The Next Employer Challenge: Addressing All the Determinants of Health at a Community Level Andrew Webber President and CEO National Business Coalition on Health

The National Business Coalition on Health (NBCH) is a national, non-profit, membership organization of employer-based health care coalitions dedicated to improving health and transforming health care, community by community. NBCH member coalitions represent a national network of 7,000 employers providing health benefits to approximately 25 million employees and their dependents.

Two goals have been central to the work of employers in health and health care, particularly those participating in coalitions:

1. improving workforce health and productivity as a competitive asset;
2. maximizing the value of health care services that employers purchase.

The value equation for employers is about realizing a positive return on their significant investments in worksite health management programs and health care services. Not as central to many employers` current definition and understanding of value, is `community` health or the health of the population where employees and their dependents reside. There are incentives and compelling reasons why business community leaders should commit to both building cultures of health and using value principles within the well known and comfortable silo of the worksite and the less familiar and complex universe of the community at large. For an employer, wishing to maximize their influence on human capital as a competitive asset, workforce and community health strategies become important components of a comprehensive approach to addressing health and health care.

With the poor state of American health and health care, opportunities for employers to improve population health abound. Current employer-led strategies can be generally described as efforts to build cultures of health at the worksite that support employee/dependent behaviors and choices towards better health and health care. These are valuable efforts that can be complemented by a broader approach, especially with business and health coalition efforts to organize employers collectively and in partnership with other stakeholders to improve community health and health care.

Changing the focus to a community health perspective also suggests the need to address:

• Measurement of the factors that impact population health with metrics that will engage business leaders and other stakeholders.
• Accessible and understandable information for all stakeholders-including the public-to take appropriate and evidence based actions to impact health
• Transforming the current health system from an acute care orientation to one that emphasizes prevention, primary care, and chronic care disease management
• Reforming the community land use infrastructure and culture to support health
• Empowering and encouraging both individuals and the private and public sectors to make better and more informed decisions to positively impact health through multiple mechanisms including policies and personal behaviors
• Developing accountability for all stakeholders to address health in the broadest way in their actions

As suggested above, a community health perspective will also mean addressing all the determinants of health. In the America`s Health RankingsTM measures, both health outcomes and health determinants are included. These measures are generally better understood by employers as health outcomes since there has been much work by leading companies on both the direct and indirect costs associated with health for employees. The health determinants associated with personal behaviors are often addressed by increasing the number of employers who have health promotion and wellness programs. The areas under the community and environment would benefit by having a correlation to the employer sector or an overall way to demonstrate the `business case` for employers as shown in Table 1.

Direct health care costs include those expenses associated with both the provision on health benefits and the expenses associated with preventive care services, chronic care treatment and management, as well as other acute care expenses typically provided in the health benefits coverage provided by employers. These are shown in health care premiums paid by the employer, contributions by employees for these premiums, and out of pocket costs paid by employees. Indirect costs are those associated with the impact on employee productivity-absence from work, inattentive work behavior that might impact safety as well as work output, worker recruitment and replacement costs, and related costs. The business sector needs to understand how each of these metrics impacts their bottom line to fully engage their leadership and skills to promote and sustain a healthy America. Linking the metrics to each stakeholder is an important goal. The link of the health of the community to the healthy bottom line for the employer needs to be evident and this information needs to be part of corporate decision making at all levels.

NBCH promotes this evolution for the business sector with its member coalitions. Currently NBCH is engaged in a five-year cooperative agreement with the Centers for Disease Control and Prevention to help establish community health partnerships between member coalitions and local public health leadership that will lead to community health intervention strategies. The vision for NBCH is to move employers along a continuum to population health, community by community. The metrics for this are an integral part of the process and America`s Health RankingsTM can play an important role as a call to action and for measuring progress. Table 2 shows the needed progression for employers - both private and public sector - and business in general. Employers are currently at varying stages in this health and health care journey, but all efforts point towards a growing recognition that improving community health through strategies that impact all the determinants of health makes good business sense.

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Health & Productivity >

Value-based Healthcare Purchaser >

Value-Based Health for Employees >

Value-Based Health for Community