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Between 1995 and 2010, the percentage of Johnson & Johnson employees who smoke declined by more than two-thirds, and the number with high blood pressure or who are physically inactive declined by more than half. In the late 1970s, Johnson & Johnson chairman James Burke established 2 health-related goals: encourage employees to become the healthiest in the world and reduce the cost of health care for the firm. The company's wide-ranging employee health promotion program includes nutrition education, weight management, tobacco cessation, stress management, onsite fitness, and other services. Johnson & Johnson's commitment to being a “healthy company” is paying off. The company estimates that its health promotion program has saved $250 million on health care costs during the past decade.1
We have conducted primary field research to study workplace health promotion (WHP) programs, often called wellness programs, at Johnson & Johnson and 9 other employers. The organizations vary in size and in industry, but all have integrated, successful WHP programs that emphasize whole-person wellness. In these organizations, wellness extends beyond physical health to include emotional and spiritual health. Stress management and disease prevention are priorities. Our research and related literature suggest a link between strategic WHP and lower health risks, lower health care use, and improved productivity for employees.1-7 A 2008 survey of large manufacturing firms indicates that 77% have a WHP program, although substantially fewer offer comprehensive programs encompassing whole-person wellness.2 Small employers are less likely to offer WHP programs.8
Wellness cannot be delegated, but it can be encouraged and facilitated. Workplace wellness is an organized employer-sponsored program designed to engage and support employees (and often family members) in adopting and sustaining behaviors that reduce health risks, improve quality of life, enhance personal effectiveness, and benefit the organization financially. Successful wellness programs use evidence-based programming to reduce employees' modifiable health risks linked to behaviors such as tobacco use, unhealthy eating habits, physical inactivity, and poor work-life balance.
Comprehensive WHP programs commonly include health-related educational services (eg, nutrition education); individual health risk identification (eg, confidential health risk assessments [HRAs]); health risk reduction services (eg, health counseling and support groups); preventive health services (eg, immunizations); treatment health services (eg, care at worksite medical clinic); and health-related regulation (eg, worksite nonsmoking policy). Some WHP services like flu shots are simpler to implement and quicker to pay off than others like weight-management programs that require sustained behavioral change.
Organizations are making increasing use of online resources to deliver interactive health education and behavior change programming and to enable individuals to track biometric data such as blood pressure, cholesterol and glucose levels, and body mass index (BMI). Employees with home computers, smart phones, or iPads may have remote access to their employers' WHP Web site whenever and wherever they need it.
Sixty percent of workers receive health insurance coverage through their employers.9 A study in 2009 estimates that employers will pay on average more than $28,000 per employee for health care by 2019, absent substantive changes.10 Companies are becoming more proactive in employee health promotion now that health care spending exceeds profits at some firms.
A compelling business case is emerging for companies that are strategically investing in keeping employees healthier. Internal analyses at supermarket chain H-E-B, an employer in our study, show that high-risk participants in its workplace wellness program have average annual health care claim costs nearly 50% lower than nonparticipants' annual health care claim costs. H-E-B estimates that shifting 10% of its employees from high- and medium-risk status to low-risk generates a 6 to 1 return on investment. Randomized controlled studies within and outside the workplace wellness literature support findings like those from H-E-B. For example, a large randomized trial in a non–workplace setting found that intensive lifestyle intervention with dietary modifications and increased physical activity were significantly more effective than metformin with standard lifestyle recommendations or than placebo with standard lifestyle recommendations in preventing onset of type 2 diabetes among adults at risk for the disease.11 A worksite-based study evaluated clinical efficacy and cost-effectiveness of a 6-month health intervention using cardiac rehabilitation and exercise training staff from Ochsner Health System. Employees (n=308) and spouses (n=31) were randomized to receive the intervention (n=185) vs usual care (n=154). Of those in the intervention group classified as high-risk at baseline, 57% were converted to low-risk status after the intervention. Average medical claim costs for the intervention group declined by 48% for the next year compared with a 16% decline for the control group, yielding a 6 to 1 return on investment.12 A 2010 meta-analysis of 15 WHP studies found that on average $3.37 in health care costs was saved for every dollar spent over 3 years.2 That finding echoes earlier analyses of peer-reviewed studies.3-5
