do the following: Offer health plans that cover the cost of screening, counseling, and treatment for substance misuse; Participate in community programs to prevent alcohol and drug misuse; Establish work-site alcohol and drug policies; Integrate alcohol prevention into existing work-site health promotion programs; Educate supervisors about alcohol and drugs so they are better equipped to make caring and effective interventions and referrals;
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The Future of the Public’s Health in the 21st Century Sponsor confidential employee assistance programs with on-site external counselors to help workers resolve substance abuse problems and link them with treatment services (especially those in safety-sensitive positions); and Educate employees about health problems associated with drinking and stress (National Institute on Alcohol Abuse and Alcoholism, 1999; Partnership for Prevention, 2001a). The U.S. Department of Labor’s Working Partners program offers resources to help employers develop drug and alcohol-free workplaces (Partnership for Prevention, 2001a). Promoting Mental Health in the Workplace The employer community can take active steps to ensure that employees with depression remain productive. Estimates show that the annual cost of depression in the United States due to work loss and work cutback reaches $33 billion (Greenberg et al., 1995). Evidence suggests that the gains in productivity from effective treatment for depression could far exceed the direct costs of treatment (Simon et al., 2001). Employers who cut back on mental health benefits face increased costs for non-mental health services and more sick days (Rosenheck et al., 1999). Therefore, the business community has an economic incentive to ensure the timely, high-quality treatment of depression in employees. One option is for businesses to become more active in improving employee awareness of the importance of the detection and treatment of depression. Another option is to require quality care for depression through private health insurance. Businesses increasingly finance mental health care for their employees through contracts with managed care organizations (OPEN MINDS, 1999). These contracts can be used as a means to require managed care organizations to improve the quality of care for depression via quality improvement programs. for all conditions examined. These very large payments are for the treatment of heart disease and not its prevention. Other high-cost health conditions highlighted in the study of Fortune 500 companies either were caused by or were the consequence of lifestyle factors. Some were highly prevalent but the cost of treatment was relatively low, such as diseases of the gastrointestinal tract (2.49 percent of total payments), essential hypertension (2.23 percent of total payments), and back disorders (2.07 percent of total payments) (Goetzel et al., 2000). Other conditions had lower prevalence rates but high average treatment costs and high total payments, such as cerebrovascular disease (1.65 percent of total payments) and cholecystitis and cholelithiasis (1.58 percent of total payments).
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The Future of the Public’s Health in the 21st Century The analysis of Fortune 500 companies also uncovered costly mental health and substance abuse disorders that may be initiated or exacerbated by stress. Bipolar disorders with major depressive episodes were the most costly (1.25 percent of total payments), followed by neurotic, personality, and nonpsychotic disorders (1.11 percent of total payments) and depression (0.77 percent of total payments). Alcoholism, with an average cost of $3,012 per patient, is the most costly substance abuse disorder on a per patient basis, although it accounts for less than 1 percent of total payments (Goetzel et al., 2000). A clear relationship exists between modifiable risk factors in a typical employed population and the employers’ health care expenditures for the treatment of the diseases and disorders caused by these risk factors. For example, in a study of 10,000 employees of the Control Data Corporation, researchers documented lower health care costs for employees who exercised regularly, ate nutritious foods, abstained from smoking cigarettes, and had low blood pressure (Brink, 1987). A 5-year study of Steelcase Corporation employees showed that as modifiable health risks increased for employees, so did their medical expenditures (Yen et al., 1992). Another study examined the effects of 10 risk factors (obesity, high serum cholesterol levels, high blood pressure, stress, depression, smoking, inappropriate diet, excessive alcohol consumption, physical fitness and lack of exercise, and high blood glucose levels) on employer health care costs (Goetzel et al., 1998a; Anderson et al., 2000). The study examined medical claims for more than 46,000 employees from both private- and public-sector organizations for 6 years. These 10 modifiable risk factors accounted for about 25 percent of all health care expenditures for the six employers in the study (Anderson et al., 2000). Interestingly, the two risk factors with the greatest effect on health care expenditures within 3 years were psychosocial: depression and stress. Health care expenditures for employees who reported depression were 70 percent greater than those for employees not reporting depression. Health care expenditures for employees with high levels of stress were 46 percent greater than those for employees who did not have high levels of stress, after controlling for demographics and other risk factors. When risk factors were combined, as they normally are for individuals at risk in multiple categories, health care expenditures increased to a far greater extent. For example, when health care expenditures for individuals with multiple risks for heart disease (i.e., smoking, hypertension, hypercholesterolemia, high stress, sedentary lifestyle, and obesity [Box 6–4], high blood glucose) were examined, they were found to be more than 200 percent greater than the expenditures for those without these risk factors. Similarly, health care expenditures for individuals at high risk for the two psychosocial risks, depression and stress, were nearly 150 percent greater than those for individuals lacking these risks.
