Good health is good business. Here's why
COVID-19 has forced health onto the agenda of every business around the world. Companies must address health and safety risks as health regulations and market conditions continue to shift. It’s understandable that many business leaders can’t wait to get back to “normal.” But retaining a focus on health can deliver lasting economic benefits.
Here’s why: The pandemic and its effects are forecast to cost the global economy up to 8% in real gross domestic product this year alone, but each year poor health costs twice as much, around 15% of global real GDP from premature deaths and lost productive potential.
Now consider the flip side: Investing in better health can boost the economy and increase productive capacity now when we most need it. Companies would be big beneficiaries. Sickness absences would decline; healthier workers would be less distracted by managing their (or their loved ones’) conditions; and fewer workers would retire early because of health conditions. A healthier workforce would translate into lower health care costs. And what’s more, healthier aging would expand both the future workforce and consumption as fewer people die prematurely and healthier older consumers continue to fuel demand.
At the McKinsey Global Institute, we spent the past year researching what it would take to make the world’s population healthier and then sizing the potential social and economic benefits. We found that by using known interventions more widely, things like adopting healthy behaviors, expanding access to primary care, and improved adherence to medication, the global disease burden could be reduced by 40% over the next two decades.
The individual health benefits would be tremendous: A 65-year-old in 2040 could be as healthy as a 55-year-old today; infant mortality would decline by 65%; the health inequity gap would narrow; and 230 million more people would be alive by 2040.
The economy would get a much-needed boost. Adding up all the ways better health lifts the economy, we estimated that better health could increase global GDP by $12 trillion in 2040—an 8% boost, or 0.4% faster growth a year.
And investing in health produces a high economic return. For every $1 invested, we found an incremental economic benefit of $2 to $4. In higher income countries, implementation costs could be more than offset by productivity gains in health care delivery. Emerging economies will continue to need more investment to build out their health infrastructure.
Our research leaves us with a strong conviction: Improving health has the potential to be a societal and economic game changer. After all, few investments deliver against so many of today’s social needs, substantially improving well-being and reducing inequity, while also delivering an impressive shot in the arm to the global economy—and all with a high return on investment.
So what can companies do? Focus on three areas: Invest in the short- and long-term health of their employees; create inclusive work environments; and actively contribute to the development of healthy communities.
There are many ways to invest in the health of your workforce. A good place to start is conventional occupational health and safety, yet that isn’t enough. In today’s work environment occupational risks are increasingly related to mental health stressors, sleep health, and high levels of sedentariness. Research shows that chronic conditions including low-back pain, mental health, and migraines can reduce the productivity of workers by up to 5%. So improving workplace health matters.
Many companies are already experimenting with this. Citibank is one example. Its health programs include rewards for participating in health assessments, sustaining health activities, and reaching health goals; support for health improvement including organized fitness-related events and challenges; and access to health programs such as WW at Work and health coaching.
Some companies have found low-cost and relatively simple health promotion strategies can make a difference to productivity. For example, a public sector employer in Middlesborough, in the United Kingdom, used health assessment questionnaires to understand the needs of staff and codeveloped a flexible and multifaceted health promotion toolkit. This program included family days, team-building days, and health walks. This led to a 44% reduction in sickness absence, from an average of 4.3 days per employee a year to 2.4 days.
Next, consider promoting more inclusive work environments. Employers that adapt the workplace to take advantage of changing demographics often benefit from higher levels of retention. This also means offering (re)training, creating a culture that addresses discrimination, offering assistive technologies, and making buildings accessible to people with mobility challenges. We also find that workplaces that offer flexible working practices help informal caregivers to stay in work.
One example is BMW . Managers at a BMW car production plant in Dingolfing, Germany, worked with employees to redesign the production line to address tasks that older workers found troublesome. The focus was on low-cost ergonomic changes that reduced physical stress. Productivity on the adapted line was equal to equivalent lines with a younger workforce age mix by volume, quality was higher, and sickness absence was below the plant average. The program has been replicated at BMW plants elsewhere.
Finally, consider fostering healthy communities. This might mean assessing your company’s health “footprint,” the ways in which activities contribute to the health outcomes of individuals, communities, and whole populations, and making health impact a priority within wider corporate social responsibility programs. For example, some global companies have included commitments to provide clean water, hygiene, and sanitation for their employees and, in some instances, their partners and suppliers, in water-stressed regions of the world.
Our research shows that 70% of actions to improve health happen before a sick patient seeks care. Half of that comes from living in healthier environments, societies, and workplaces that encourage healthy behaviors and mindsets. Long-term prevention and health promotion cannot simply be left to health care providers or health care systems. It is quite literally everybody’s business. And just plain good business at that.
This article first appeared in Fortune .
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Employers Can Do More to Advance Health Equity
- Shantanu Nundy,
- Lisa A. Cooper,
- Ellen Kelsay
Covid-19 exposed wide inequities in health in the United States and around the world. But health disparities persisted long before the pandemic.
In this article the authors explain why businesses should help find solutions to health inequities and showcase companies innovating in this space. The article outlines four opportunities for companies. They can optimize benefits and health plan offerings, address social determinants of health, expand primary care and mental health access through virtual care and community partnerships, and make benefits and health care easy to navigate.
To improve health equity among their employees and communities, businesses will need to invest in a multiyear effort and equip themselves with the right leadership, resources, and processes. Key steps for getting started include building a business case for investments, collecting data to understand specific problems, identifying an initial population to focus on, engaging a broad group of stakeholders to design solutions, and measuring progress.
They can optimize benefits, address social issues, and expand access to care.
Idea in Brief
The Covid-19 pandemic revealed major disparities in health around the world: Economically and socially marginalized groups have experienced higher rates of Covid-19 infections and mortality.
Who Should Produce Solutions
Many business leaders have assumed that governments and health systems are responsible for addressing health inequities, but employers can also play a major role and have compelling reasons to do so.
Build a business case for investments. Collect data to understand specific problems. Identify an initial population to focus on. Engage a broad group of stakeholders to design solutions. Measure progress. And commit to advancing health equity.
One of the starkest lessons from the Covid-19 pandemic has been the deep health inequities present in the United States and around the world. Nearly everywhere, groups that have been economically and socially marginalized experienced higher rates of Covid-19 and morbidity and mortality from infection. In the United States, before vaccines and effective treatments were widely available, Black and Latino people were three times more likely than white individuals to be infected with Covid-19 and twice as likely to die, according to a study in the Annals of Internal Medicine.
Covid-19 wasn’t an anomaly. It was a magnifying glass. It exposed inequities that persisted long before the pandemic—in life expectancy, birth outcomes, maternal health, chronic disease prevalence and outcomes, and more.
There is a silver lining, however. Increased awareness of the problem has led business leaders and employers to ask what more can be done to address health disparities, and many have taken meaningful steps toward improving health equity. In this article we explain why employers should help find solutions and showcase companies innovating in this space.
What Is Health Equity?
The Centers for Disease Control and Prevention defines health equity as the state in which “every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health equity is a broad concept and is inclusive of a number of groups that are marginalized by society and the health care system and therefore are not attaining their full health potential: people who are Black, Latino, and Native American (who collectively make up 33% of the U.S. population); people who identify as LGBTQ+ (4%); individuals in rural communities (23%); people living in poverty (11%); and people with disabilities (12%).
A multitude of data supports prioritizing the health needs of these populations:
- Black persons are 30% more likely than non-Hispanic whites to die from heart disease.
- Native Americans and Alaska Natives have an infant mortality rate that is 60% higher than the rate for their white counterparts.
- Hispanic women are 40% more likely to have cervical cancer and 30% more likely to die from cervical cancer than non-Hispanic white women.
- Adults with disabilities are four times as likely as adults without disabilities to report having fair or poor health.
- Thirty-nine percent of men who identify as gay, 15% of women who identify as lesbian, 20% of men who identify as bisexual, and 15% of women who identify as bisexual report experiencing physical violence, property crime, or attempted crime because of anti-LGBT bias.
