7: No. 6, November 2010
Andrew Webber, Suzanne Mercure
Suggested citation for this article: Webber A, Mercure S. Improving population health: the business community imperative. Prev Chronic Dis 2010;7(6):A121.
http://www.cdc.gov/pcd/issues/2010/nov/10_0086.htm. Accessed [date].
Information on the economic effect of poor population health is needed to
engage the business community in population health improvement. In a
competitive global market, the United States has high health care costs and
poor outcomes (measured by such factors as healthy and productive lives)
compared with other countries. US business needs to understand population
health and not focus just on the health of employees at the worksite. We
describe a long-term approach to population health, including incentives,
and identify what is needed to engage business leadership in population
Back to top
The Competitive Challenge
Today, we are spending over $2 trillion a year on health care — almost 50%
more per person than the next most costly nation. And yet, as I think many of
you are aware, for all of this spending, more of our citizens are uninsured, the
quality of our care is often lower, and we aren’t any healthier. In fact,
citizens in some countries that spend substantially less than we do are actually
living longer than we do.
President Barack Obama, Speech to the American Medical Association, June 15, 2009
The US business community competes in a dynamic global economy. The United States has historically achieved success in the global marketplace by excelling at traditional measures of business performance: innovation, technology application, production engineering, capital deployment, marketing, sales, distribution, and customer service. Increasingly, however, 2 related factors put the US business community at a competitive disadvantage: disease burden such as obesity (1) and increases in
costs such as health insurance premiums for employers (2).
Business leaders not yet schooled in all the determinants of health (3) and a US health care system biased toward the treatment of illness often say, “With the growing and added investments I am making in health care for my workers and their dependents, surely my company is producing a healthier and more productive workforce.” Sadly, this is not the case. As President Obama stated, the United States spends twice as much per citizen on health care as any other country on earth yet ranks in the lowest
tier of advanced countries in health outcomes. In other words, the United States produces more health care for less health (4).
A Commonwealth Fund study illustrates more precisely the competitive disadvantage the United States is facing (5). The study demonstrates that the United States, in comparison with other industrialized countries, ranks lowest in metrics of health care that include quality, access, efficiency, and equity indicators; lowest in metrics of long, healthy, and productive lives;
and highest in per capita costs. Other data from the Dartmouth Atlas (6)
show not only wide variation in health care services but that populations in
regions with higher spending levels and more physician visits and
hospitalizations do not experience better outcomes or quality
of care. Seen through this lens, how well the US business community responds to the related challenges of improving health and transforming health care becomes a key driver of market success
and of America’s future competitiveness and economic security.
This commentary focuses on the role of employers in improving population health. Four
issues are addressed: 1) population health from the perspective of employers, 2) incentives for employers to improve
population health, 3) opportunities for employers to improve population health,
and 4) employers as change agents for improving population health.
Back to top
Population Health From the Perspective of Employers
Currently used constructs and measures of population health illustrate the multidimensional nature of the determinants
of population health outcomes. Many of the determinants of health (7,8) are affected, both positively and negatively, by
employers, who contribute substantially to population health by generating industrial production, creating jobs and family income, setting employment policies, and
influencing health behaviors through worksite cultures, safety practices, and purchasing health care.
Despite their broad influence on population health outcomes, employers’ views of population health are narrowly framed by their self-interests. Simply stated, the
population that employers care about is their human capital — active employees — followed by employee dependents, and, for the few remaining employers providing generous benefits, their retirees.
Not as central to employers’ definition and understanding of population health is community health or the health of the population where employees and their dependents reside. However, business leaders have incentives and compelling reasons to commit to building cultures of health in the worksite and the community.
Employers that wish to maximize their influence on human capital as a competitive asset
must develop strategies for workforce and community health.
Back to top
Incentives for Employers to Improve Population
Incentives and rewards are the lifeblood of competitive industries and central to the thinking and culture of business leaders. Moral responsibility and doing the right thing are not dominant factors in corporate decision making. Investment decisions are
made by building a business case that an investment today will lead to an economic benefit and
a competitive edge tomorrow. The challenge is to broaden the scope of self-interest in building the business case.
