5
Community/Population Health as an Intentional Business Strategy
As discussed in Chapter 4, businesses undertake a variety of activities that positively affect health but which were not designed specifically with population health improvement in mind. In this session, moderated by James Knickman, the president and chief executive officer of the New York State Health Foundation, panelists from two companies described how their organizations have intentionally included population health improvement in their overall business strategy. Fikry Isaac, the vice president for Global Health Services at Johnson & Johnson, discussed the company’s commitment to improving population health through global reach with a regional focus. Charles Yarborough, the director of medical strategies at Lockheed Martin, described how the company selects sites for its outreach efforts and assesses outcomes for modifiable determinants of health.
THE EXAMPLE OF JOHNSON & JOHNSON
From a business perspective, it is critical for a company to earn the right to be in the communities in which it operates and to give back to the communities, said Isaac of Johnson & Johnson. The Johnson & Johnson strategy starts with its credo, which is the value system that the company operates under.1 The company’s first responsibility, Isaac said, is to the customers it serves—the doctors, nurses, patients, mothers,
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1 See http://www.jnj.com/about-jnj/jnj-credo (accessed December 12, 2014).
fathers, and others who use its products and services. The company is also responsible to its employees throughout the world, to the communities in which it lives and works, and to the world community as well. Finally, the company is responsible to its shareholders, and when the aforementioned principles are followed, there should be a positive return on investment for the shareholders. The credo is about leading with a purpose, he said.
The Johnson & Johnson approach to improving global health has three focus areas: saving and improving the lives of women and children, addressing unmet needs and preventing disease among the most vulnerable, and strengthening the health workforce. Echoing the comments made by IBM’s Grace Suh, Isaac noted that Johnson & Johnson’s efforts are focused on how the company can make a difference, not just by giving money, but by using its expertise to make a lasting impact.
In working to improve population health in its communities worldwide, Johnson & Johnson strives to have global reach, with a regional focus. Even though the three strategy areas are consistent around the globe, Isaac said the approach varies by region and by country, depending on needs. In North America, for example, the company supports health education through the U.S. Head Start program. The approach is to add value to existing programs, such as offering a 2-week executive management program for Head Start administrators. There are also health literacy programs for Head Start families that educate the families about managing their children’s illnesses at home and avoiding unnecessary hospital visits. In Africa, the company supports the Total Control of the Epidemic Campaign, a person-to-person and village-to-village informational campaign about HIV/AIDS. The program has reached more than 4 million people thus far.
Isaac shared several specific examples of programs across the three focus areas, highlighting the impact of each on population health (see Box 5-1). In response to a question about topic selection, Isaac said that some of the topics (e.g., Gateway to a Healthy Community–Healthier Kids) are identified as unmet needs by the Johnson & Johnson Sustainability Taskforce or other committees. The intentional strategic initiatives that are linked to corporate goals require the involvement of the business leaders. For example, offering pharmaceutical support for millions of people comes at a cost, but it is also a part of the strategy of reaching out, he said.
Intentional Strategies
Having an intentional strategy brings measurable results, and Johnson & Johnson has established specific social goals and targets as part of its overall strategy. The goals and objectives are outlined in the corporate strategic plan, Healthy Future 2015, and the company is committed to mea-
suring and reporting on global and community health initiatives annually.2 As an example, Isaac offered the 2015 goal of providing 200 million doses of mebendazole per year to children infected with intestinal worms and reported that 161 million doses were provided to affected children in 16 countries in 2013. Another 2015 goal is advancing community wellness through health education, and in 2013 seven disease-related programs were launched in nine countries. Isaac said that in 2013 Johnson & Johnson reached more than 4.9 million people with its human wellness initiatives.
In closing, Isaac said that Johnson & Johnson believes in creating a healthier world, one community at a time, and that the company fulfills this mission through essential partnerships. He added that businesses that are doing good can influence and inspire others.