A related term is social determinants of health, which refers to the conditions in which people are born, grow, live, work, and age that impact their health. Differences in exposure to the social determinants of health are often at the root of health inequities. These include educational and employment opportunities, access to safe environments, affordable housing, nutritious food, access to care, and social relationships and networks—factors that influence health and occur largely upstream of the traditional health care delivery system.
The Business Case for Health Equity
Some business leaders may ask: Why isn’t health equity solely the responsibility of the government or the health care delivery system? Why must my business play a role? The short answer is that income, economic stability, workplace benefits such as paid time off and medical benefits, and social conditions in the communities where companies operate are major drivers of health disparities, and employers can play a lead role in addressing many of them. This is especially true in the United States, where approximately 55% of people receive health insurance coverage and additional health benefits such as well-being programs, on-site clinics, and telemedicine through their employers.
Many employers have become attuned to how diversity benefits their businesses. Studies conducted by McKinsey over the years show that companies with the most ethnically and racially diverse workforces or executive teams are more likely to financially outperform others. A BCG study found that companies with above-average diversity had revenues from enhanced or new products or services that were, on average, 19 percentage points higher. But less appreciated is how health inequities can influence diversity efforts and business outcomes. A McKinsey survey conducted in June 2021 found that 30% or more of Black, Hispanic or Latino, LGBTQ+, and younger employees said they had considered switching employers because of their health benefits; employees who reported not receiving the care they needed were two times as likely to consider changing employers.
Inequities in health can also lead to groups of employees missing work more often or being less productive at work. The same McKinsey study found that if employees who are Black, Hispanic or Latino, and Asian were able to meet their own health needs and those of their dependents while missing the same average number of days as white employees, the U.S. economy could expand by around $20 billion—the equivalent of as much as 10% of the total cost of absenteeism.
Covid-19 wasn’t an anomaly. It was a magnifying glass, exposing health inequities that persisted long before the pandemic.
Health disparities also contribute to $93 billion in excess medical care costs. Groups that have been economically or socially marginalized often have higher rates of chronic diseases and greater preventable morbidity and mortality—yet they have lower rates of utilization of primary care and mental health services. The result is that a significant proportion of preventable medical costs is spent on providing care to those groups, contributing to the year-over-year increases in health care costs experienced by most self-insured employers and in health care premiums for fully insured employers.
Businesses can positively impact health equity in ways that will improve their businesses and society overall. Beyond investing in diversity, equity, and inclusion, here are the major opportunities for all employers regardless of size or geography.
Opportunity 1: Optimize Benefits and Health Plan Offerings
Some plan designs may inadvertently exacerbate health disparities. One example is co-payments for emergency room visits. Because people from groups that have been marginalized face barriers to accessing primary care (such as a dearth of nearby providers), they may rely on the emergency room for routine medical care. So cost-sharing efforts may inadvertently worsen health outcomes for employees most at risk of serious complications.
With careful plan design, employers can improve health outcomes. In a randomized clinical trial whose results were published in the New England Journal of Medicine and Health Affairs, patients from racial and ethnic minoritized groups whose employers covered all the costs of their preventive medications after they had suffered heart attacks had 35% fewer major complications than patients with co-payments, and 70% lower total health care costs.
Plan design changes can also cover out-of-pocket expenditures that are too costly for low-income families yet are proven to reduce health disparities. In 2021, in response to concerns about rising rates of Black maternal and infant mortality nationally, Walmart expanded benefits under its medical plan to include up to $1,000 in coverage for doula services. Doulas provide emotional and informational support and guidance to mothers during pregnancy and birth. Aware of research demonstrating that having a doula on a birthing team decreases C-sections by 50% and the need for other medical interventions by over 50%, Walmart began offering doula benefits in Georgia, where a large proportion of its associates are African American. Encouraged by its early success, it recently expanded the program to Louisiana, Indiana, and Illinois in partnership with the National Black Doulas Association and DONA International.
Opportunity 2: Address Social Determinants of Health
Decades of scientific research reveal that 80% of health outcomes are determined by income level, educational attainment, health behaviors, and environment (transportation systems, workplaces, schools, air quality, and access to clean water and healthful food). The 2021 McKinsey survey found that 65% of the full-time employees of large U.S. employers had experienced at least one unmet basic need, and 66% of LGBTQ+ employees and 69% of employees of color with a household income of less than $100,000 had experienced two or more unmet basic needs.
All of this suggests that employers should invest in benefits and policies that are not traditionally considered part of medical coverage but that indirectly improve health by addressing barriers to achieving optimal health. An example of such an initiative is the Thrive Local program that Kaiser Permanente launched in Northern California in 2019, which it plans to make available to its 12 million members and to the 68 million individuals in the communities that it serves throughout the United States. The program identifies someone with a social need (such as food, housing, or transportation), refers the individual to a community resource, and tracks the referral to make sure the needs have been met.
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The Importance of Small Business Safety and Health Climates During COVID-19
This study examines employee perceptions of safety and health climates for well-being during the COVID-19 pandemic in a sample of small businesses.
We evaluated changes to employees’ work and home life resulting from COVID-19 and perceptions of safety and health climates. Cross-sectional relationships were assessed using multivariable linear regression models for a sample of 491 employees from 30 small businesses in Colorado in May 2020.
Employee perceptions of safety and health climates were significantly related to their self-reported well-being during the first wave of COVID-19, even when there were changes to childcare, the ability to work, and limited social contacts.
Safety and health climates may influence employee well-being even when other disruptions occur, suggesting that during emergencies, small businesses with strong climates may be better prepared to maintain employee well-being.
The global coronavirus pandemic (COVID-19) has radically shifted the way businesses operate and has elevated the importance of occupational safety and health (OSH), employee benefits, and organizational culture. Small businesses, in particular, have faced a number of challenges, including closures, lay-offs, and limited cash on hand. In a survey conducted of 5843 small businesses in late March/early April 2020, 41% of respondents indicated their organization was temporarily closed due to COVID-19 and among all respondents, the number of full-time employees had decreased by 32% (17% decrease among businesses that were still operating). 1 Workers have borne the brunt of how countries respond to the pandemic. 2 This includes threats to their health, changing working conditions, and a changing work-family interface, as well as exacerbation of existing health inequities based on race, ethnicity, employment status, and socioeconomic status.
How an organization responds to the COVID-19 pandemic can have profound effects on the safety, health, and well-being of its employees. Small business employees may be especially vulnerable, in light of the observation that they were already at higher risk for occupational injuries, illnesses, and poorer health. 3 Even before the pandemic, smaller organizations offered fewer health and safety programs and fewer benefits for workers when compared with larger enterprises. 4 Prior to COVID-19, we observed that enterprises’ organizational support and adoption of best practices for worker health, safety, and well-being varied by company size, with larger organizations scoring higher across safety and health benchmarks. 5 Perceived barriers and challenges to small businesses include lack of safety and health resources, lack of dedicated staff, and inability to identify hazards. 4 , 6 – 9 In addition, small businesses present unique challenges and diversity in characteristics such as business age, structure, culture, and management. 10
Total Worker Health® (TWH) is gaining momentum as a holistic workplace approach focused on “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.” 11 Related to COVID-19, Dennerlein and colleagues recommend that employers apply a TWH framework to help protect worker health, safety, and well-being. 12 Two important characteristics of this, and other, TWH frameworks are leadership commitment and fostering supportive working conditions through policies, programs, and practices. A similar model targeting the challenges in small enterprises has been proposed, emphasizing the role of small business leadership and culture. 13 In order for TWH practices to be most effective, employees must perceive that they are supported and rewarded for participating in activities that promote safety, health, and well-being and that leaders in their organization are committed to OSH, as reflected by measures of safety and health climates. 13 – 16
Organizational climate is the result of a shared perception of what is valued and rewarded at the workplace and is driven by company leadership. Previous research in safety climate and health climate demonstrates that climates are related to a number of outcomes. 17 – 19 For example, safety climate has been shown to be related to better worksite safety practices, as well as safety motivation, knowledge, behavior, and accidents. 20 – 24 Though less research has been conducted on health climate, researchers have demonstrated that health climate is related to employee outcomes such as physical health and health behaviors. 19 , 25 , 26
Our own research has demonstrated the importance of safety climate and health climate, which together reflect organizational support for TWH, in small businesses. For example, we observed a positive relationship between leadership commitment to safety and health, employee perceptions of safety and health climates, and participatory behaviors regardless of how large or small a company was. 27 In regard to the climate behavior relationship, we specifically found that motivation played a significant mediating role. 28 Finally, we observed that TWH business practices exhibited differential relationships with health and safety climates after accounting for leadership commitment to safety and health. 29 Taken together these results indicate that health and safety climates are important TWH constructs in small businesses. They are, in effect, contributing to an overall “TWH climate.”