Keeping workers healthy boosts productivity by decreasing both absenteeism and presenteeism (employees present at work but less productive due to illness, high stress, or injury). A study of more than 50,000 employees at 10 employers found that the costs of reduced productivity were significantly greater than medical and pharmacy costs (by 2.3 to 1).6
Additionally, WHP investment has the potential to strengthen an organization's culture and employee loyalty if done for employees rather than to employees—encouragement rather than penalty, assistance rather than pressure, inclusiveness rather than discrimination. Computer software company SAS Institute, selected as the best company to work for in America in 2010 by Fortune magazine, has an annual voluntary turnover rate of 4%. For context, one study of North American employers with 11 million workers found that those with more effective health and productivity programs report lower voluntary turnover rates than do those with less effective programs (9% vs 15%).13 The causal relationship between WHP and turnover is unclear. Advocates of WHP believe the programs contribute to low turnover; it is plausible that firms with low turnover are more likely to offer wellness programs.14
Many WHP studies use quasi-experimental designs with nonrandomized assignments or cohort analyses. The quasi-experimental studies often benefit from large samples and from realism but are subject to confounding with, for example, selection bias (wellness programs tend to attract healthier participants) and secular effects (benefit design changes are often implemented concurrently).14 However, the findings from randomized controlled studies appear to be congruent with the overall affirmative findings in several WHP research reviews.2-4
The classic health belief model proposes that behavioral change requires belief that the action will be beneficial and at an acceptable cost, confidence that change is possible, and an incentive to take action.15 Employers are better positioned to eliminate certain barriers to change than the medical community. First, employers have continuous access to the working population. People do not eat or exercise at the physician's office, but many do at work. Offering nutritious food, fitness activities, and health screening to employees are major thrusts in WHP. Chevron has fostered healthier eating in its cafeterias by relying less on highly processed foods and by creating healthful menu items that appeal rather than require sacrifice. Of SAS employees on its main campus, 70% use the onsite Recreation & Fitness Center 2 to 3 times a week. Chevron professional trainers conduct daily 10-minute “stretch breaks” for employee groups in stressful, sedentary jobs. At MD Anderson Cancer Center, wellness coaches go to departments, laboratories, and other work units to deliver workshops on topics such as stress management, getting sufficient sleep, and healthful eating. Custom-built laboratory buses travel to Lowe's stores and other facilities so that employees can conveniently receive biometric health screenings and complete HRAs in a private space. Biltmore, a North Carolina tourism enterprise, sponsors annual health fairs for employees and families that include health screenings such as bone scans, BMI, cholesterol, blood sugar, blood pressure, lung capacity, hearing, and skin testing along with flu shots and health-related seminars.
Second, employers can use financial and social incentives to encourage participation in wellness activities. Johnson & Johnson offers a $500 medical benefit plan credit to employees who complete their HRAs and receive recommended health counseling. More than 80% do so. Employers can establish new wellness norms and recruit peer opinion leaders.16 Lowe's makes wellness programming fun and engaging with peer persuasion (featuring participant testimonials on its wellness Web site), interactivity (online health quizzes and games), team and individual competitions (weight-loss campaigns and recipe contests), and reinforcers (free pedometers and wellness participation points redeemable for gifts).
Progressive, well-managed, responsible companies are primed to become prevention partners with the medical community. Companies need medically trained staff to help design their health promotion strategy and perhaps lead it. Physicians, nurses, and other medical personnel are needed to staff company medical clinics, either as company employees or through direct contracting.17 Medical practices and hospitals can add new revenue streams by delivering specific health care services to business clients, for example, collaborative chronic disease monitoring and treatment programs. Health care providers can collaborate with companies on community-wide health promotion initiatives. Medical organizations can implement WHP programs for their own employees, perhaps adapted from a company with a strong program.
The business community needs the medical community to integrate wellness into the workplace. However, the medical community also needs the business community. Payers compensate medical providers for diagnostic and treatment care. Employers' health promotion programs emphasize behavioral change, which is undercompensated in the medical community but pays off in the business community. A business-medical partnership opens a new path to achieving a greater balance between prevention and treatment of disease. Wellness is the common goal.
We acknowledge William B. Baun, MS, manager of the wellness program at the MD Anderson Cancer Center, for his constructive suggestions on earlier drafts of the commentary.