THE EXAMPLE OF LOCKHEED MARTIN
Yarborough of Lockheed Martin briefly shared two examples of ways in which community and health come together at Lockheed Martin. The program A Million Makes a Difference is part of the company’s commitment to making a positive impact in communities where its employees live and work.3 The goal is for employees to collectively volunteer an average of 1 million hours each year. In addition, Lockheed Martin invests more than $25 million worldwide in nonprofit organizations, and employees donate $20 million annually to various organizations through workplace giving programs. Another program, Accelerating a Better You, focuses on the overall well-being of employees and their families, helping them to achieve a series of lifestyle changes that will help them to get healthy and stay healthy.4 Yarborough said that this is a cultural shift in how Lockheed Martin views its employees’ health and wellness.
Lockheed Martin has dozens of company sites across the country, and Yarborough described the method used to select the sites for the various outreach efforts as well as a report card to assess achievement levels for modifiable determinants of health.
The Site Selection Process
In selecting company sites for the launch of initiatives, the first key criterion is being ready. Yarborough referred to this as “persuadability,”
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2 See http://www.jnj.com/caring/citizenship-sustainability/performance/healthy-future-2015 (accessed December 12, 2014).
3 See http://www.lockheedmartin.com/us/who-we-are/community/volunteers.html (accessed December 12, 2014).
4 See http://www.lockheedmartin.com/us/employees/healthcarereform/aby.html (accessed December 12, 2014).
BOX 5-1
Examples of Johnson & Johnson Initiatives on Population Health Improvement
Asia Pacific Economic Cooperation—Johnson & Johnson participates in the Asia Pacific Economic Cooperation (APEC) and co-chairs the APEC Life Science Innovations Forum (industry co-chair). There are 21 APEC member countries or “economies,” including the United States. The Life Science Innovations Forum engages representatives from government, academia, and business and forms public–private partnerships with the goal of sustainable and inclusive growth in the region through health and innovation. The forum facilitates the sharing of best practices among the economies. The results described by Isaac included a renewed focus on non-communicable diseases and health care–acquired infections and the development of a mental health roadmap for the region. There has also been an evolution of the dialogue from health as a cost to health as an investment that drives economic growth.
Campaign for Nursing’s Future—Johnson & Johnson is working in cooperation with professional nursing organizations, schools, hospitals, and other health care groups to promote opportunities in nursing and to increase awareness of the value of the nursing profession to society and to America’s health care community. Isaac reported that their 750,000 new nurses have joined the workforce since the campaign began in 2002. In the past 2 years, employment of registered nurses has increased by 243,000 nurses. Discovernursing.com, the Johnson & Johnson information and resource website for the campaign, is the number one website for nurses. The campaign has distributed 35 million pieces of recruitment and retention materials in more than 50 countries, awarded $20 million in scholarships and grants, produced 12 award-winning documentaries on nursing, and developed more than 25 key partnerships.
or the potential for engaging in healthy actions. Persuadability scores for each site take into account eight health actions: pedometer use, disease management, flu shot participation, biometrics, preventive examinations, cardiovascular exercise, nutrition, and stress management. Scores are determined using decision trees and regression analyses of de-identified data.5 The second key site criterion is the potential health benefit relative to the average prospective health care cost for each site’s employees. This is a proprietary risk score that comes from the company’s data warehouse vendor, Yarborough said. The score is based on a relative risk model and takes into account age, gender, and medical claims data as well as
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5 For further information, Yarborough referred participants to Chapter 9 of Victory Lab by Issenberg (2013), which discusses big data and campaigns, and The Signal and the Noise by Silver (2012).
Gateway to a Healthy Community–Healthier Kids Initiative—Johnson & Johnson has partnered with local and state health departments and other organizations to combat childhood obesity and diabetes. The Gateway to a Healthy Community–Healthier Kids Initiative offers innovative tools and applications developed with the support of Johnson & Johnson, including Activity Works, a curriculum-based module that delivers 12-minute exercise bursts in elementary school classrooms to increase physical activity. The program was started in school districts in Atlanta, Houston, Newark, and Philadelphia where a need was identified. According to Isaac, from January 2012 through early February 2013 the program enabled 150,000 children in grades K through 3 to burn more than 150 million calories by engaging in physical activity for 712,789 hours. User surveys and feedback indicate an increase in student physical activity and high levels of classroom and teacher/principal satisfaction, engagement, and support.