COVID-19 has unexpectedly amplified and accelerated changes in the nature of work, creating an unexpected challenge to how we ensure worker safety, health and well-being. 2 , 12 A major rationale for applying a holistic approach to worker health protection and health promotion is predicated on the assumption that the TWH approach better prepares employers and employees for changes in our future, by helping to ensure worker well-being. 30 If the TWH assumption is correct, we should predict that the well-being of employees, even in the face of a pandemic, will be better preserved if they perceive health and safety climates to be strong even during COVID-19. At the time that COVID-19 spread to Colorado, USA, we were nearing completion of a longitudinal intervention study of TWH in small enterprises, called Small + Safe + Well (SSWell). 31 This presented us with a unique opportunity to re-engage a well-characterized cohort of small businesses and their employees during the early stages of the COVID-19 pandemic. Following the findings from previous research, we hypothesized that employee perceptions of safety climate and health climate are associated with higher levels of well-being. Further, we hypothesized that higher ratings of employees’ perceptions of organizational response to COVID-19 and changes to employee work/life experiences will moderate the relationship between employee perceptions of safety and health climates and well-being.
Public Health Context
Following discovery of the first reported COVID-19 cases in Colorado on March 5, 2020, the state's “Stay at Home” Executive Order was issued on March 25, 2020 and extended through April 26, 2020. 32 We timed our COVID-19 Employee Impact Survey, described below, to coincide with Colorado's “Safer at Home” Executive Order which began on April 27, 2020. 33 This order relaxed several previous restrictions of the “Stay at Home” order and allowed for limited reopening of postsecondary institutions and specific business organizations. The “Safer at Home” Executive Order was extended and amended throughout the survey period as restrictions continued to be lifted during this timeframe.
Businesses and Employees
The SSWell study is a longitudinal intervention study at the Center for Health, Work and Environment (CHWE), a National Institute for Occupational Safety and Health (NIOSH) Total Worker Health Center of Excellence. SSWell utilizes a TWH intervention focused on small businesses in the state of Colorado, with the overarching goals of improving worker health, safety and well-being. Details of the SSWell study have been previously described. 31 SSWell enrolled a cohort of organizations that participated in a TWH initiative called Health Links™ and that completed a TWH leadership program. Each year of the study, businesses completed the Health Links Healthy Workplace Assessment™ that focuses on 6 distinct areas of workplace safety and health, which capture the essential elements of TWH at the organizational level. 5 Following the organizational assessment, employees were asked to complete the Employee Health and Safety Culture survey for each year of study enrollment.
COVID-19 Employee Impact Survey
From May 6, 2020 to May 30, 2020 the COVID-19 Employee Impact Survey was sent to organizations participating in the SSWell study. The COVID-19 Employee Impact Survey included selected items derived from the SSWell annual Employee Health and Safety Culture Survey, described elsewhere, particularly constructs of safety climate, health climate and well-being. 29
Well-Being, Safety Climate & Health Climate
The mental well-being construct utilized the WHO-5 Well-Being Index. 34 The index elicited responses to five Likert-type questions ranging from “at no time” to “most of the time” with a higher mean score representing a higher well-being index. An example item is “My daily life has been filled with things that interest me.” The safety climate construct was comprised of six organization-level questions requesting employees to assess their organization's commitment to safety. 35 An example in this question set is, “My organization used any available information to improve existing safety rules.” Health climate was evaluated using the organization-level items from the assessment of Zweber, Henning and Magley. 19 An example item is, “My organization has been providing me with opportunities and resources to be healthy.” The climate measures were scored on five-point Likert scales with the continuum of strongly disagree to strongly agree, with higher mean scores indicative of more positive perceptions of safety and health climates. Questions were modified to prompt responses specific to the immediate pandemic timeframe by including such phrasing throughout the survey as, “over/in the past 30 days.”
Other questions selected from the SSWell annual Employee Health and Safety Culture Survey were incorporated into the COVID-19 Employee Impact Survey. Items focused on leadership commitment, (eg, “Leaders consistently communicated the importance of safety activities”), work stress (“How often have you felt stress because of your work?”), access to employer-sponsored healthcare benefits, overall health, absenteeism (“In the past 4 weeks, how many hours of work did you miss due to your physical and mental health?”), and presenteeism (“In the past 4 weeks, how would you rate your overall job performance on the days that you worked?”). As noted for the climate and well-being constructs, questions were modified as appropriate to include phrasing associated with the COVID-19 outbreak. Several questions were prefaced with, “The following asks you about your work experiences over the past 30 days during the coronavirus (COVID-19) pandemic.”
Perceptions of Organizational Response & Other Work and Life Experiences Related to COVID-19
We developed additional questions targeting work and life experiences applicable to the pandemic. One such construct was employees’ perceptions of their organization's response to COVID-19, which comprised nine items asking about leadership, communication, and safety systems related to the pandemic. Example items included “I was confident in the organization's leadership team to make the right decisions to manage through the COVID-19 crisis,” “Employees received comprehensive training in COVID-19 issues at work,” and “Employees were able to discuss their concerns about COVID-19 issues with their supervisor.” Other items developed by the research team asked about how COVID-19 affected their work, essential worker designation, changes to childcare arrangements, potential exposure to COVID-19, and personal behavior changes related to COVID-19 over the past 30 days. An example question is, “How has COVID-19 affected your work over the past 30 days?” with responses such as worked remotely, worked fewer hours, worked more hours, income/pay reduced, change in job duties, not able to work, unemployed. If the respondent indicated they had children under the age of 18 at home, they were asked “Have you experienced any of the following regarding childcare in the past 30 days?” with options such as childcare closed, childcare arrangements changed, etc. An example question about personal behavior changes was “I’ve limited social contacts to my immediate household members” with a five-point scale ranging from never to always.
Results from a confirmatory factor analysis of the well-being, safety climate, health climate, and perceptions of organizational response to COVID-19 items demonstrated the empirical distinctiveness of these measures (see Appendix A). 36
The survey was administered via the REDCap electronic data capture tool. 37 , 38 Anonymity was maintained and no identifying information was collected. To incentivize participation, 15 $100 electronic gift cards were offered to employees who completed the survey. Upon survey completion to preserve employee confidentiality, employees were invited to provide an email address through another database for the random drawing. Our study protocol was approved by the appropriate institutional review board.
The main outcome of interest was employee well-being. The main predictor variables were employee perceptions of safety climate and health climate. Linear mixed-model regression with a random intercept for business was used to examine all hypothesized relationships. Models for safety climate and health climate were assessed independently. Correlation coefficients were calculated between all predictor variables to assess multicollinearity. A final multivariable model was created for each of the climate variables including any of the COVID-19 specific variables that was significant at the α = 0.15 level in the univariate analyses. Multivariable models were adjusted for business size, region (rural/urban), employee age and gender. Regression analyses were completed using SAS version 9.4. 39
Post-hoc analyses examined the relationship between the availability of employer-sponsored health care benefits and employee well-being. Furthermore, to understand the stability of the estimate of effect of the childcare change variable on employee well-being, we re-ran the analysis examining only the subset of individuals who reported having children under the age of 18 in the household. Alpha levels for association were set at α = 0.05.
Of the 143 organizations who had enrolled in the SSWell study, there were 74 organizations that were eligible for this study (eg, were considered active, had not officially dropped out) and were invited to participate by distributing the survey to their employees. Thirty organizations responded (41% business response rate). The average size of participating organizations was 90 employees (range: 4 to 561). Almost one third (30%) of participating organizations were from the healthcare and social assistance sector. Most organizations (70%) were located in urban areas of Colorado. Table Table1 1 presents organizational demographics.
