In terms of the concept of Total Worker Health, the employees are beginning to see this as their program.
[Unions] have to be at the table as equal partners [in discussions about worker health], but I would say let’s first talk about having a safe workplace and a healthy workplace.
Health in the workplace can be viewed as a continuum, beginning with how people work safely in an environment, through how employers begin to promote personal health issues, to how they create an environment that augments worker health and safety and promotes health and well-being. Traditional employee health-related services (e.g., wellness programs, workers’ compensation, occupational medicine) have many models, said Pamela Hymel, Chief Medical Officer, Walt Disney Parks and Resorts. But, she added, as employers move toward the prevention and health promotion end of the continuum, followed by more proactive health assessments and lifestyle initiatives, models may be fewer and more challenging to implement. In some environments (e.g., government), going all the way to integrating primary care with workplace initiatives may be impossible.
A panel of speakers explored several employer programs and the ways in which their value is being measured. An expanded notion of return on investment may take into account not just monetary return, but a return in terms of improved health and safety, improved employee engagement, and improved worker vitality. Although employers are striving to measure many of these effects, their efforts are relatively unnoticed,
Hymel said, because they rarely appear in peer-reviewed journals, and alternative means to disseminate those best measurement practices may be necessary.
This session, moderated by Hymel, asked several representatives of large businesses to reflect on the following questions:
- What is success? What is the value of these programs?
- What specific measures or outcomes are being used to demonstrate success?
- What metrics could be more useful? What are the differences of opinion over the validity of various metrics and their use?
Speakers in this session included Jules Duval, Medical Director of Occupational Health Services, Smithsonian Institution; Kathleen McPhaul, Chief Consultant, Occupational Health, Veterans Health Administration (VHA); Peter Wald, Vice President and Enterprise Medical Director, USAA; and Nancy Lessin, Senior Staff for Strategic Initiatives, United Steelworkers–Tony Mazzocchi Center.
A challenge with a new workplace wellness program is to build a case to convince senior leadership of its importance and the need for resources and other forms of support. This was a challenge facing newly hired Duval. He began by giving employees a health risk assessment and comparing the results to U.S. norms. The results helped counter leaders’ preconceptions that the Smithsonian’s employees were not experiencing the same kinds of health problems as Americans overall. Duval was especially attentive to the prevalence of predisease states (e.g., prehypertension and overweight, elevated fasting blood sugar, and low rates of exercise). These data effectively made the argument that prevention efforts could benefit this specific workforce.
Duval said evidence of management’s acceptance of the program is reflected in the most tangible of assets—space. When one of the Smithsonian’s museums was due to be renovated, the health unit was slated for elimination, as it was then serving as a one-person shop doing walk-in care. Before that could happen, Duval and several nurses had the facilities staff take out a couple of walls, build a bay area, create several rooms for conducting individual health risk assessments and counseling, and create a
fitness area with equipment available around-the-clock (key card access). The new space became so popular that when the museum was finally renovated the wellness space was rebuilt as a new 1,500-square-foot health center that retained the treatment rooms and fitness area.
Within VHA, the overall safety and wellness effort has been integrated in the Central Office, said McPhaul. Three Total Worker Health pilot projects are beginning within medical facilities. Next steps, she said, will be to tackle stress and the psychosocial environment, including psychological safety—higher rates of which increase job satisfaction, retention intention, engagement, civility, and innovation. Efforts to foster acceptance of the overall program by both labor and management are ongoing.
USAA is a financial services company with more than 10 million members and is the leading provider of advice about financial planning, insurance, banking, investments, and financial security to members of the U.S. military and their families, said Wald. The company focuses on providing a high level of service to all of its members, which includes all of its employees, and thinks of employees as a fixed resource, he said. The purpose of the USAA wellness program,1 which began in 2002, is to keep that resource working well and productively, making it integral to the company’s mission. By keeping their employees and their families physically, emotionally, and financially healthy, those employees can focus at work on member services, said Wald. “That is the goal. Anything that gets in the way of member services is something we want to flatten out.”
When McPhaul first joined the U.S. Department of Veterans Affairs (VA), she saw her position as traditional occupational health: focused on the many hazards in the health care environment and on injury prevention and recognizing that hospitals and nursing homes have a higher rate of occupational injuries and illnesses than U.S. private industry as a whole. She said that with more than 304,000 employees, more than 117,000 of whom are veterans, and, on any given day, perhaps another 100,000 volunteers, students, and contractors on site, the demand for traditional occupational health and safety services was high.
1The USAA wellness initiative won the C. Everett Koop National Health Award in 2006.