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The Future of the Public’s Health in the 21st Century area and recognizes that executives look at the quality of the community when deciding whether to move their families and businesses there. Representatives from potential new businesses explore factors such as competition, wages, cost of living, and the employee base, as well as the educational system, economic development potential, and the attitude of the community. The association and other Schuylkill County partners recognize that collaborative efforts are needed to bring new resources to the communities but note that a community does not have to be big to be successful (McAullife, personal communication, 2001). GTE GTE, which has recently merged with Bell Atlantic to form Verizon, is a founding member of the Georgia Healthcare Leadership Council. The council is an organization of managed care plans and local employers such as Delta Air Lines, Georgia Pacific, Lockheed, GTE, UPS, and pharmaceutical companies. Its goal is to improve the medical care provided to Atlanta residents. The primary focus of the council, formed in the fall of 1999, has been the development of preventive care standards based on evidence-based medicine. The council distributed posters to 3,500 metropolitan Atlanta doctors outlining standard prevention measures for children and adults. Upcoming initiatives include issuing guidelines for women’s health and standardizing treatments for asthma and allergies. GTE also has provided funding to support a Washington Business Group on Health project, Community Partnerships to Prevent Violence. The project will create a forum consisting of Texas-based employers; community organizations; school, mental health, and public health organizations; and parents. Its objective is to jointly develop strategies for businesses to assist parents (including their own employees) and schools in working to prevent school and youth violence. Forum participants will assess the community’s inherent ability to work cooperatively on these issues and identify their roles and responsibilities in meeting this challenge. The participants will develop a set of goals and recommendations. They will also identify resources to share, such as information to be provided to parents on identifying risk behavior, working with school personnel on children’s emotional and behavioral issues, and identifying community resources for children who need educational, mental health, and other services (WBGH, 2000). 3M A core value at 3M is to embrace a commitment to strengthening the communities that are home to 3M locations. Through the 3M Foundation and the 3M Community Affairs Department, 3M links resources to community needs. 3M employees volunteer in multiple activities, such as tutoring programs and visiting scientist programs in local schools. Employees who participate are given paid time off from work to provide these services (WBGH, 2000).
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The Future of the Public’s Health in the 21st Century selves as engaged partners in the public health system. Groups such as the Washington Business Group on Health are leading efforts to identify strategies to build greater collaboration between corporate leaders and governmental public health agencies. In 1999, the Washington Business Group on Health hosted a public health forum for employers that brought together large employers and governmental public health leaders to discuss maternal and child health. A summary of the findings from the forum highlights the difficulties that employers and public health agencies must overcome if collaborative actions toward common health goals are to be achieved (WBGH, 2000). These findings include: Employers and governmental public health agencies have had little interaction; this situation needs to change, and both will benefit from such a change. There is a need for a common language and for dialogue among public health employers about issues related to health care costs. Employers need data on pressing community health problems, but the data gathered need to be interpreted in ways that are meaningful to corporate health leaders. There are significant limits to both the extent and the efficacy of employee health education. There is a need to improve employee utilization of preventive health services that are covered but not being accessed by employees. The findings from the forum also noted that partnership and collaboration could bring needed public health expertise to employers and business expertise to public health agencies (WBGH, 2000). Governmental public health officials and business leaders would benefit from a formal dialogue on the health issues facing communities and the workforce. For example, corporate leaders should be invited to participate in community assessments and health planning and promotion activities (see Chapter 4). Such communication with corporate leaders and the participation of corporate leaders would allow the exchange of data on employee health as well as population-based health data from the community that are interpreted in ways that are meaningful to both public health officials and corporate health leaders. Such a dialogue would also provide the public health community with a better understanding of the processes that business leaders use to diagnose problems, review options, make decisions, and implement actions. Business leaders would gain a better understanding of the reasoning behind public health statutes, regulations, and other requirements that may affect businesses. Moreover, such a dialogue
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The Future of the Public’s Health in the 21st Century would help businesses leaders better understand their critical role as partners in the public health system. The scientific basis of the health promotion and disease prevention programs needs to be better explained so that employers can better determine the most effective and efficient strategies to promote and sustain employee health, lower costs, and increase worker productivity. The public health community, the business community, and philanthropies may all play a role in such an effort. Public health researchers and philanthropies could be active partners in helping employers who want to develop, manage, and evaluate these types of programs. Strong communications strategies must be developed to disseminate information on the costs (to employers and businesses) of modifiable health risk factors and the evidence-based interventions available to reduce these risk factors. This is especially critical if employees (as noted in the forum of the Washington Business Group on Health) are not taking advantage of covered preventive services. The corporate world is already steeped in marketing techniques but could benefit from the social marketing and media advocacy strategies described in Chapter 7 to motivate behavioral change