Organization Characteristics ( N = 30)
Responses were received from 491 employees from the 30 businesses who distributed the survey. Based on the most recent assessment data that collects information on the number of employees, we estimate 2211 employees received the survey (22% response rate). Table Table2 2 presents the characteristics of respondents. The mean age of respondents was 38.1 years (SD = 13.5) and were mostly white, non-Hispanic ( n = 376, 79%) and female ( n = 398, 82%). Approximately one third ( n = 153, 32%) indicated that they had children under the age of 18 at home.
Table Table3 3 presents the well-being outcome and predictors including safety and health climates, perceptions of organizational response to COVID-19, and other work and life experiences related to COVID-19 over the past 30 days. The mean well-being index score of respondents was 3.1 (SD = 0.89) on a five-point scale. Employees’ mean rating of their perceptions of organizational response to the pandemic was 4.2 (SD = 0.96). The average employee rating of safety climate was 3.9 (SD = 0.83) and the average reported rating of health climate was 4.0 (SD = 0.89). Internal consistency values for the three scales were all excellent (organizational response α = 091; safety climate α = 0.93; health climate α = 0.91).
Employee Well-Being, Perceptions of Safety and Health Climates, and Change to Work and Home Life Experiences Due to COVID-19
A majority of respondents ( n = 284, 58%) reported changes in remote work and 35% ( n = 170) reported a change in job duties. Employees reported that they were limiting social contacts more frequently in response to COVID-19 (M = 4.1, SD = 1.02) and staying at home more often (M = 4.5, SD = 0.73). Of the 153 respondents who had children under the age of 18 at home, 40% ( n = 61) responded that childcare had been closed or was not available during the prior 30 day period asked about in the survey. Less than 1% ( n = 4) indicated options for employer-sponsored childcare were available. Employer-sponsored healthcare benefits were available to 74% ( n = 361) of the responding employees; 60% ( n = 292) reported provisions for paid sick leave, 71% ( n = 350) reported paid vacation leave, and 65% ( n = 318) indicated flexible work schedules.
Associations with Well-Being
Table Table4 4 presents univariate analyses. Well-being increased with increases in perceptions of both safety and health climates, independently. On average, for every one-point increase in perceptions of safety climate, well-being increased 0.23 points ( P < 0.0001, 95% CI = 0.135, 0.327). Similarly, for every one point increase in perceptions of health climate, employee well-being increased by 0.26 points ( P < 0.0001, 95% CI = 0.170, 0.350). Positive perceptions of organizational response to COVID-19 were also associated with increased well-being. Higher well-being was found in individuals who responded that they limited social contacts. Workers who experienced changes in job duties had lower reported well-being that did those whose job duties remained the same during the COVID-19 pandemic. Workers who were unable to work during the COVID-19 pandemic reported lower well-being compared to those who remained on the job.
Results of Univariate Analyses for Health Climate and Safety Climate (Main Predictor Variables) and Potential Effect Modifiers with Well-Being (Outcome Variable)
There was no observed association between safety climate and well-being after adjusting for perceptions of organizational response to COVID-19 (Table (Table5). 5 ). Associations between safety climate and well-being were preserved after adjusting for all other COVID-19 potential modifiers. Similarly, the associations between changes in childcare, ability to work, and limited social contacts with well-being were preserved when controlling for safety climate.
Results of Bivariable Analyses for Safety Climate and Well-Being, Adjusting for Other Potential COVID-19 Modifiers
Table Table6 6 presents bivariable results for health climate and well-being. After adjusting for differences in perceptions of organizational response to COVID-19, well-being increased, on average, by 0.20 for each one-point increase in perceptions of health climate ( P = 0.001, 95% CI = 0.048, 0.347). Associations between health climate and well-being were preserved after adjusting for all other COVID-19 potential modifiers. Similarly, the associations between changes in childcare, ability to work, and limited social contacts with well-being were preserved when controlling for health climate.
Results of Bivariable Analyses for Health Climate and Well-Being, Adjusting for Other Potential COVID-19 Modifiers
As shown in Tables Tables7 7 and and8, 8 , none of the COVID-19 impact variables assessed in this analysis provided moderating effects on the relationship between either safety climate or health climate and well-being.
Multivariable Linear Regression Analyses Comparing the Relationship of Safety Climate and Selected Potential Modifier Variables with Well-Being
Multivariable Linear Regression Analyses Comparing the Relationship of Health Climate and Selected Potential Modifier Variables with Well-Being
After the bivariable analyses were conducted, we assessed the correlation between safety and health climates and perceptions of organizational response to COVID-19. Employees’ perceptions of their companies’ safety climate and health climate were strongly correlated with their perceptions of the organizational response to COVID-19 (safety climate, r = 0.82; health climate, r = 0.80). Due to concerns about collinearity, perceptions of organizational response was excluded from the final multivariable models. Our final multivariable model included childcare changed, not able to work, and limited social contacts for both climate measures.
Tables Tables9 9 and and10 10 present the associations between employee perceptions of safety climate and health climate and well-being. The association between safety climate and well-being was preserved after adjusting for childcare, ability to work, and limited social contacts (Table (Table9). 9 ). There was, on average, a 0.21 higher well-being score for each one-point increase in safety climate perceptions ( P < 0.0001, 95% CI = 0.115, 0.307). Similarly, the association between health climate and well-being was preserved after adjusting for childcare, ability to work, and limited social contacts (Table (Table10). 10 ). Well-being scores were, on average, 0.24 points higher for each one-point increase in health climate. This association was significant, after adjusting for changes in childcare, ability to work, and limited social contacts. ( P < 0.0001, 95% CI = 0.148, 0.330)
Results of Multivariable Analyses for Safety Climate and Well-Being After Controlling for Business Size, Region, Employee Age and Gender
Results of Multivariable Analyses for Health Climate and with Well-Being After Controlling for Business Size, Region, Employee Age and Gender
Post Hoc Analysis of Associations of Well-being with Healthcare Benefits and Childcare Changes
Post hoc analysis of employer-provided healthcare benefits indicated no significant association with well-being. Additionally, the analysis conducted with the subset of individuals who reported having children under the age of 18 in the household found similar results to models run with the full sample, indicating stability of our multivariable models for this variable (Appendix B).
Our results offer several interesting findings regarding how the COVID-19 pandemic has impacted small business employees in the early months of the crisis. The way in which employees felt their small businesses responded to the pandemic was significantly related to employee well-being, as was the ways in which employees’ home and work lives changed. However, these relationships were no longer significant after accounting for employee perceptions of safety and health climates. Ultimately, our findings suggest that small business employees report better well-being during the COVID-19 if they work for a company that they perceive as having strong safety and health climates. These findings have implications for how small businesses prepare for emergencies.
As COVID-19 continues to have major impacts on small businesses and their employees, it is important to learn how organizations can influence workplace safety, health, and well-being. This is particularly important for small businesses, which face different challenges and have different resources available than their larger counterparts. In this study, we found that employees of small organizations have experienced a number of disruptions both to their work and home life due to COVID-19, including working remotely more frequently than usual, changes to job duties, changes to childcare, and limiting social contacts. Interestingly, there were about equal numbers of respondents who were working more hours than usual and fewer hours than usual. All of these factors can affect well-being, particularly when changes are out of the employee's control. While we could not assess whether these changes were an employee's choice, research suggests that higher levels of job autonomy and perceived control are correlated with lower work-family conflict, lower depression, less turnover, and higher job satisfaction making it important to understand how to involve employees when making changes to work. 40 , 41 However, in the current study, none of these other work and home life factors were related to well-being after accounting for perceptions of safety and health climates, suggesting the over-riding strength of organization climate in a time of disruption.
Our findings that perceptions of safety and health climates are related to well-being are consistent with research that finds safety and health climates are related to a number of factors, including safety practices, motivation, knowledge, and accidents, as well as physical health and health behaviors. 17 – 24 , 25 , 26 We add to this literature by demonstrating that these relationships hold during a global pandemic and that they are more important than perceptions of organizational response to COVID-19 and work and life changes during COVID-19. Employee perceptions of safety and health climates may be more important for well-being than employer-provided benefits such as paid sick leave, which had no effect on employee well-being in our study. Additionally, we find that the climate variables were highly correlated with perceptions of organizational response to COVID-19. This suggests that small businesses that are committed to employee safety and health are also likely to have strong leadership support and use of safety and health procedures specifically to protect employees from an illness. These findings suggest that during emergencies small businesses that have strong safety and health climates may be better prepared to maintain employee well-being, although we acknowledge that our study design does not permit us to establish cause and effect.