Sophisticated employers understand the link between maintenance of workforce health, enhanced productivity, and corporate performance. Building a worksite culture of health with executive leadership, making a sustained commitment to developing human capital, and investing in a spectrum of evidence-based worksite health and health care management programs can increase productivity, reduce employer direct (eg, medical claims) and indirect
(eg, absenteeism) costs, and improve bottom-line
performance (9). A growing number of business leaders now believe that, in a global economy, workforce health is an important competitive asset that affects employer operating costs and shareholder earnings. For leaders in the nonprofit sector, improving workforce health and productivity is a key driver in advancing any organization’s mission.
Incentives to invest in community health are less direct and salient to business leaders than incentives to invest in workforce health. Nevertheless, a compelling business case can and should be made for business leaders to look beyond the worksite to the communities where their organizations do business and their employees reside. 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.
Influences on community health and, by extension, workforce health and productivity, include unsafe communities; the presence of a cheap and convenient but a nutritionally
unsound food supply; the absence of health education in school curricula and
adequate physical education programs; land use and neighborhood design that discourage physical activity and create dependency on car transportation; a health care system with a weak prevention and primary care infrastructure
that is oriented toward treatment of acute illness; and poor air and water quality.
Using this broader perspective, the business community’s view of population health can radically shift, and strong incentives emerge for employers to invest in community health intervention strategies. What also emerges is an
understanding that individual employers do not have the needed leverage on their own to influence community health and health care. Instead, employers must work together collectively and with other community stakeholders on population health strategies
that can make a difference. Such an understanding has led during the past several decades to the establishment of business and health coalitions dedicated to improving health and transforming health care, community by community.
The incentives and the business case for employers investing in building healthy communities include the following:
- Improve the health status, and therefore the productivity, of an
employer’s current and future workforce.
- Control direct (health care) and indirect (absenteeism, disability, presenteeism) costs to the employer.
- Create both the image and the reality of a healthy community that may help recruitment and retention of workforce talent in tight labor markets.
- Increase the buying power and consumption level for business products, in
particular nonmedical goods and services, by improving the health and wealth
of a community.
- Strengthen an employer’s brand and recognition in the community.
- Generate, for individual business leaders, positive feelings of civic
pride and responsibility and of being a constructive member of the community.
- Channel corporate philanthropy in a direction that will improve community
relations, goodwill, or branding with the potential for a positive return for the
business enterprise itself.
- Help create public and private partnerships and a multistakeholder community leadership team that can become the foundation for collaboration, cooperation, and community-based problem solving
for many other issues affecting the business community, such as economic development and education.
Back to top
Opportunities for Employers to Improve
|Box. National Business Coalition on Health, Sample of Member Coalitions With Initiatives to Improve Community Population Health
||Coalition-Led Initiative for Community Population Health
|Buyers Health Care Action Group
|Collaborative initiative with public and private employers to measure and improve health with Healthiest Twin Cities including diagnosis and treatment for chronic conditions and healthier lifestyles
|Employers Health Coalition Arkansas
Fort Smith, Arkansas
|Cooperative effort with public health for fluoridation of water to promote oral health
|Heartland Healthcare Coalition
|Community public campaign to address inappropriate
use of antibiotics with employer action component and outreach to primary care
|Louisiana Business Group on Health
Baton Rouge, Louisiana
|Medical home initiative including Medicare and Medicaid to address integrated health care with patient engagement and prevention with emphasis on primary care
|Memphis Business Group on Health
|Founding member of Healthy Memphis Common Table, which includes consumers, providers, government, and other stakeholders, to address treatment and prevention of obesity and other chronic conditions for a healthier community
|Mid-America Coalition on Health Care
Kansas City, Missouri
|Three-part program to address depression with public education, practitioner engagement for diagnosis and treatment, and worksite initiatives; now leading a Healthier Heartland initiative with multiple stakeholders
|Savannah Business Group on Health
|Leader in an initiative with city and other stakeholders targeting nutrition, exercise, and obesity with a special focus on schools
Whereas current employer efforts focus on building worksite health promotion initiatives, community-based health improvement strategies are emerging that enjoy the active participation from and leadership of the business community. Many of these initiatives have emerged from employer-based health coalitions that surfaced during the past 3 decades principally to address rising health care costs through
value-based purchasing (10). Coalitions have learned that community-based
organizations collectively representing employers (and their aggregate purchasing power) can provide
more leverage on the local health care delivery system than any single company.