In addition, like many employers, VHA has many older workers, whose risk of injury may be greater than for younger workers. McPhaul believes effective injury reduction for the older worker cohort requires consideration of the other health issues in their lives. These contribute to the longer time older workers need in order to return to work and their higher rates of disability.
With limited resources, Duval and his Smithsonian staff focused on the problem of overweight and obesity. Data from the employee health risk assessments showed that only about a third of the Smithsonian’s employee population was normal weight. The staff created a program that would enable them to work with employees who were overweight and obese on an ongoing basis, providing exercise prescriptions and nutrition counseling, along with opportunities to exercise more. The aim was to reduce the prevalence of higher blood pressure, fasting blood sugar, and cholesterol levels.
USAA demonstrates its commitment to its employees through attention to the built environment and the development of programs that focus on primary prevention and keeping people well, said Wald. To operationalize and support employee-directed health information, management makes sure the messages it is sending—through, for example, foods available in the cafeteria, offering an on-site pharmacy, and exercise and relaxation options—point in the same direction.
USAA management formed a wellness council that reports to the head of human resources, who reports to the chief executive officer and has responsibility for integrating the overall effort. All the initiative’s individual components—which are as diverse as workers’ compensation, disability, safety, corporate communications, corporate real estate, and corporate services—formerly had difficulty making their voices heard, Wald said, but presenting as a unified group under the wellness council umbrella, has proved more successful.
Duval embedded his wellness staff into the Smithsonian’s traditional occupational health organization in order to establish a team approach, while nonetheless providing services in an engaged, individualized way.
A concern is that a good occupational health program is systems oriented, whereas health promotion has usually been about individual behavior, which can make integration difficult and risks blaming individuals for being overweight or smoking, said Laura Welch, Medical
Director, Center for Construction Research and Training (CPWR). Even when health promotion activities might not overtly target individuals as being responsible for high health costs, lower productivity, and so on, workers may hear that as the message, Lessin added. Initiatives should work to provide employees with education and the tools they need to make better choices for themselves and their families, Wald said, citing as an example of a positive systems approach USAA’s 5 percent health insurance premium reduction for employees who participate in wellness programs.
Welch noted one situation in which an employer might not want to engage in a Total Worker Health initiative would be if the workplace’s safety situation is inadequately addressed. Lessin added that resources should instead be devoted to providing safe and healthful workplace conditions as required by law. In addition, she said, employers’ support of the health of their workforce should include the provision of such things as paid sick time, paid parenting leave, paid vacation time, pensions, and a living wage.
The Smithsonian’s wellness program has added about 600 employees every year, and currently engages nearly 2,800 employees, Duval said. Program staff do not wait for employees to come to the wellness center; instead, they reach out to the organization’s 19 museums and 9 research centers in the United States and abroad. Meanwhile, traditional occupational health program enrollment has grown from 1,400 in 2006 to 2,400 most recently. Workers are becoming persuaded that the occupational health tests are not being done “on them,” but “for them,” Duval said. Employee satisfaction questionnaire responses bear out this positive response.
Even though wellness messages need to be aligned across an organization, Wald said, they can take different forms, because different messages appeal to and motivate different individuals. For example, he said variations on the “getting in shape” message might discuss looking good, being around so you can see your kids graduate from college, wearing a bathing suit at the beach, feeling better, and executing the company’s mission. USAA’s Healthy Points program rewards workers for healthy behaviors and combines both participation and outcomes.
Executive support for USAA’s program is maintained by monitoring four important kinds of information, Wald said. They are:
- Satisfaction, including personal anecdotes, which not only resonate but also show the program is having powerful effects on individual employees;
- High participation rates, which indicate the extent to which employees believe the program is valuable;
- Risk factor reduction, including such activities as ergonomic evaluations of work stations, which may be associated with a decrease in repetitive motion injuries; and
- Economic impact analyses, which have shown decreases in both short- and long-term disability.
McPhaul said that in the VHA environment, success can be viewed from various perspectives: public health, occupational health, health care delivery (primary care), employer, and employee. VHA has its own views about success in each of these areas, McPhaul said. For example, public health success might be reflected in having different structures work together more effectively; primary care success might be achieved through clinicians’ greater attention to occupational histories and workplace risks; employer success might be measured by employee engagement and productivity; and employees might measure success in terms of work’s impact on their physical and mental health and job satisfaction. In the end, if the VHA’s Total Worker Health initiative is successful, McPhaul said, that success can be measured by improvements in health-related behavior, the psychosocial work environment, and job satisfaction, along with a reduction in occupational injuries and illnesses. Ultimately, she added, these improvements should have a positive impact on the quality of health care veterans receive and the support of facility leadership.