As workers have been impacted with how countries have responded to COVID-19, it is important that organizations respond to threats to employee safety, health, and well-being by implementing evidence-based workplace strategies. 42 The results from this study support the notion that organizations focused on implementing a comprehensive TWH approach focused on both safety and health across management, benefits, and practices can be positioned well to maintain the well-being of their employees in times of crisis. A systematic review examining challenges to organizational systems including manmade and natural disasters, disease outbreaks, and environmental changes found that organization resilience is achieved by adapting and transforming and relies on factors such as resources, leadership practices, and organizational culture. 43 In the case of COVID-19, TWH serves as a public health emergency response for employers to ensure guidelines are in place for safe return to work. 12
The response to the COVID-19 pandemic continues to evolve and small businesses and their employees will continue to be impacted by an organization's response to the pandemic, among other, larger economic and societal factors. The return to in-person work, continued exposure to COVID-19, the re-opening of schools, and other considerations will continue to affect employee safety, health, and well-being. On-going and future research should follow-up with organizations to learn how organizational response continues to evolve as the COVID-19 pandemic and response shifts. These data were collected in May 2020, two months into the pandemic curve in Colorado and at the time that initial restrictions from Colorado's Stay at Home Order were beginning to lift. 32 , 33 As organizations have been able to re-open, businesses and employees likely are facing different challenges than they were in late spring 2020. It is important to learn about the ongoing and new challenges facing small organizations and their employees, with the ultimate goal of implementing and testing workplace interventions. Further, the lessons learned from COVID-19 are applicable to a number of crises that an organization may face, including natural disasters, other infectious diseases, and workplace fatalities, among others. More research is needed to learn about the buffering effect of positive safety and health climates on employee well-being when faced with crises.
Strengths and Limitations
Due to the network of employers already enrolled in the SSWell study, we were able to quickly recruit small businesses and their employees to complete the COVID-19 Employee Impact Survey, providing timely information about the challenges and opportunities faced by employees. Collecting information from employees themselves, as opposed to just organizational-level responses, is a strength of this study. Employees came from organizations across multiple industries, small business sizes, and in rural and urban areas of the state, improving the generalizability of our findings.
Limitations to this work include that the businesses and employees who were most impacted by COVID-19 were likely not represented in this study as the organization may have closed or reduced hours and some employees may have been no longer working for the business. Data were self-reported, which could bias results if respondents reply in ways that attempt to make themselves or their organizations appear favorable. Finally, though we tried to address the timeframe of the previous 30 days during the COVID-19 pandemic, this was a time of heightened stress and many changes which could have affected participant recall.
Safety and health climates continue to be positively related to employee well-being, even when other disruptions occur in and out of the workplace. As businesses continue to adapt to the operational changes that are brought about by the COVID-19 pandemic, it is more important than ever for organizations to focus on the safety and health of their employees by building strong safety and health climates. Total Worker Health offers a comprehensive and approachable way for small employers specifically to build strong health and safety climates. Future efforts should build upon this study to develop a greater understanding of how COVID-19 impacts small businesses and how those businesses can impact the safety, health, and well-being of their employees.
This publication was supported by the grant number U19OH011227, funded by the Centers for Disease Control and Prevention/National Institute for Occupational Safety and Health. Its contents are solely the responsibility of the authors and to not necessarily represent the official views of the Centers for Disease Control and Prevention of the Department of Health and Human Services.
The authors report no conflicts of interest.
The protocol was approved by the Colorado Multiple Institutional Review Board (COMIRB ID: 16-1482).
Clinical significance: Safety and health climates influence employee well-being. When substantial societal and business disruptions occur, such as the current COVID-19 pandemic, small businesses with strong climates may be better prepared to help preserve employee well-being. Small enterprises should continue in efforts to sustain a health-centered and safety-centered culture.
Supplemental digital contents are available for this article.
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The Business of Medicine in the Era of COVID-19
- 1 Department of Economics, Harvard University, Cambridge, Massachusetts
- 2 Vanderbilt University Medical Center, Nashville, Tennessee
- 3 Harvard Business School, Boston, Massachusetts
- JAMA Forum How Will COVID-19 Affect the Health Care Economy? David Cutler, PhD
- Viewpoint Supporting the Health Care Workforce During the COVID-19 Global Epidemic James G. Adams, MD; Ron M. Walls, MD
- Viewpoint COVID-19 and the Financial Health of US Hospitals Dhruv Khullar, MD, MPP; Amelia M. Bond, PhD; William L. Schpero, PhD
- Viewpoint Telehealth in a Postpandemic Future—Regulatory Changes and Opportunities Carmel Shachar, JD, MPH; Jaclyn Engel; Glyn Elwyn, MD, PhD, MSc
- Viewpoint How Academic Health Systems Can Move Forward Once COVID-19 Wanes Steven D. Shapiro, MD; Paul B. Rothman, MD
- A Piece of My Mind A Bond Allison Bond, MD, MA
The United States will eventually get through the acute coronavirus disease 2019 (COVID-19) crisis but not without fundamental changes to the medical care system. Since the epidemic began, payment policy has stretched to remedy the bias of the health care system for in-person treatment provided by physicians. In response to the need for social distancing, new policies include broader payment for telemedicine, expanded scope-of-practice ability for nonphysician practitioners, and increased ability of physicians and nurses to practice across state lines. While these policy reforms address some of the immediate needs of this crisis, such as getting personnel to where they are most needed, they are not a complete solution to the COVID-19 crisis. How the aftermath of the current COVID-19 wave is handled will be just as important for the business of health care as what is happening now.
Two issues about the medical system after the current wave are particularly important: What type of organizations will be available to treat patients a few months from now? And how will those patients be most effectively served?
What Will the Health Care Landscape Look Like?
Hospitals and physicians treating most patients with COVID-19 have 2 financial challenges. The direct costs of caring for patients with COVID-19 are clear; many such patients are uninsured or require care that costs more than insurance pays. Likely much larger, however, is the financial effect of having postponed nonemergency care, ranging from office visits to elective surgery. These are the cases from which physicians and hospitals derive most of their profits. Elective care has declined across the country, with reductions in some services of 50% or more.
The good scenario for population health is also the good scenario for the business of medicine. It is possible that COVID-19 will be contained sooner than expected and that the economy will recover earlier rather than later. In that case, physicians and hospitals will fare well; indeed, there could be excess demand for services still deemed essential. But there could be pockets of concern even in this scenario. Will patients have concluded that some services are not so essential and thus not return for them? Will the rush of patients who do seek services lead to delays in scheduling and the rationing of capacity, both of which may lead patients to abandon valuable treatment out of frustration?
If the COVID-19 shutdown lasts for months or the normal business of health care does not resume until the fall, the implications for physicians and hospitals would be much more severe. In the past month, the response of many health care organizations to the reduction in primary and elective care has been to reduce staff providing those services. Employment in health care declined by an estimated 43 000 people from mid-February through mid-March 1 and has undoubtedly declined further since then. Approximately half the cost of primary care practices is attributable to salaries, so furloughs help ensure solvency. 2 But bills will have to be paid, and remaining costs cannot be reduced as much. The bank accounts of many practices are not large enough to absorb a long-term shutdown.
Some organizations are more vulnerable than others. In the hospital industry, rural institutions have lower margins than urban hospitals. This is particularly true in the South, where governors have been slow to enact stay-at-home measures and many states have not undertaken Medicaid expansion. Nearly 100 hospitals have closed in the South over the past decade.
Small primary care and specialty offices are also vulnerable because they are, in the end, small businesses: a significant share of primary care physicians work in practices with 1 or 2 physicians. 3 If primary care or specialty visits are either deferred or foregone, the reduction in physician practice income could shutter some practices. It is unclear how effective the small-business loans that have been made available to many of these practices will be in ensuring they become operational again when social distancing ends.