Now coalitions are applying that same philosophy to influence strategies for broader community health improvement.
Distinct opportunity areas for improving community health quickly surface when employer-led coalitions and members of the National Business Coalition on Health (NBCH) work in partnership with public health officials and other community stakeholders (Box). Many of these partnerships focus on the more clinical aspects of health (eg, cardiovascular health, diabetes, asthma, and depression) but are quickly moving to a more
upstream approach focused on primary prevention and better
support for healthy lifestyles.
A cross-cutting example is from the Florida Health Care Coalition (FHCC)
(11). FHCC, a member of NBCH,
partnered with the American Lung Association of Central Florida to bring to the
local schools Open Airways for Schools, a school-based asthma risk assessment
and health education program for children with asthma in grades 3 through 5
(ages 8-11). FHCC worked with 2 school district members to secure funding for
Open Airways instructors to visit the schools and provide asthma education for
school officials as well as children. This type of population outreach to dependents of
employees — and the broader school community — benefits employers by reducing children’s emergency
department visits and the associated work time lost by parents. Business-led health coalitions demonstrate creativity and distinctive approaches to improving the health of the population.
Back to top
Employers as Change Agents for Improving Population Health
Examples of population health improvement — from workforce to community health improvement — demonstrate that models exist. But what is needed to expand this work, particularly at the community level, and with employers in a leading role?
We recommend four distinct needs here: 1) evidence-based interventions, 2) performance incentives, 3) metrics, and 4) business leadership.
As business leaders know, success often depends on a good business plan and disciplined execution. As employers become more convinced that they should invest in improving workforce and community health, they will then want to identify the evidence-based intervention strategies that work. Building the evidence base and the lessons learned from a long history of population health strategies and organizing such information so it is easily accessible to community leaders is a priority (12,13).
In workforce health improvement initiatives, employers are aggressively implementing incentives to motivate and help move employees and their dependents toward better health. Provider pay-for-performance strategies have become a central and universally recognized element of health care reform legislation and corresponding value-based purchasing initiatives in the private sector.
Performance incentives are needed as a catalyst and motivator for community health
improvement. With rare exceptions, not enough attention has been paid to strategies and mechanisms that could reward population health improvement (7). Innovative performance incentives should be rapidly explored and tested. Approaches might include making performance-based payments to integrated
accountable care organizations that can manage population risk or tying the allocation of federal and state public health dollars to communities
improving population health status.
Meaningful metrics are an essential ingredient of employer engagement in population health. The field of worksite health has increasingly generated a set of metrics that tie improved workforce health status and reduced illness burden to quantifiable business performance. Similar metrics
for community health indicators relevant to business are more elusive.
Typical population health measures relate to length of life, self-reported health status, access to care, disease prevalence, individual health behaviors, socioeconomic factors, and the physical environment. Are these considered meaningful metrics to a business leader? And what is the benefit to business of an improved population health score?
Any metric embraced by the employer community needs to speak the language of business. In particular, understanding the
revenue benefits of a healthier community is essential, whether the effect comes from reductions in direct health expenditures, improvements in workforce productivity, or customer buying behaviors.
Business leaders go to work each day with this question in mind: “How can I make my company’s products and services more competitive in a global economy?” Business leaders do not often think about their company’s role as a primary contributor and change agent for improving health and health care. Yet, as key stakeholders with a substantial influence on health and health care, they must
— or risk continuation of the status quo. Deteriorating workforce and community health and an
expensive and broken health care system affect the bottom line and warrant the immediate attention of business leaders (13). The business community, in its role as employer, health care purchaser, and respected community leader, is in a unique and powerful position to be a change agent. Who else has both the motivation and status in the community to play this key leadership role?
