When economically stressed communities lack the health-promoting amenities available in more affluent neighborhoods, such as access to fresh food and exercise facilities, residents are more likely to develop chronic health conditions. That's why more employers are working on community health initiatives with their local business associations and municipal governments.
While social conditions, or determinants, play an outsize role in employees' wellness and well-being, addressing these issues through a company benefits program can be tricky. How, after all, is an employer to deal with substandard housing, lack of affordable food, social isolation or unsafe streets?
Fortunately, social determinants are getting more attention.
The American Medical Association and UnitedHealthcare have collaborated on identifying social and environmental factors that lead to poor health—such as access to nutritious food and the ability to pay for medications and utilities—and created medical insurance codes so doctors can identify these conditions when treating patients. UnitedHealthcare said that physicians would not be reimbursed for adding the new codes on a claim, but that the insurer would use the codes to provide patients with referrals to local social services. If accepted by the Centers for Medicare & Medicaid Services, the new codes would become effective Oct. 1, 2020.
"One in four families in this country are one paycheck away from being homeless," said Jeffrey Brenner, senior vice president for clinical redesign at UnitedHealthcare, speaking in April at the Business Health Agenda 2019 Conference in Washington, D.C. Employers may not think they have employees who are dealing with homelessness, he noted, but "almost every employer has an employee, somewhere in the organization, who is living in their car and then coming to work."
Other employees may be dealing with food insecurity.
He asked employers to "think about the roles you can play in supporting your employees" by helping them to get the services they need.
Local and regional business organizations also are helping employers to address social conditions that are detrimental to good health. Among those advocating for more action around these issues is Diane Hess, executive director of the Lancaster, Pa.-based Central Penn Business Group on Health, which serves a seven-county region in the state. In May, the group's annual health summit will focus on social determinants and how they affect employees' health.
A robust economy in the region and the need for companies to bring more people into the workforce has encouraged employers to address at least one social impediment to health and well-being: access to transportation so that people making lower incomes can find and accept jobs beyond their immediate neighborhoods, Hess said. Employed people are likely to be healthier than those who are unemployed.
"Finding workers is really very challenging," Hess noted, "so the [Lancaster] Chamber of Commerce, in conjunction with two area employers, has started a transportation service to get employees to work."
The program provides partially subsidized transportation to and from the participating employers from five locations in Lancaster. The service costs $104 per month, and the companies pay $64 of that.
In another outreach to mainly lower-income employees, the University of Alabama at Birmingham (UAB) wellness staff surveyed workers at the university's Avondale facility, who indicated that it was hard for them to get access to healthy food or places to exercise, and that they would benefit from onsite classes to help them get healthier.
In response, UAB and digital coaching vendor Pack Health partnered on Wellness 720, an onsite wellness program that includes monthly visits from wellness staff, modest incentives for participation and employee input. For instance, workers got to vote on which healthy snacks should be included in the vending area.
The project concentrated on weight and blood pressure control. At the end of the six-month program, almost 60 percent of participants saw positive changes in weight, and nearly 40 percent saw positive changes in blood pressure.
At a recent webinar sponsored by the National Alliance of Healthcare Purchaser Coalitions, UAB wellness director Anna Threadcraft said it was crucial to survey employees prior to launching a program. When the employees took ownership of their situation, she said, "was when we saw success."
Beyond Company Walls
Often, addressing social factors linked with poor health is beyond the scope of an HR benefits department. Those who are delving into these issues say socially conscious investment and public policies are needed instead.
The approach to health care "for hundreds of years was about treating the symptoms and the disease," said Elisa Mendel, vice president of strategic customer engagement at Kaiser Permanente. "In the last 20-plus years, it's been more about what causes those diseases—lifestyle choices and behavior change. And now this is going further upstream, which is to say your ZIP code is a better predictor of your health than your genetic code."
The Trust for America's Health, a nonpartisan health-policy think tank, recently released Promoting Health and Cost Control in States, a report outlining how public policy could be changed at the state level to improve the health of communities. Report author Adam Lustig said some of the policies outlined, such as expanding the earned income tax credit, were outside the purview of individual businesses or local business groups. Employers could, however, act on recommendations to offer paid sick or family leave.
As more businesses and groups such as Lancaster's chamber begin to address social determinants, Lustig said, crucial evidence is emerging that implementing policies such as sick leave is smart business and leads to improvements in employee health.
"If your average employee tenure is only two years, then you might think it's not worth making those long-term investments," Lustig said. "But many arguments that have been used in the past [against spending on these benefits] do not speak to the evidence," he noted.
For example, Lustig said, a cost-benefit analysis of a paid-sick-leave ordinance in Austin, Texas, produced by the nonprofit Institute for Women's Policy Research, found businesses would save $4.5 million a year from reduced turnover and $3.7 million annually from reduced illnesses, reduced disease transmission and low-productivity "presenteeism."
[SHRM members-only how-to guide: How to Establish and Design a Wellness Program]
Partnering with Government
Kaiser Permanente sponsors several programs to improve health in poorer communities, said Loel Solomon, the company's vice president for community health. These initiatives include Cultivate, which uses the firm's resources to aid community health improvement projects such as improving access to preventive health care and substance abuse treatment and recovery programs, and CityHealth, which helps municipal leaders adopt policies for improving community health.
"There are ample political thickets you can get into," Solomon said. Kaiser helps local authorities to identify areas for government investment where there is bipartisan support and examples of these policies making a difference. "We are pursuing those kinds of approaches everywhere we are," he said.
Mendel said more employers are recognizing the validity of the concept of social determinants.
"We started pulling data by ZIP code to show people's health status," she said. "Lo and behold, where you live is the best predictor of this. Employers see that data and are more willing to be engaged."
Greg Goth is a freelance health and technology writer based in Oakville, Conn.