This fall, and certainly into 2021, there could be additional consolidation of practices, both large and small. Smaller hospitals will look for capital infusions by merging with bigger hospitals, and physicians may find more security in larger groups. Several factors hasten these trends. Hospitals have started to work together to care for patients with COVID-19; merging may be a natural extension of that activity. Further, hospital personnel will be exhausted by caring for patients with COVID-19. Some clinicians will have become ill while caring for patients or will, in the worst circumstances, have succumbed to the virus. Additional physicians and nurses may thus be necessary. For services that do not come back, physicians in specialties that provide those services may need immediate job security.
The benefit of consolidation will be facilities that do not close and communities that maintain sources of care. But there are likely to be costs as well. Consolidation among hospitals and between hospitals and physicians significantly increases health care prices. 4 This trend will further increase health care spending at a time when the lingering effects of the virus will already be raising private insurance premiums.
How Will Patients Be Served?
For physicians, COVID-19 may affect how they practice in even more fundamental ways. In response to the need to maintain social distance, many physicians have turned to telemedicine. In March, the federal government substantially eased restrictions it had previously placed on Medicare reimbursement for care provided via telemedicine. To support this move, federal and state governments also provided physicians with greater latitude to practice across state lines. In addition, nurse practitioners and other nonphysician clinicians were allowed greater ability to treat patients without direct supervision from physicians.
The substantial increase in the use of telemedicine during the crisis has been pervasive across health care systems. For instance, the Cleveland Clinic based in Cleveland, Ohio, reported being on track to complete more than 60 000 telemedicine for visits for the month of March compared with its prior average of about 3400 visits per month. 5 Similarly, Jefferson Health in Philadelphia, Pennsylvania, has seen an increase in virtual visits on its JeffConnect telemedicine platform, from 60 visits per day before the pandemic to a recent figure of 2000 visits per day. 6 These are but 2 examples of a much broader phenomenon.
The rapid growth of telemedicine and the broadening of clinician license raise the question of what becomes of these new approaches to treatment once the immediate COVID-19 crisis has passed. At this point, most of the easing of regulation has been temporary. What is not clear is whether, when, and to what extent these regulations will be re-established. There are many arguments for making these regulatory changes permanent. Just as telemedicine and the expansion of clinician capacity may help patients needing certain types of urgent care during this crisis, it may be a useful outlet to serve the wave of elective visits that is currently welling up. Further, it may also be helpful once the system returns to something approaching a “normal” level of volume. If keeping older patients and those with chronic disease home is necessary in an epidemic, it also could be beneficial outside of an epidemic. Many long-standing efforts to reform the health care system have suggested that this may well be the case.
But the push for mergers and remote practice could go much farther, changing in a fundamental way what it means to be a physician and to practice medicine. Hospitals and medical practices have already reduced benefits and decreased hours for clinical staff. 7 Might organizations decide that it is better to hire physicians on an as-needed basis rather than through employment? Emergency department care in the last decade offers a fitting analogy. Many hospitals, especially those with small volumes, found it difficult to staff a full-time emergency department. As a result, they turned to outside staffing companies. Having less to manage was good for hospitals, but the outsourcing of emergency care was identified as a key driver of the surprise billing phenomenon the nation is still addressing. 8 To the extent that such practices become more widespread, new forms of regulation may be needed just as others are being relaxed.
Everyone hopes that medical care will return to normal in the coming months. But the new normal may be not as recognizable as some think. Some changes may be good, but the road is fraught with risk. It is possible, perhaps likely, that the painful process of reaching a new health care equilibrium will last well into 2021. Ideally, this time will allow for thoughtful discussion of how the intertwined forces currently affecting clinicians and other health care personnel, as well as hospitals, health care centers, and practices, can lead to sustained improvement of the overall system for delivering care.
Corresponding Author: David M. Cutler, PhD, Department of Economics, Harvard University, 1805 Cambridge St, Cambridge, MA 02138 ( [email protected] ).
Published Online: May 1, 2020. doi: 10.1001/jama.2020.7242
Conflict of Interest Disclosures: Dr Cutler reported receiving personal fees from Fidelity and MDL Litigation; nonfinancial support from the Commonwealth of Massachusetts; and personal fees and nonfinancial support from the American Medical Association, Brookings, Mercer, and Colorado Center for Nursing Excellence as well as serving on an academic and policy advisory board for Kyruus Inc, an advisory board for Firefly Health, and nonpaid positions at the National Academy of Medicine, National Bureau of Economic Research, National Academy of Social Insurance, and the Center for American Progress. Dr Huckman reported receiving personal fees from Kaiser Permanente, Partners Healthcare, MD Anderson Cancer Center, OhioHealth, and Ochsner Health; serving as an advisory board member for RubiconMD, Arena, and Carrum Health; and being an uncompensated trustee of the Brigham and Women’s Physicians Organization. No other disclosures were reported.
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Cutler DM, Nikpay S, Huckman RS. The Business of Medicine in the Era of COVID-19. JAMA. 2020;323(20):2003–2004. doi:10.1001/jama.2020.7242
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Mental Health Has Become a Business Imperative
- Workplace, Teams, & Culture
- Talent Management
- Organizational Behavior
- Work-Life Balance
Of the many issues we have faced throughout the past two years, perhaps the most surprising but important is mental health. Studies now show that nearly 81% of workers face some form of burnout or mental health issue, and 68% of employees say their daily work has been interrupted by these challenges. 1
Health care is one of many industries, along with retail, transportation, and hospitality, that has been especially affected by burnout and stress as a physically and mentally depleted workforce has faced peaks in demand for services.
Large health care providers like Provident and HCA, among others, have told us that their employees are “undergoing trauma, just like our patients.” This, in turn, is leading to sickness, absenteeism, and staff turnover. There’s a domino effect on remaining teams, too, as these employees are overstretched and unsettled and face high levels of stress in order to meet patient needs with fewer people.
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From our regular discussions with HR leaders around the world, it’s clear that the organizations outperforming their peers are those that have cultivated a strong sense of empathy and flexibility, developed new skills to address workforce needs, and extended holistic mental health support to employees.
Like many of the changes that have come out of the pandemic, this new approach to mental health looks set to be a permanent one. As they begin to see the value in the link between mental health and the well-being and overall performance of a business, leading companies are going the extra mile to understand and respond to the way employees feel day to day.
The CEO of Starbucks has stated publicly that he considers the mental and emotional health of the company’s workers to be its biggest challenge coming out of the pandemic. 2 Morgan Stanley, which employs many people who have advanced degrees and are exceptionally high performers, now has a chief medical officer dedicated to maintaining and improving mental health across the organization.
Within human resources departments, we’re seeing a growing trend of companies promoting new roles focused on measuring and improving mental health at work.
Our research (a study of over 1,000 companies) examined which business and people practices have the most impact on business outcomes, people outcomes, and innovation. This analysis points to the importance of transitioning from the traditional focus on employee benefits to one that encompasses job and work design, management, rewards practices, a demonstrated commitment to psychological safety and fairness, and a culture of employee listening.
This research shows that “healthy” organizations outperform their peers in a range of ways. Rates of absenteeism are almost 11 times more likely to be lower, and these employers are more than three times more likely to retain people. Companies that care about staff well-being are at least twice as likely to delight customers, to be identified as a “great place to work,” and to exceed financial targets. These companies also adapt more readily to change and are more effective at innovating . 3
From HR Issue to Management Priority
We’ve found that within organizations, the higher up that mental health is prioritized, the bigger the impact of any interventions. Until recently, mental health was seen as a benefits problem, relegated to the realm of HR. Companies offered employee assistance programs, for instance, or insurance-provided advice networks to help staffers find a counselor. These programs, while widely available, were rarely used in practice, due to employees’ worries about the stigma of asking for help. Plus, benefits managers were continuously concerned about the programs’ cost.
Now, this equation has changed completely. Mental health is scaling the management agenda, and money is being made available to invest in identifying and addressing issues with positive, proactive, and increasingly creative solutions.
