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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Leading by Example—Health Systems Improving the Care of Employees

Payment reform is expanding the focus of health systems beyond care for individual patients to improving the health outcomes of populations. Improving population health is a daunting new task for health systems, requiring novel approaches and partnerships. Yet many health systems have an opportunity to make early and meaningful improvements in the health of one particular population—their own employees.

Health systems employ approximately 10% of the US workforce. Despite health care being their primary focus, health care workers, at least those in US hospitals, generally have poorer health status and higher costs than those in other industries. For the many health systems that are self-insured, organizations are at full risk for their employees’ health care expenditures. As employers, health systems are also motivated to improve worker satisfaction and well-being as a means of increasing productivity and retention and reducing sick days.

Several features set health systems apart from other industries in the pursuit of employee health. Health systems may provide medical care for a large portion of their workforce, a relationship that facilitates health systems’ addressing their workers’ health. For example, biometric screening programs, common in many workplaces, may identify employees with certain risk factors (such as elevated blood pressure or a high body mass index).

In health systems, however, once a screening program has identified a risk factor, the individual can be directly connected with appropriate follow-up—often with a clinician whom the employee already trusts. Furthermore, employees in a health system are a “captive” patient audience. Health systems can craft healthful environments through more nutritious meal options, exercise programs, and workplace redesign, thereby promoting sustained behavior change that is otherwise difficult to achieve within traditional medical settings and relationships.

Across the United States, a number of health systems are leveraging these advantages to develop promising innovations in employee health. For example, the employee health management program at the University of Pittsburgh Medical Center (UPMC) uses financial incentives such as reduced annual deductibles to encourage healthy behaviors. The program targets annual completion of a health risk assessment, blood lipid and glucose screening every 5 years, and participation in a comprehensive program that integrates an incentive platform, health coaching, and a web portal for tracking progress and accessing health education tools.

An evaluation of the UPMC program found that it improved risk factor profiles, increased the use of preventive and chronic disease management services, and reduced absence from work. The UPMC health plan also experienced reduced growth in costs after the inception of the employee health initiative, although a causal inference cannot be made about this finding.

Challenges to Employee Program Effectiveness

Despite these positive examples, evidence for the effectiveness of employee health programs has been decidedly mixed. Although a 2010 study found a return on investment of $3.27 for every $1 spent on wellness programs, subsequent analyses have not confirmed this finding. More recent studies have shown more modest effects on health improvement and cost savings. Although care management interventions that provide assistance managing chronic disease have demonstrated cost savings in some settings, broader wellness programs targeting primary prevention have not. Moreover, both care management programs and wellness programs have faced low enrollment rates, averaging below 50%.

Programs also are often hamstrung by the lack of a shared organizational vision for employee health. For example, occupational health programs are often structured to meet regulatory requirements rather than to improve health outcomes or reduce employee medical costs. Employee benefit design, usually the realm of human resource departments, is commonly divorced from the clinical needs of the population served or the overarching goals of the health system.

Another challenge is the legitimate concern of protecting employee privacy and confidentiality. Although the privacy of individual health information is protected under federal and state laws, critics have called for greater firewalls in the health system context, in part because employee health programs may involve coworkers accessing sensitive information. Furthermore, recent studies have suggested that incentive-based employee wellness programs could facilitate discrimination based on genetics, health status, or disability by shifting costs to less healthy workers.

Employee-Centered Health Management

Efforts to address these employer-centric goals are likely to be successful only if informed by the needs of the population served. In a 2014 study, the top reason consumers cited for not participating in workplace wellness programs was that the programs were not relevant to them or their situation. Health systems are spending time and resources on programs that do not address the problems most relevant to their employees—and they consequently go underutilized. For example, child care or eldercare, burnout or stress, and back and neck pain are common causes of worker absenteeism, but employee health programs commonly begin with a focus on cardiovascular disease prevention.

Although it is possible for employee health programs to address both daily quality-of-life issues and population health concerns, sequencing of programs to engage employees is important. In the same way that a primary care physician might choose to treat a patient’s knee pain before addressing the underlying cause of obesity, an employee-centric approach would strive to achieve relevance and build trust before addressing fundamental risk factors that may not be at the forefront of an employee’s mind.

Because employees are the most knowledgeable in identifying barriers to being present, productive, and fulfilled at the workplace, they must be integrated into the process of deciding program priorities. They also offer a unique perspective on their health care needs, utilization patterns, and ways to reduce health care costs. Health systems should therefore share governance of employee health programs with employees themselves.

Successful employee-centered health management also requires meaningful integration of continuous feedback from employees. Currently, many health systems take a step toward this goal in collecting information from employees through comprehensive questionnaires known as health risk assessments (HRAs). However, typical HRAs are often not connected to programs that can modulate the risks they identify. An employee-centered approach would entail an iterative cycle of measuring employee needs, incorporating this information into the design of employee health programs, and then evaluating how well programs meet employee needs.

Investing in employee health programs also could reap long-term dividends for health systems beyond the central goals of improving employee health and performance. As value-based payment models hold more sway, such programs are an important means of developing and testing an infrastructure that would allow them to succeed in risk-based contracts. Developing internal expertise in employee health management could in turn present a compelling source of new revenue by packaging the services and offering them to other employers.

More broadly, healthy and health-focused employees would enhance the credibility and reputation of these health systems. Perhaps most important, health systems that invest in the well-being of their workforce may develop employees who can deliver better care to patients.

The authors have no potential conflicts of interest to report. The views expressed here are those of the authors and not of their respective institutions.
Lindsay Jubelt, MD, MS, is assistant professor of medicine and population health at New York University (NYU) School of Medicine and director of clinical performance at NYU Langone Medical Center in New York, New York.
Dave A. Chokshi, MD, MSc, is assistant vice president in the Office of Healthcare Improvement at the New York City Health and Hospitals Corporation. He is a primary care internist at Bellevue Hospital and is an assistant professor of population health and medicine at NYU Langone Medical Center.
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