A new unit set up at VHA headquarters is responsible for occupational metrics and surveillance and holds great potential for providing insights regarding Total Worker Health, McPhaul said. While VA Central Office staff habitually think in system terms, that kind of integrative thinking may be less common in the system’s 150-plus hospitals and several thousand clinics, with tremendous diversity in culture and practices across the system. In general, VHA has quite a few resources aimed at improving employee health, but not good measures of integration
among them. Existing VHA data that can be used for this purpose include those describing employee demographics, health behavior (from self-reported surveys and health risk appraisals), information about occupational safety (incident reports, workers’ compensation claims), job satisfaction and turnover, and indirect measures of job stress.
Data from each of the VHA’s hospital regions indicate performance variations, analysis of which may yield clues about how to improve performance throughout the system. Similarly, analysis of data by occupation may identify employee groups where prevention efforts could be usefully concentrated. An example McPhaul used was injuries that occur when lifting or repositioning patients, which are more than twice as high among nursing assistants as among other nursing occupations.
Measuring Health Risk
Since 2006, the Smithsonian’s focused wellness program has seen fairly steady declines in the proportions of employees with positive health risks (for the measures being tracked),2 Duval said, most dramatically in the proportions of employees identified with prediabetes and a sedentary lifestyle.
USAA uses the health risk appraisal as “a personal dashboard for employees,” Wald said. It comprises an online questionnaire and biometrics (body mass index [BMI], blood pressure, fasting glucose, and lipids measures). The number of employees completing these appraisals and participating in other wellness programs has steadily increased. More important, health risk assessments show a 28 percent reduction in the number of employees’ total risk factors between 2009 and 2013, as well as in BMI for those in the highest weight groups (BMI of 30 or more). And, since 2002, USAA has seen about an 80 percent decrease in long-term disability costs, as well as a decrease in short-term disability, Wald said.
In terms of any effects on employee productivity or offsetting savings, as a federal agency, the Smithsonian is not allowed to access data
2Measures include prehypertension, overweight, prediabetes, inadequate exercise, high cholesterol, depression risk, and smoking.
on insurance claims, Duval said, but it can look at employees’ use of sick leave. Many employment metrics can be difficult to interpret, and sick leave is one of them. Is a low number of sick days a good thing, or a bad thing? Duval asked. If it indicates that employees are becoming healthier, it would be a positive result. But if it means employees are coming to work when they are sick, and thereby reducing productivity or infecting other workers, that is not good. At the Smithsonian, leadership actively encourages people to stay home when they are sick. Some union representatives participating in the workshop commented on the growing trend across the country for employers to establish “no-fault attendance policies.” Lessin said that any time missed from work equals an “occurrence,” and under such policies, workers can be fired if they have too many occurrences. A consequence of these policies, she said, is that workers go to work sick. Lessin added employers in Sweden, for example, use a different approach to attendance: if there is high absenteeism in a workplace or work area, the occupational safety and health committee is dispatched to investigate whether there is something wrong with the job and, if so, what is needed to address the problem.
Data supplied by the Smithsonian’s human resources office show a decline (from 4.46 hours of sick leave for every 100 hours worked to 3.99). Although this is a modest trend in the right direction, it is still a higher rate of sick leave hours than among other federal workers or U.S. private-sector employees, Duval said. Nevertheless, over the population of employees, sick leave costs have declined $12.7 million in the program’s first 5 years.
Data analysis has revealed that only 2.5 percent of employees account for 40 percent of USAA’s health care costs, Wald said. When the workforce is divided into quintiles by how much is spent on health care, only 649 employees are in the highest two groups. By contrast, the vast majority of employees are healthy, with almost 22,000 in the lowest quintile.
Wald does the cost analyses for USAA, which may approximate the situations in which private companies find themselves, based on total costs, because he believes that if companies squeeze down on, for example, workers’ compensation benefits, those costs pop up elsewhere instead, likely in the health plan. According to Wald, a significant advantage of having a centralized, integrated program is that you cannot have this
“squeezing the balloon” effect in which costs are not actually lowered, but instead shifted to another area. Over the past 5 years, USAA’s health plan costs have grown about 2 percent, about half that for employers generally.
Lessin reflected on the issue of value in Total Worker Health programs from her perspective within organized labor, making the following major points:
- Employers currently are not providing safe and healthful workplaces, as they are required to do by law.
- The way work is being restructured and organized is contributing to injuries and illnesses, including cardiovascular disease.
- A growing body of scientific literature questions the assumptions and underpinnings of wellness programs.
- Who gets to define health in health promotion?