Pioneering companies are creating programs for sabbaticals, time off, child care benefits, and far more flexible work arrangements. Tools like real-time pay systems , regular feedback sessions, the four-day workweek , and far more discussions with leadership are all efforts to make work more humane and healthier for workers. Simple policies like allowing dogs in the office can cost so little yet matter so much to employees.
In many cases, technology platforms and targeted apps are providing some of the answers — from meditation apps geared toward mindfulness to tools that improve the employee experience by helping to alleviate administrative strain. But for maximum and lasting impact on mental health, change needs to happen within the context of culture, where conversations about mental health are encouraged and normalized.
Any good, proactive mental health initiative starts with listening. Most companies, and most business leaders, won’t know how much stress there is in the organization unless employees tell them. Sentiment surveys, open town hall meetings, and exit interviews are all crucial inputs for gathering facts and bringing attention to the issues employees are facing.
The real shift here is that many companies are now removing the stigma attached to talking about matters of mental health. People can say, “I’m not feeling well today,” or “I’m tired,” or “I’m having troubles at home”; that type of feedback is critical.
Monitoring in this way will help senior managers pinpoint any particular hot spots in the business for further investigation.
Innovation in Action
During the pandemic, the leadership team at global telecommunications provider Verizon created a series of biweekly conference calls to help senior managers empathize with the high levels of turnover, stress, and employee burnout in its field force and share ideas on how to address these urgent issues.
JPMorgan Chase implemented a well-being application for all of its employees that asks staff members and leaders to check in regularly to tell the system how they feel that day. HR monitors these signals and data inputs to see whether certain groups are experiencing major changes in stress, enabling HR team members to connect managers and challenged teams with support.
Royal Bank of Canada requested that all managers take a course in mental health, developed by the public mental health council of Canada. This course helps leaders develop skills for recognizing various forms of stress or other illnesses, using the language of mental health.
Airline reservation and technology company Sabre surveyed employees regularly to understand their stress and productivity challenges in the move to remote work. Using this input, the company shifted to a new management model, creating a set of focused tools for managers to diagnose, improve, and continuously monitor employee stress and productivity.
Toward the Genuinely Healthy Organization
Creating a robust and consistent process for monitoring employee well-being allows employers to spot issues before they escalate and to provide timely help. Encouragingly, of the 1,000-plus companies we studied, about 15% now think about overall employee well-being as an integrated part of their strategy .
This has implications for leaders’ skill sets and personal attributes, too, which over time will have a bearing on who is promoted into senior roles. I believe very strongly in human-centered leadership — the idea of putting your people first and prioritizing their health. Managers or team leaders have to keep in mind that people’s sense of safety and security is the most important thing. Once that’s in place, you can talk about everything else. But if that isn’t there, everything else you’re working toward will suffer.
Now more than ever, it’s time to think about the employee experience more holistically. It isn’t just my own work that’s highlighting this. Study after study shows that mental health is the top-rated benefit requested by workers. In response, leaders, managers, and employees at all levels must advocate for a proactive approach to mental health. It’s both the right thing to do and a solid business strategy.
About the Author
Josh Bersin ( @josh_bersin ) is a global industry analyst covering HR, talent, and leadership and is the founder of the Josh Bersin Academy.
1. “ Employer Support Has a Direct Impact on the Health and Resilience of Employees, According to a Mercer Survey ,” Mercer, Sept. 13, 2021, www.mercer.com; “American Worker in Crisis: Understanding Employee Mental Health in Unprecedented Times,” PDF file (Burlingame, California: Lyra Health, July 2020), https://get.lyrahealth.com; and “ Edelman Trust Barometer 2022 ,” PDF file (Chicago: Edelman, January 2022), www.edelman.com.
2. A.R. Sorkin, “ Howard Schultz: Starbucks Is Battling for the ‘Hearts and Minds’ of Workers ,” The New York Times, June 11, 2022, www.nytimes.com.
3. J. Bersin, “ The Healthy Organization: Next Big Thing in Employee Wellbeing ,” Josh Bersin (blog), Oct. 27, 2021, https://joshbersin.com.
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The Business Role in Improving Health: Beyond Social Responsibility
Although there is growing understanding that fundamental population health improvement will require multisectoral partnerships (Posner, 2010), the specific role of employers in such partnerships has been less well explored. While corporate social responsibility plays an important motivational role, more traction will be possible if improving health can be linked to corporate bottom-line performance. This paper explores why business should engage in improving population health.
Corporate Business Goals and Community Health
Improving the health of the community where a company is located can contribute to achieving corporate business goals. The involvement of business with health care and public health is often focused on reducing health care costs and improving employee productivity (Baicker et al, 2010). As important as these are, we believe that current understanding of the many factors that contribute to better health provide a rationale for an even wider role for businesses in making surrounding communities healthier. This role can be rooted in core business objectives far beyond corporate social responsibility. According to Andrew Webber, President and CEO of the National Business Coalition on Health, “Business leaders must understand that an employer can do everything right to influence the health and productivity of its workforce at the worksite, but if that same workforce lives in unhealthy communities, employer investments can be seriously compromised” (Webber and Mercure, 2010).
Determinants of Population Health
Improving population health requires much more than high-quality, affordable health care. Health outcomes in the United States lag behind those in most developed countries by a wide margin, despite the fact that the United States spends substantially more on health care than its peers (IOM and NRC, 2013). Within the United States, we continue to experience substantial disparities by race, income, and geography, and, as shown in a recent report, there has been absolute worsening in mortality rates in many U.S. counties over the last decade (Kindig and Cheng, 2013).
As important as health care quality and access is, the last several decades have shown that health outcomes are the product of many factors beyond health care. The widely used County Health Rankings (County Health Rankings is a collaboration of the Robert Wood Johnson Foundation and the University of Wisconsin. ) weight the multiple factors as 20 percent for health care, 30 percent for health behaviors, 40 percent for social factors like education and income, and 10 percent for the physical environment (see Figure 1 ).
The Critical Role of Business
We believe that the business sector plays a critical role in many determinants of health. While the health care system has primary responsibility for health care quality and access and, to some extent, for health behaviors, it has more limited roles in the social and physical environments. The business sector usually strives to maximize the value of health care dollars invested in the workforce because lower costs or better outcomes generally translate to a healthier and more productive workforce and a more successful enterprise. Business can also influence health care through purchasing requirements. Such requirements can specify the health care product they are purchasing and mandate that health care providers must practice evidence-based medicine. The focus is primarily on controlling the cost of services provided to employees and their dependents while ensuring an acceptable level of quality. Some larger employers also directly provide employee health services. Health care benefit design impacts both health care costs and employee recruitment and retention.
The business case for focusing on health behaviors has been to foster employee wellness, which is seen as improving productivity in the short run and reducing health care costs in the long run. With respect to social and economic factors, the strongest business contribution may be in employment itself, both in the employment-to-population ratio and the contribution to individual and family income. There is also growing realization by employers that K-12 and early childhood education programs in their communities contribute to business profitability in the short and long runs. In terms of the physical environment, some industries have substantial responsibility in areas of air and water quality and in community land use planning. There also has been a growing interest in the environmental factors that contribute to obesity in communities, for example, lack of opportunities for physical activity or for purchasing healthy food.
Impact of Community Health on Business Objectives
Improving the health of communities and individuals is important to core business objectives. While corporate social responsibility must be valued and encouraged, we believe the role of business in communities’ health improvement efforts will be limited in impact and sustainability if not tied to bottom-line performance.
Better community health can contribute to the bottom line in many ways beyond reducing health care costs. Cathy Baase, Dow Chemical’s Global Director of Health Services, has identified the following benefits of business involvement: attracting and retaining talent, employee engagement, human performance, personal safety, manufacturing and service reliability, sustainability, and brand reputation.
Also important is the link between employee well-being and profitability. One large retailer regularly assesses employee well-being and compares these data with sales and profitability figures.
The business community understands the health care and education connection. The poor health of our children will lead to rising health care costs, which will then exhaust the resources for education. One approach to long-term investments in youth development is through mentoring relationships. For example, one company recruits youth (from as early as the first grade) who might otherwise end up on the street or in jail to participate in supportive relationships and then guarantees jobs as long as the students earn good grades. The business case for investing in education in the community is that the company needs employees.