Moms in Motion—Johnson & Johnson has recently become involved with this existing program that helps busy moms get fit by connecting socially to local or virtual fitness groups as well as through mission-driven coaching toward a fitness goal (e.g., running a 5K race or half marathon). There are more than 10,000 participants in the network. The company’s involvement is with an energy management program covering the physical, nutritional, emotional, and mental aspects of energy. A 10-week, 1-day-per-week training program was held for 125 moms who lead fitness teams to help them define their fitness missions and become energy management coaches for their teams. The results, as summarized by Isaac, included increased energy levels; self-reports of positive change in fitness and health behaviors; weight loss; improvement in stress levels, mood, and sleep; and positive program feedback.
SOURCE: Isaac presentation, July 30, 2014.
an analysis of known chronic conditions and acute and new conditions that might occur. Average scores are then plotted on a graph to identify the priority sites for intervention; these are sites that fall into the upper right quadrant in a diagram that maps both persuadability and potential benefits (see Figure 5-1). This quadrant is referred to as the “slingshot” area. “Slingshot,” Yarborough explained, is an entrepreneurial term from Silicon Valley that refers to places where one would want to invest funds in a start-up company. These company sites are those that are most ready (persuadable) and that are predicted to have higher health care costs in the coming year (meaning they offer the most potential benefit from an intervention). The site selection process identified 18 company sites as higher priorities for community and industry collaboration on health. Yarborough said that this process is also used for identifying sites for safety performance interventions (considering data such as safety sta-
FIGURE 5-1 Selection of company sites for health initiatives.
SOURCE: Yarborough presentation, July 30, 2014. Used with permission.
tistics, time to report the incident, lost work days, etc.). Interestingly, he said, there was an almost complete correlation, site by site, of the plots for safety and health, and he emphasized that this reflects the interrelationship between the protection of workplace health and safety and the promotion of employee health (Hymel et al., 2011).
Site Report Cards
As part of the Lockheed Martin HealthWorks employee health plan, employees and their spouses complete a voluntary and confidential well-being assessment. This health risk appraisal is used to create a personal roadmap to health for the individual. Using de-identified data from these assessments, Yarborough explained, scores were derived for individual behavior, physical environment, social and economic determinants, and
health care in order to identify the areas where the company sites should focus attention. Scores were reported as grades (A through F), with the distribution of grades used as an indicator of performance.
Yarborough shared data for 2012 from 47,000 of Lockheed Martin’s U.S. employees (see Figure 5-2). There were very few As in the areas of individual behavior and social and economic determinants. Generally, male and female employees were similar he said, except for health care, where men, not unsurprisingly, got more D and F grades. Yarborough said that charts like these are very useful when talking to site managers about what actions are needed at the local level.
Partnering for Health
There are various models of intervention used across the many Lockheed Martin “slingshot sites.” In Fort Worth, Texas, the company is partnering with the Blue Zones® project described by Buettner (see Chapter 2). At a plant in Cobb County, Georgia, the site manager is in a
FIGURE 5-2 Report card grades for 47,000 U.S. employees for 2012, based on de-identified, self-reported well-being assessment data.
SOURCE: Yarborough presentation, July 30, 2014. Used with permission.
YouTube video for the kickoff of the Cobb County 2020 campaign, conducted in partnership with the local public health department, school district, and others. In Manassas, Virginia, the company is a part of the business sector of the comprehensive community plan, Manassas Next, and in Palmdale/Lancaster, California, the company is involved with the community collaborative Antelope Valley Partners for Health, a 501(c)(3) nonprofit organization. Working with these community-led initiatives is a good tactic to improve the determinants of health where most needed in order to benefit both communities and business, Yarborough concluded.