Safe and Healthful Workplaces
The Occupational Safety and Health Act of 19703 was enacted to ensure the nation’s workplaces and working conditions are safe, healthful, and free from recognized hazards that can cause death or serious physical harm. Established under the act were the Occupational Safety and Health Administration, which has regulatory authority, and the National Institute for Occupational Safety and Health (NIOSH), which provides research, training, information, and education aimed at helping ameliorate hazardous workplace conditions. Lessin noted that NIOSH’s roots are centered around the need to reduce and eliminate hazards and hazardous conditions on the job, and that in her opinion, NIOSH has gone “off course” with Total Worker Health.
The U.S. Bureau of Labor Statistics (BLS) reported that 4,628 workers in the United States died from occupational injuries in 2012 (BLS,
3Occupational Safety and Health Act of 1970, Public Law 596, 91st Cong. (December 29, 1970).
2014). In addition, a report from the AFL-CIO notes that 49,000 workers die each year from workplace-acquired diseases (AFL-CIO, 2014). The report also notes that many more workers (approximately 3.8 million) reported non-fatal work-related injuries or illnesses in 2012, but asserts the true range is between 7.6 and 11.4 million per year. BLS data indicate a sharp decline in recordable injury rates between 1992 and 2012, but Lessin said research attributes these declines to employer practices that discourage the reporting of occupational injuries and illnesses rather than fewer actual injuries. A 2009 U.S. Government Accountability Office report documented such practices and cited many shortcomings in the reporting of work-related injuries and illnesses (GAO, 2009).
According to a 2008 congressional report (U.S. House of Representatives, 2008), employers have a number of methods to discourage accurate reporting of injuries and illnesses. Lessin said that in surveys conducted by the United Steel Workers (USW), more than 90 percent of employers at USW-represented workplaces engage in at least one of these practices. “These are the same employers who are telling us they care about our health and want us to be involved in wellness programs.” The pattern of underreporting is of concern both from a regulatory standpoint, and from a public health standpoint. While known hazardous conditions can be difficult to correct, hazardous conditions that remain unidentified (because job injuries and illnesses are not reported) will remain unaddressed, she said.
The Restructuring and Organization of Work
Many of the most significant health and safety concerns of workers today suggest the need for system fixes, said Lessin, including the need for engineering controls to prevent hazardous exposures, improved training and equipment maintenance, remediation of ergonomic hazards, and greater concern for the pressures on workers that arise from downsizing and increased production demands (including extended hours and multiple shifts). Many of these concerns have to do with how work is being restructured and reorganized in ways that create a more stressful—and hazardous—workplace, she said. Although some of the health risk factors that wellness programs intend to address have a stress component, she added, the programs typically focus on individual behavior change and not on changing systemic factors in the work environment. Lessin noted a growing body of scientific literature documenting the adverse health and safety impacts associated with job stressors and with the way employers
are organizing and restructuring work (Anna, 2011; Belkic et al., 2004; Chandola et al., 2008; Eatough et al., 2012; Karasek and Theorell, 1990; Landsbergis et al., 2013a, b; NIOSH, 2002; Schleifer and Shell, 1992; Schnall et al., 2009; Schulte et al., 2012; Smith et al., 1992).
Lessin also noted a body of literature questioning the value of wellness programs (CHBRP, 2013; DiNardo and Horwitz, 2013; Horwitz et al., 2013; van Dongen et al., 2011). The extent to which reducing unhealthy behavior actually saves health care costs is unclear, she said, and programs that reward people for healthy behavior may tend to disadvantage lower-income, less educated workers whose environmental and other health risks are greater, risking discrimination. The health benefits of worker wellness programs versus increases in low-wage worker income is untested, she said.
Lessin reiterated that resources should first be devoted to providing safe and hazard-free workplace conditions as required by law. According to Lessin, workers’ priorities for health promotion include
- Paid sick and family leave,
- Paid maternity and paternity leave,
- Paid vacation time,
- A living wage,
- Comprehensive health care for workers and retirees,
- Meal time more than 20 minutes, and
- A clean environment.
Finally, she asked, who defines health? From her perspective, the World Health Organization’s definition—“Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity” (WHO, 2014)—with its emphasis on well-being is where the country should aim. If health is more than the absence of disease or infirmity, it is surely more than a person’s BMI, said Lessin.
For the above reasons—persistent high rates of employee injury, illness, and death (despite underreporting of job injuries and illnesses); fundamental and systemic changes in the organization of work itself that have increased job stress; and uncertainty about the benefits of wellness programs in the workplace—Lessin believes it is timely for NIOSH to go back to the basics before moving into worksite wellness efforts: first, make sure occupational health and safety programs are comprehensive and effective in identifying and eliminating or reducing hazards; second, look at all sides of the debate about wellness and health promotion programs, including controversies and down sides; and third, make sure worker organizations, including unions, have a seat at the table when future NIOSH directions and programs are planned and implemented.