Social responsibility commitments of businesses can often lead to enhanced company reputation and customer loyalty. When a business reflects customers’ values (such as making a strong financial commitment to education), people feel good when they walk in, and it improves the brand.
Business Roles in Health Improvement Vary
Large employers with stable, older workforces may see greater bottom-line return than employers with younger, high-turnover workforces. Smaller employers will be limited in what they can do alone but could operate through employer coalitions or Chambers of Commerce.
No single sector is solely responsible for health improvement. Businesses can lead or play strong supporting roles in community multisectoral partnerships. It follows from a multideterminant understanding of health that no one organization or sector is totally responsible for improving health outcomes. For the business sector, the relationship of core corporate objectives to each of the determinant areas is different than for the health care sector, since businesses have less control over what is necessary to improve health. Real and meaningful improvement will require active participation and resources from multiple sectors of society, including health care, public health, schools, businesses, foundations, and government at all levels.
We believe that meaningful improvement requires collective action by sectors not used to working together. Many sectors do not understand how activities in their sector are important to and impact the overall goal of improving health. In some communities, because of their prestige, political clout, and financial resources, businesses can be the super integrator (Kindig, 2010) across the stakeholders. Businesses must partner with others to achieve health improvement in communities and thereby reap the advantages for their workforces and overall well-being of business activity. Michael Porter observed that the “solution lies in the principle of shared value, which involves creating economic value in a way that also creates value for society by addressing its needs and challenges. Businesses must reconnect company success with social progress” (Porter and Kramer, 2011).
Steps to Action
What steps need to be taken to assist businesses to take a more active role in community health improvement? How do we get to that future from where we are today? What are the gaps and the barriers? We have identified seven activities that could advance understanding and action in this area.
- Set galvanizing goal targets. Most business leaders understand the concept of impact metrics and know how they can drive strategic investments.
- Extend a meaningful invitation from those currently engaged in improving population health to business regarding their views, needs, and involvement. There is no shared understanding of who “owns” the health improvement space in communities. In some sense, the community health improvement “sandbox” still seems largely controlled by health care and public health, with business sector participation limited due to fear of meddling, revenue loss, or disruption of an ecosystem configured to maximize success for a designated few.
- Engage in education efforts for CEOs and others in the C-Suite. One useful tool might be a population health primer from a business perspective or an action kit for business involvement. Such efforts would need to be built into existing channels of information for businesses, such as a Conference Board or Business Roundtable. To be successful, business-sector engagement must address issues beyond health care costs.
- Sponsor convenings with broader community partners. It is important to engage community partners but were much less certain about how to do so is not certain. One approach might be to create a chartered value exchange to foster multi-stakeholder dialogue and convene around health for employers, health providers, public health organizations, and consumers
- Develop and widely share case studies of businesses that are already making progress in community health improvement activity.
- Promote “Triple Aim” collaboration with business. The Triple Aim is a policy framework developed by the Institute for Healthcare Improvement. It advocates the simultaneous improvement of patient experiences of care (including quality and satisfaction), reduction in per capita health care costs, and improvement of population health. Although most Triple Aim sites define their populations by the service areas of health care delivery systems, several initiatives have adopted a regional approach and are defining their populations geographically (Kindig and Whittington, 2011). Business-sector partners could benefit greatly from recognizing the value of Triple Aim goals and engaging in collaborative efforts to achieve them.
- Identify permanent revenue streams for carrying out these activities. In addition to corporate contributions, businesses can partner with others in obtaining foundation or government grants for activities. In addition, many experts argue that as much as 25 percent of current health care spending is ineffective, improving neither outcomes nor quality. Capturing these dollars for reinvestment in more effective programs and policies within and outside of health care will not be easy, but nevertheless should be a high priority for both public- and private-sector leaders. Consideration should be given to setting aside a community share from savings anticipated under the implementation of accountable care organizations, which are designed to provide higher-quality care in a more efficient manner (Magnan et al., 2012). Also, as uncompensated care burdens are reduced under health reform, community benefit resources required by the Internal Revenue Service for nonprofit tax-exempt status could be redirected from charity care into broader health-promoting investments (Bakken and Kindig, 2012). This is a considerable sum; as of 2002, the most recent year examined, the national value of this tax exemption was $12.2 billion (U.S. Congressional Budget Office, 2012).
The authors believe that there is a solid argument to be made for a much stronger role for businesses in population health improvement. Such improvement can enhance corporate core objectives beyond those of social responsibility. It is hoped that the ideas presented here will contribute to a more robust discussion of this potential and lead to action at all levels, from individual communities to the nation as a whole.
- Baicker, K., D. Cutler, and Z. Song. 2010. Workplace wellness programs can generate savings. Health Affairs 29(2):304-311. https://doi.org/10.1377/hlthaff.2009.0626
- Bakken, E., and D. A. Kindig. 2012. Is community benefit charity care? Wisconsin Medical Journal 111(5):215-219. Available at: https://pubmed.ncbi.nlm.nih.gov/23189454/ (accessed May 22, 2020).
- U.S. Congressional Budget Office. 2006. Non-profit hospitals and the provision of community benefits. http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/76xx/doc7695/12-06-nonprofit.pdf (accessed September 5, 2012).
- County Health Rankings. 2012. County health rankings model. http://www.countyhealthrankings.org/resources/county-health-rankings-model (accessed July 2, 2013).
- Institute of Medicine and National Research Council. 2013. U.S. Health in International Perspective: Shorter Lives, Poorer Health . Washington, DC: The National Academies Press. https://doi.org/10.17226/13497
- Kindig, D. A. 2010. Do we need a population health super-integrator? Improving Population Health. Available at: http://www.improvingpopulationhealth.org/blog/2010/09/super_integrator.html (accessed May 22, 2020).
- Kindig, D. A., and J. Whittington. 2011. Triple Aim: Accelerating and sustaining collective regional action. Improving Population Health. Available at: http://www.improvingpopulationhealth.org/blog/2011/11/triple-aim-accelerating-and-sustaining-collective-regional-action.html (accessed May 22, 2020).
- Kindig, D., and E. Cheng. 2013. Even as mortality fell in most US counties, female mortality nevertheless rose in 42.8 percent of counties from 1992 to 2006. Health Affairs 32(3):451-458. https://doi.org/10.1377/hlthaff.2011.0892
- Magnan, S., E. Fisher, D. Kindig, G. Isham, D. Wood, M. Eustis, C. Backstrom, and S. Leitz. 2012. Achieving accountability for health and health care. Minnesota Medicine 97(11):37-39. Available at: https://pubmed.ncbi.nlm.nih.gov/23243752/ (accessed May 22, 2020).
- Porter, M., and M. Kramer. 2011. The big idea: Creating shared value. Harvard Business Review 89(1-2):1-17. Available at: https://hbr.org/2011/01/the-big-idea-creating-shared-value (accessed May 22, 2020).
- Posner, S. 2010. Mobilizing Action Toward Community Health (MATCH) special issue on partnerships. Preventing Chronic Disease 7(6). Available at: http://www.cdc.gov/pcd/issues/2010/nov/toc.htm (accessed May 22, 2020).
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Kindig, D. A., G. J. Isham, and K. Q. Siemering. 2013. The Business Role in Improving Health: Beyond Social Responsibility. NAM Perspectives. Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/201308b
The ideas for this paper emerged from discussion at a meeting that was supported by a MATCH grant from the Robert Wood Johnson Foundation (RWJF) to the University of Wisconsin Population Health Institute (UWPHI). The meeting was held January 9-10, 2012, at Health Partners in Bloomington, Minnesota, and was attended by Catherine Baase from Dow Chemical, Larry Becker from Xerox, Bridget Catlin from UWPHI, Abbey Cofsky from RWJF, George Isham from Health Partners, David Kindig from UWPHI, Joshua Riff from Target Corporation, Kirstin Siemering from UWPHI, and Andrew Webber from the National Business Coalitions for Health.
The views expressed in this discussion paper are those of the authors and not necessarily of the authors’ organizations or of the Institute of Medicine. The paper is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of the Institute of Medicine and is not a report of the Institute of Medicine or of the National Research Council.
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