Engagement, Scalability, and Sustainability
Participants discussed further the challenges of getting businesses engaged in their communities, especially large corporations in small communities. Yarborough said that even though Lockheed Martin has more than 100,000 employees in the United States, each local site manager and each business area of each division is responsible for the productivity of his or her employees and the economic health of the local site. The managers are approachable on a local level, he said, and he suggested that communities think of them as individual entities, rather than as part of a large system. A challenge for the surrounding community in engaging local employers, however, is that many of the company employees do not actually live in the community. Isaac suggested that part of the problem is that there is no framework to help match businesses’ interests and expertise with community interests and needs. There is no way for a corporation to post its focus areas or for communities to share which of their systems need support or for several of a corporation’s employers to come together as part of a solution to a particular community problem. Any matching among different groups has been ad hoc and informal, Isaac said. He added that one of his company’s sustainability goals is to extend education and on-site guidance to the various companies in the supply chain—for example, instructing them on how they can protect their employees if they are making products or parts for Johnson & Johnson. Baase noted that the Lockheed Martin examples were all in partnership with existing groups, initiatives, or frameworks (e.g., the blue zones in Forth Worth). She noted that the Institute of Medicine roundtable has previously discussed the importance of a backbone organization or integrator function in enabling partnerships (discussed further in Chapter 6).
Participants also discussed the issue of scalability. Well-constructed health promotion campaigns have been shown to work in terms of both participation and actual results, Yarborough said, but it can be difficult
to put those together to be sustainable and scalable across multiple sites. The issue goes back to local readiness and need, and the efforts are often around health disparities. A key question is how to implement initiatives equitably, realizing that some places will adopt initiatives faster than others. Isaac suggested the need for a platform to transfer proven business or private-sector programs elsewhere, perhaps to areas where the company does not have a presence but where another entity could duplicate the effort. Isaac also said that an obstacle in dealing with governments around the world is a lack of trust in the private sector, combined with a feeling that there must be a hidden agenda for a business to want to be involved in community health. He added that this is an area where business has a responsibility to try to address the concerns in order to really be successful in creating healthy communities here in the United States or elsewhere.
Baxter said that companies, whether they are discussing corporate philanthropy, social responsibility, sustainability, or employee engagement, tend to take credit for the good they intentionally do, but do not always take ownership of some of the other impacts that their work may have. He suggested a “health in all business practices” framework that would look at the overall health impacts of an organization (including, for example, hiring practices, sourcing practices, and waste or environmental impact). Some frameworks for sustainability already exist, but there are not yet any for health. Isaac responded that health objectives are included in the Johnson & Johnson sustainability framework, covering topics such as cultural health programs, health risks, access to medicines, education, health literacy, waste and environmental issues, and safety. He agreed that there is value in including health as part of a sustainability framework.
Policy
Terry Allan of the National Association of County and City Health Officials asked about the involvement of companies in policy change at the state or local levels where the companies do business (e.g., smoke-free legislation or nutrition labeling). Yarborough said he has been studying the costs associated with low-back pain and knee pain in employees and spouses, both the health care costs and the loss-of-productivity costs. He said that there is often little incentive for people to come back to work while collecting disability. His company is looking into ways to safely bring employees back to work earlier, but a challenge is that the workers’ compensation system varies by state.
Isaac said that his company works directly with the government in some countries and not in others. For example, it has not gone directly
to states or health departments for tobacco bans. Rather, the company worked through the CEO Roundtable on Cancer6 and with the American Cancer Society to try to ban smoking in workplaces. It also worked to improve the benefits coverage for smoking cessation and created a toolkit for other businesses interested in banning tobacco to become an accredited “Cancer Gold Standard” employer. Through the CEO Roundtable and the American Cancer Society, the company has also been working to influence state-level policy changes, for example, to raise taxes on cigarettes.
Impact on Health Care Costs
José Montero of the New Hampshire Division of Public Health Services raised the issue of financing health promotion and community engagement activities and analyzing the benefit of these programs not just in savings to the company, but in outcomes that could enhance the company’s health insurance purchasing power. Isaac responded that Johnson & Johnson has not incorporated its health and wellness programs into its benefit planning, and it does not use the health plan as the delivery arm for its wellness programs. The company has been able to definitely measure and publish data on the performance of these programs, and the measurements have shown an impact on health care costs, specifically, a reduction in the rate of growth of health care costs for Johnson & Johnson in the United States (a 1 percent increase relative to a 4.7 percent in the comparative group). Yarborough said that Lockheed Martin has built its health plan around its wellness programs and metrics.
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6 See http://www.ceoroundtableoncancer.org (accessed December 12, 2014).