among individuals (e.g., to increase the levels of use of preventive services) or to change public policies that would contribute to a healthier community and workforce (e.g., support educational programs in the community). In addition to contributing to the health of employees and communities, greater corporate engagement in the public health system can improve public opinion about companies. A 2000 Business Week/Harris Poll explored Americans’ views of corporate America. Two findings are of particular relevance to this discussion. When asked to rate large U.S. employers on “really caring about what is good for America,” 25 percent of respondents answered “pretty good” and 7 percent answered “excellent.” The remaining 66 percent answered only “fair” or “poor.” Respondents were also asked to show their agreement with one of the following two statements: (1) “U.S. corporations should have only one purpose—to make the most profit for their stakeholders—and the pursuit of that goal will be best for America in the long run” and (2) “U.S. corporations should have more than one purpose. They also owe something to their workers and the communities in which they operate, and they should sometimes sacrifice some profit for the sake of making things better for their workers and communities” (Business Week, 2000). The respondents were almost unanimous (95 percent) in agreeing with the second statement. Recognition of exemplary corporate responsibility can affect the public’s view of a company’s social responsibility and corporate reputation. A number of programs recognize corporations for their investments, and several partnerships between governmental and nongovernmental bodies
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The Future of the Public’s Health in the 21st Century recognize corporate efforts. For example, EPA, the Department of Energy, and the Center for Resource Solutions sponsor the Green Power Leadership Award, which recognizes the actions of organizations that advance the development and use of renewable energy sources. The Ron Brown Award for Corporate Leadership is a presidential award that rewards corporate leadership for promoting employees’ development and well-being and for enhancing the communities where the employers work and live. For the past 10 years, the C. Everett Koop National Health Award, sponsored by the Health Project,2 has been presented to U.S. companies that have documented improved employee health and cost savings from the health promotion and disease prevention programs at their work sites (Tully, 1995; Ziegler, 1998, 1999). The committee recommends that the corporate community and public health agencies initiate and enhance joint efforts to strengthen health promotion and disease and injury prevention programs for employees and their communities. As an early step, the corporate and governmental public health community should: Strengthen partnership and collaboration by Developing direct linkages between local public health agencies and business leaders to forge a common language and understanding of employee and community health problems and to participate in setting community health goals and strategies for achieving them, and Developing innovative ways for the corporate and governmental public health communities to gather, interpret, and exchange mutually meaningful data and information, such as the translation of health information to support corporate health promotion and health care purchasing activities. Enhance communication by Developing effective employer and community communication and education programs focused on the benefits of and options for health promotion and disease and injury prevention, and Using proven marketing and social marketing techniques to promote individual behavioral and community change. 2 The Health Project is a White House-initiated public–private partnership of health care leaders dedicated to improving family, individual, and community health through programs that are also proven to reduce overall costs.
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The Future of the Public’s Health in the 21st Century Develop the evidence base for workplace and community interventions through greater public, private, and philanthropic investments in research to extend the science and improve the effectiveness of workplace and community interventions to promote health and prevent disease and injury. Recognize business leadership in employee and community health by elevating the level of recognition given to corporate investments in employee and community health. The Secretaries of DHHS and the Department of Commerce, along with business leaders (e.g., chambers of commerce and business roundtables), should jointly sponsor a Corporate Investment in Health Award. The award would recognize private-sector entities that have demonstrated exemplary civic and social responsibility for improving the health of their workers and the community. CONCLUDING OBSERVATIONS Strong partnerships among governments, communities, philanthropies, and the corporate community to facilitate actions to improve the health of employees and their communities are critical for the public health system to achieve its goals. These partnerships could stimulate national debate and commentary to draw more attention to the importance of health promotion and disease and injury prevention in improving the health of the nation. Such partnerships could also serve to identify the incentives that can be used as tools to further engage the corporate community in providing high-quality programs that promote employee and community health and to develop shared actionable strategies to achieve the vision of healthy people living in healthy communities. REFERENCES AHRQ (Agency for Healthcare Research and Quality). 2002. Guide to Clinical Preventive Services, 3rd Edition (2000–2003). Available online at http://www.ahrq.gov/clinic/prevnew.htm. Accessed March 18, 2003. Aldana SG. 2001. Financial impact of health promotion programs: a comprehensive review of the literature. American Journal of Health Promotion 15:(5):296–320. AMA (American Medical Association). July 1999. Rethinking health insurance: the AMA’s proposal for reforming the private health insurance system. Available online at www.ama.assn.org/ad.com. Accessed September 18, 2002. Ames GM, Grube JW, Moore RS. 1997. The relationship of drinking and hangovers to workplace problems; an empirical study. Journal of Studies on Alcohol 58(1):37–47. Amler RW, Dull HB (Eds.). 1987. Closing the Gap: The Burden of Unnecessary Illness. New York: Oxford University Press. Anderson DR, Whitmer RW, Goetzel RZ, Ozminkowski RJ, Dunn RL, Wasserman J, Serxner S, HERO Research Committee. 2000. The relationship between modifiable health risks and health care expenditures: a group-level analysis of the HERO database. American Journal of Health Promotion 15(1):45–52.
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