Back to top
Poor health and rising health care costs in America are problems in search of employer leadership and solutions. Although many businesses still treat health as an operating cost to be managed, an increasing number of employers — large and small — have begun investing in human capital and building cultures of health at the worksite. There has been less employer attention, leadership, and investment in improving the health of communities and understanding the influence and
impact of population health status on business performance. Nevertheless, the work of business and health coalitions indicates that strategies for community health improvement are building momentum
and that employers play a lead role. These efforts would be buttressed by more inspired leadership from individual corporate leaders, a stronger evidence base for community health intervention strategies, the establishment of performance incentives for population health, and metrics that
speak the language of business.
Back to top
This work was funded by the Robert Wood Johnson Foundation as part of the Mobilizing Action Toward Community Health (MATCH) project.
Back to top
Corresponding Author: Suzanne Mercure, National Business Coalition on Health,
1015 18th St NW, Ste 730, Washington, DC 20036. Telephone: 703-845-7712. E-mail:
Author Affiliations: Andrew Webber, President and Chief Executive
Officer, National Business Coalition on Health, Washington, DC.
Back to top
- Obesity trends among US adults — BRFSS 1990, 1998, 2007. Centers for
Disease Control and Prevention.
http://www.cdc.gov/obesity/data/trends.html#state. Accessed August 16, 2010.
- Claxton G, Gabel J, DiJulio B, Pickreign J, Whitmore H, Finder B, et al.
benefits in 2007: premium increases fall to an eight-year low, while offer rates and
enrollment remain stable. Health Aff (Millwood) 2007;26(5):1407-16.
- World Health Organization. The determinants of health.
Accessed July 23, 2010.
- Murray CJ, Frenk J.
Ranking 37th —
measuring the performance of the U.S. health care system. N Engl J Med
- Davis K, Schoen C, Schoenbaum SC, Doty MM, Holmgren AL, Kriss JL, et al. Mirror, mirror on the wall: an international update on the comparative performance of American health care. The Commonwealth Fund; 2007.
Accessed July 23, 2010.
- Fisher E, Goodman D. The Dartmouth atlas of health care. http://www.dartmouthatlas.org/keyissues.
Accessed July 23, 2010.
- Kindig DA. Purchasing population health: paying for results. Ann Arbor
(MI): University of Michigan
- Webber A. The next employer challenge: addressing all the determinants of health at a community level. In: America’s
health rankings: a call to action for individuals and their communities; 2009
edition. United Health Foundation, American Public Health Association, Partnership for Prevention.
http://www.americashealthrankings.org/. Accessed July 23, 2010.
- Goetzel RZ, Ozminkowski RJ.
What’s holding you back: why should (or shouldn’t) employers invest in health promotion programs for their workers? N C Med J 2006;67(6):428-30.
- Woolf SH, Huston CG, Lewin LS, Marks JS, Fielding JE, Sanchez EJ. The
economic argument for disease prevention: distinguishing between value and
savings. Partnership for Prevention; 2009. http://www.prevent.org/data/files/initiatives/economicargumentfordiseaseprevention.pdf.
Accessed July 23, 2010.
- Open airways for schools. Florida Health Care Coalition. http://www.flhcc.com/openair.cfm.
Accessed July 23, 2010.
- Loeppke R, Taitel M, Haufle V, Parry T, Kessler RC, Jinnett K.
Health and productivity as a business strategy: a multiple employer study. J Occup Environ Med 2009;51(4):411-28.
- Pelletier KR.
A review and analysis of the clinical- and cost-effectiveness studies of comprehensive health promotion and disease management programs at the worksite: 1998-2000 update. Am J Health Promot 2001;16(2):107-16.
Back to top
Comment on this
article at PCD Dialogue
Learn more about PCD's