A "big tent" approach to wellness: bringing EAPs, safety programs, and other resources to bear on employee health can make wellness programs much more effective in managing the health risks of workers and their dependents.

Do wellness and other health promotion programs actually improve the health of workers? Do they also increase workers' productivity and save money? And, if so, can such improvements be measured?

These questions lie at the heart of the health promotion movement and promise to pique the curiosity of more and more researchers--not to mention business leaders, corporate medical directors, employee assistance professionals, and others with an interest in workplace productivity--in the coming decade. If current trends hold, over the next 10 years the health promotion field will be busier and under more pressure to deliver quantifiable results than at any time since its inception in the 1960s.

DRIVING ECONOMIC BENEFITS

In their infancy, wellness programs focused primarily on a single risk factor, cardiovascular disease, that was cutting short the careers--and, in many cases, lives--of male executives at Fortune 500 corporations. Some of the larger companies, like Mobil and Exxon and Xerox, actually constructed wellness facilities almost as an extension of their cardiac rehabilitation programs. The purpose of these facilities (essentially, gyms) was to provide a venue for executives to exercise and thereby reduce their risk of a cardiac event or help them recover more quickly if an event occurred. In essence, these gyms had a single focus--to keep male executives alive by addressing some of the risk factors known to be associated with heart disease.

Then, in the 1980s, businesses began to feel the brunt of spiraling health care costs. They responded by utilizing health maintenance organizations and shifting their younger workers into these plans while leaving their older workers, who represented a smaller percentage of the workforce, in traditional fee-for-service indemnity plans. Meanwhile, progressive corporations (such as Kimberly-Clark, General Foods, and PepsiCo, to name a few) expanded their wellness programs on two fronts: first, by addressing several risk factors (not just cardiac arrest), and second, by serving not just executives but many of the other employees of the company.

By the 1990s, wellness programs had begun to focus not just on disease prevention but also on health promotion. Both are important and necessary, but the distinction has critical cost implications. By trying to encourage participation in activities that can help people live healthier lives and effectively manage existing risks (or, better yet, reduce the number of risk factors), health promotion programs stand to drive various economic benefits--including reduced absenteeism and higher productivity--that can position a company to survive and prosper in the 21st century. Today, with the aging of the workforce, increasing pressures on productivity (resulting largely from disparities in labor costs), and rising health care costs, U.S. companies have no alternative but to take a more proactive approach to wellness programming.

In summary, the dynamics of health promotion have changed dramatically from the early years. With that change we've witnessed what I call a "migration" of a whole host of subsets of corporate America--including health and safety, employee assistance, insurance, recruitment, and retention--to the cause of wellness. Initially, only the medical director and the exercise physiologist and the chief executive officer would be at the table when the talk turned to health promotion, but over the past three or four decades employers have broadened their approach to touch more employees and dependents in a quest to have a healthier workforce in hopes of generating more health care savings.

TARGETING RISK FACTORS

a result, today well-designed and well-operated wellness programs are bringing a diverse array of resources to bear on the goal of improving and maintaining the health of workers and their dependents. Ironically, this is allowing corporations to narrow the focus of such programs and target certain workers. Whereas it used to be that only a select few people--namely, corporate executives--were entitled to participate in wellness programs, now a select few are targeted and strongly encouraged to participate.

Who are these select few? Utilization data consistently show that far more than half of the health care costs paid out by employers are directed toward less than 20 percent of employees. There are all different ways to slice and dice that, but in essence there is a relatively small population of workers using lots of health benefits and a much larger population using few of them. So, if you can target the risk factors common to workers who consume lots of health benefits and use your other corporate resources to create a supportive workplace environment for all employees--by offering better food options in the cafeteria, for instance, or improving ergonomics at workstations--you can go a long way toward managing your health care costs.

This is an example of how the migration of disciplines I mentioned earlier can benefit not only wellness programs but also the individual initiatives as well. By themselves these disciplines are helpful, but in isolation they can never demonstrate their full value to the organization. That's especially true when health care costs are very high. A single resource, be it an EAP, a corporate safety program, or a fitness program, simply can't have the same impact on double-digit increases in health care costs that several resources bundled together could have.

The same is true for business as a whole. One company, by itself, can't do much about the cost of health care in the open market; that's set by someone else. But a company can try very hard to manage its risks. Businesses today are taking more responsibility for knowing and managing their risks, and as a result they're in a much better position today to tailor interventions to specific individuals. Progressive companies are targeting their wellness programs and using their full arsenal of resources to create incentives for people to manage their health.

LONG-TERM APPROACH

Does this mean that wellness programs are necessarily cost-effective? I always say, "Yes, but it depends." It depends on whether there are well-qualified people running the program and whether they're targeting risk factors in both employees and dependents, where two-thirds of the benefits are spent. If it's a comprehensive, well-documented program with a good set of metrics, highly targeted risks, and a good policy in back of it, it can save some money.

Different risk factors, of course, have different returns--some pay off sooner than others. For example, if you have an undiagnosed diabetic in your company and you intervene and are able to change and stabilize the condition, you're going to see almost immediate savings at some level. On the other hand, if you have a young smoker in your workforce, the health care costs of that person are not going to be much higher than for someone who doesn't smoke because of the long-term nature of smoking-related illnesses. It can take as long as 20 years or more of day-to-day smoking to develop lung cancer.

