Recently, we were invited to participate in a symposium sponsored by the Massachusetts Institute of Technology's Sloan School of Management and funded by Pfizer Pharmaceutical Company. Entitled the "Competitive Advantage of a Healthy Work Force," the conference, held November 4th and 5th, 1996, in Naples, Florida, attracted a considerably diverse group of professionals representing business, government, and academia. In this period of change affecting all types of medical practice, as well as occupational medicine, we were struck by the virtually unanimous consensus among the over 100 attendees on the strategic value of healthy employees. The meeting included representatives of the European Community, the Joint Commission on the Accreditation of Health Care Organizations, the World Health Organization, managed care companies, and a variety of benefit groups, among others. Most notable in attendance were two chief executive officers of $6 billion companies, Pfizer and Ryder. The message was clear: Good health is good business. Improving the health status of the populations we serve promises to be the greatest occupational medicine opportunity ahead.
This conference was noteworthy because it went beyond theory and included the results of new, specific research. We were impressed by recent epidemiological studies that point to three specific areas which are likely to be of importance in occupational medical practice; First, the extent of unrecognized mental illness, in particular, depression, and its effect on work performance.1 The range of disability associated with the illness and corresponding costs was highlighted.2 An epidemiologist, clinical psychologist, and economist presented data from separate settings with consistent results: mental illness is unrecognized, undertreated, and inadequately addressed in working populations.
The second major feature that emerged was the impact of medications, in particular, their side effects on work performance. Examples of antihistamine-induced drowsiness, and other medications with potentially troubling effects on cognition and alertness were described by many speakers. As a result of managed care inroads into health care delivery, an employer may be enticed to save direct health care costs by a highly restrictive medication formulary; however, indirect costs that may affect employee productivity may be adversely affected. For example, in a strict managed care environment, a less expensive antidepressant or antibiotic may be the first choice; however, when one considers the potential side effects of the treatment or that a antidepressant may take many weeks to have a beneficial effect, the practicality of such a choice may be dubious. Drug formularies that base decisions simply on direct costs and not associated indirect costs, such as periodic blood testing and side effects, are another example of areas in which managed care policies appear in need of improvement.
The final message of note was the critical need to consider total costs in managed care decisions on treatment. For example, intensive early treatment, with frequent evaluations and physical therapy for back pain, was described as resulting in higher direct medical costs but lower overall costs, because of a more timely return to work and a corresponding decrease in the indemnity component of the workers' compensation bill, which customarily makes up two thirds of the costs.
From our perspective as occupational physicians, we found it valuable to gain a better understanding of how benefits directors, mental health professionals, and the academic research community approach a common challenge: evaluating the effect of health on work performance. The conference also caused us to consider the importance of addressing the impact of illnesses not traditionally considered occupational in origin on work.
In considering the effect of health on work, one needs to recognize that productivity is an elusive concept to measure. From a medical perspective, a variety of factors may contribute to productivity, including absenteeism associated with short-term and long-term disability, and time taken away from the job to care for family members. The type of health care administered may also affect a person's productivity. For example, if a person undergoes arthroscopic knee surgery, absence from normal activities, including work, may be one to two weeks, in contrast to a more invasive open knee surgical procedure, which may lead to absences of up to four weeks or more. Another example to illustrate this point is laparoscopic gallbladder removal, which can result in lost time from work of only one to two weeks, in contrast to a six- to eight-week period of disability for the traditional cholecystectomy. Other factors that affect productivity include the type of medication that a person takes for a chronic illness, such as the use of sedating antihistamines, which may affect mental clarity. Treatment of migraine headaches and depression may also require the use of medication that leads to side effects which can affect a person's ability to perform optimally at work.
A recent study estimated that as many as 90 million Americans live with chronic medical ailments.3 In fact, in the working age group (those persons aged 18 to 64), upwards of 63 million Americans reported at least one chronic medical condition. In this analysis, days lost from work were determined through a review of the National Center of Health Statistics Report.4 In the survey, more than one third of the people aged 18 to 44 and two thirds of adults aged 45 to 64 identified at least one chronic medical condition. The investigators estimated that morbidity costs attributed to lost workdays from chronic disorders approached $73 billion. The study indicated that the vast proportion of people with chronic medical ailments are not disabled from work, but their illnesses place them at risk of higher out-of-pocket health care costs, more time lost from work, and serious limitations in the future, in comparison with people without chronic disorders.
Although corporations have used various direct and indirect measures of productivity, there appear to be few examples in which such information has been integrated with health and disability databases. Some corporations, such as First Chicago NBD, have integrated health data management databases that include medical claims (inpatient, outpatient), health risk appraisals, pharmaceutical, occupational and medical nursing records, laboratory results, personnel files, disability claims (including workers' compensation and short-term disability records), absenteeism, productivity, and wellness program participation, among others.5 Such data, even if computerized, may be in separate systems and not well integrated. Few corporations are known to have productivity databases that are integrated with measures of health and disability.
Deciding which diseases to target at the workplace for intervention should obviously be based on the best available information especially health risks and problems specific to the organization. For example, for many companies, repetitive strain injuries are common and lead to sufficient lost time as well as medical and workers' compensation costs and lost productivity. Ergonomic intervention in such situations can have a beneficial effect on both productivity and in the reduction in health care costs.
In the 1980s, employers began addressing rapidly escalating health care costs. In the 1990s, employers are addressing the quality and value of health care purchasing. In the twenty-first century, employers will need to address the relationships between employee health, disability, and productivity in health-benefit decisions. Linking employee health to productivity will create enormous opportunities for innovative companies as well as occupational health professionals.
As we discussed our impressions of the conference, we drew a number of conclusions that may be of value for the American College of Occupational and Environmental Medicine (ACOEM) as occupational medicine participates in these new directions. Educational sessions, with presentations from business leaders and academics as well as benefits professionals, will enhance our understanding of the complexities of this topic. Ideally physicians will gain the tools to be influential in the changing times ahead. Training programs directed to early recognition of mental ailments, especially depression, would also appear to be valuable. When physicians are conducting fitness-for-duty or back-to-work assessments, careful considerations of side effects of medication would likely add to the quality of occupational medical practice. Further recommendations include the establishment of data-collection systems to facilitate analysis of the prevalence and effect of certain illnesses on work. Clearly, these are only examples. As the connection between health and productivity is better understood, most conditions will present an opportunity.6 The specific disease opportunities will vary greatly depending on the population and the partners. An encouraging note from the meeting was that occupational medicine was at the table with influential leaders and has arrived at the cutting edge of new developments affecting the impact of health at work.
Should the Journal of Occupational and Environmental Medicine continue this initiative and promote a special issue that addresses the effect of health on productivity? We believe that such an approach is warranted and that it could be based on academic and professional presentations at the fall and spring ACOEM meetings. Need and opportunity exist. Occupational physicians can assume leadership in this important era of managed health care.
Robert J. McCunney, MD
Massachusetts Institute of Technology; Cambridge, MA
George Anstadt, MD
Eastman Kodak Company; Rochester, NY
Wayne N. Burton, MD
First National Bank of Chicago; Chicago IL
David Gregg, MD
HealthPartners; Minneapolis, MN