Taking a health promotion approach to wellness--say, by building a fitness center or starting an exercise program--produces much the same results. I did a lot of cost-benefit research for the Department of Defense in the 1980s, and the prevailing view was that "if you build it they will come." Those who came said, "Gosh, this is nice. I like to exercise and now you're making it convenient for me." That wasn't necessarily so bad because it helped keep healthy people healthy, but it didn't do much for those who don't like exercise. As the obesity statistics demonstrate, only a very small percentage of the U.S. population pursues activity at a level that truly makes a difference to their health.

By itself, then, an exercise program won't produce an immediate decrease in costs; in fact, it may even increase them. That's because if you don't exercise and I help you understand and appreciate the potential health benefits of exercise, one of the things I'm going to do before I develop an exercise plan for you is require you to undergo a good physical examination. That's going to impose a cost. But over the long haul, if I can make you cognizant of your own physiology and the health indices that you can manage, you're probably going to become a far more productive and cost-effective employee.

The bottom line on wellness programs is that you can't say you're going to save a dollar or three dollars today for every dollar invested. But if it's well designed and well targeted, a wellness program is clearly a positive return on investment.

I ask my corporate clients, "How long has your company been around--50 years, 100 years? If you want it to be around for another 100 years, you need to take a long-term approach. This issue isn't going to change; there isn't going to come a time when all of a sudden, you don't have to worry about people's health."

THE ELUSIVE OBVIOUS

Cost savings aside, if your wellness program only has a single focus--to improve workers' health--you aren't necessarily going to have a more productive workforce. Many leading business executives believe intrinsically that if they create a healthy environment for their workers, they're going to have a productive workforce. I suspect this belief flows from the reverse situation: If the work environment is unhealthy and people aren't happy, they're going to leave and take their intellectual capital with them, and the workplace will be less productive. So there's a very strong feeling that a positive correlation must exist between health and productivity

It does exist, but sometimes the belief in it is unfounded. When I conduct a health audit of a corporation and I hear someone in management say their workers are more productive because they're healthier, I want to see evidence of that--how they've quantified it and the metrics they've used, even if they're soft. A company can improve the health if its workforce but not see a direct economic correlation in terms of productivity There's an art to health promotion programming, and part of it is to ensure a fair return from a corporate standpoint.

The challenge lies in documenting this return. There are many, many variables--the age of the worker, the genetic predisposition of the worker, what you're asking the worker to do in an ever-changing environment, the worker's home environment, his or her educational background that can make it very difficult to get absolute reformation about the impact of health on productivity, It's more of an intuitive correlation. It's referred to as "the elusive obvious."

Certainly, if a wellness program can identify and stabilize or reduce the health risks to a worker and the worker appreciates what the company has done, s/he will be more loyal and more likely to work harder and perform better. But you have to be able to capture the relationship between the intervention and the performance. That challenge is all the more critical because we're competing in a global economy, and we're doing it with an aging workforce.

The good news is that if we can proactively identify risk factors and develop intervention programs for workers and their dependents, we can curb significantly the costs associated with health care. We may only succeed in delaying cost increases, but we will increase the health span within the work span, if you will. That means older employees will be healthier and potentially more productive. They will "be there" as opposed to just showing up.

A "BIG TENT" CONCEPT

The imperative of identifying risks and targeting interventions shouldn't be construed as advocating a narrow view of wellness. Far from it. I believe in a "big tent" concept when it comes to health promotion. If you want a program that just takes care of the "healthy" population, you don't have a health promotion program, in my opinion.

When I conduct health audits of corporations, I want to see who's at the table. If the employee assistance people don't show up at the table or the safety people don't show up at the table, I say, "You don't have a full house here." You really can't have a discussion about creating a healthy work environment unless all constituencies are represented, maybe even including retirees and dependents.

Depression illustrates the need for a broad interpretation of health. Depression is one of the biggest health challenges in the world today, and it's probably going to increase. There are many people who are physically fit and are depressed. But if you don't have the EAP at the table, you may not recognize that depression is even an issue.

How big of a concern is depression, and how big of a concern is substance abuse or disability? That's where your audit comes in. But without having all the constituencies at the table, you can't know what all the issues are.

Resources like EAPs and safety programs and the cafeteria service should always be on the leading edge of how to address the specific issues they are charged with solving. Each of these resources, however, can be far more effective if it is working in a collaborative way and trying to create a healthy environment for everyone.

The Workforce of the Future

For many years, the National Center for Health Fitness at American University conducted smoking cessation programs for corporations and helped design and evaluate them. Lots of smokers came to these programs, but most didn't stay to complete them. We had very, very high turnover rates.

Over time, many corporations began to put smoking policies in place. Not all the policies were good policies, but as employers implemented them, it helped a lot of people make the transition from being a smoker to being a nonsmoker and deriving the benefits thereof. The long-term effect of these policies has been to change the work environment dramatically.

That said, about 98 percent of all regular adult smokers are regular smokers by the age of 20. They don't start smoking as adults, but that's when we try to solve the problem--long after smoking has become an addiction. We spend millions and millions of dollars trying to stop people from smoking or treating the adverse effects of smoking on our workforce, even though we actually know it starts long before that point.

When we talk about wellness programming, we like to talk about strategic planning and cost savings, but we don't often talk about dependents--the children of our workers who are following in their parents' footsteps and starting habits like smoking at an early age. There are so many things we could be doing in a progressive, positive way that would help the workforce of the future, but we're not addressing this issue. That's food for thought for employee assistance professionals, because they often deal with family issues that underlie workers' performance problems.

Robert C. Karch, Ed.D.

Bob Karch is chairman of the Department of Health and Fitness and executive director of the National Center for Health Fitness at American University in Washington, D.C. He specializes in the management, development, and evaluation of employee health fitness programs and has conducted health audits of numerous national and multinational corporations. He can be reached at [e-mail].