Work-site health promotion programs and health care reform.

About a third of this country's $900 billion-plus medical care costs in 1993 were paid for by employers through employment-linked health insurance, workers' compensation, and other payment mechanisms. Not surprisingly, as medical care costs have increased dramatically in the past two decades, employers have taken steps to try to control their medical care expenditures. In an effort to reduce employees' need for medical care services, many employers have implemented worksite health promotion and disease prevention programs. ',, These programs have proliferated in recent years, and, according to the US Department of Health and Human Services' 1992 National Survey of Worksite Health Promotion Activities, most large employers now conduct work-site-based health promotion programs. Many small and medium-sized employers also sponsor various kinds of work-site wellness activities. The most common work-site health promotion activities are targeted at smoking cessation, stress management, health risk assessment, cardiovascular risk reduction, weight control, and exercise and fitness.l'-4 Other common activities include "backsaver" classes, hypertension detection and treatment, nutrition education, and off-thejob injury control. And now, an increasing number of programs are being developed with secondary prevention in mind, targeting such conditions as complicated pregnancies, diabetes mellitus, arthritis, and long-term pain. Numerous evaluation studies of these efforts have been conducted in the past several years, and compelling data now show that when these programs are properly planned and implemented, they both improve health outcomes and are cost beneficial.3`5 According to two review articles, 24 peer-reviewed studies published from 1980 to 1991 and 24 more published from 1991 to 1993341 indicated positive health outcomes relative to smoking cessation, weight loss, and the reduction of coronary heart disease risk factors, as well as improvement in nonmedical areas such as absenteeism and employee morale and retention. Of the 31 studies analyzed to date for cost effectiveness or cost benefit, only 1 failed to indicate a positive return on investment. Evaluations have ranged from six months to six years, with the studies of longest duration, largest number of participants, and randomized clinical trial designs all occurring after 1991. An increasing number of the recent and more rigorously designed studies support earlier studies in showing both health benefits and cost reductions. From an employer's perspective, some of the most important benefits of work-site health promotion programs are their potential to reduce absenteeism, increase productivity, improve recruitment and retention, heighten employee morale and company loyalty, and enhance public image. For most employers, however, the primary reason for implementing these programs has been to control medical care costs. Despite the other benefits, control of these costs has been management's principal concern. The control of medical care costs is also the primary motivation for and driving force behind health system reform. A logical question, then, is what effect will reform of the health system have on work-site wellness programs? All of the recently espoused national health care reform proposals said little or nothing about work-site health promotion. Any successful health care reform scenario-whether national or state-will affect these programs, however. Because most medium-sized and large employers buy experience-rated health insurance or insure themselves, they would benefit from any medical care cost savings that would accrue from work-site wellness activities-the cost-benefit of such efforts. Under many proposed health system reform scenarios, however, employers will have their medical care benefit payments determined by community rating and formulas for caps and subsidies that are unrelated to their actual experience. In such cases, will employers see diminished value in supporting work-site health promotion activities? Will the other demonstrated economic benefits such as reduced absenteeism and increased productivity be sufficient to justify the continued expense of such activities? Although the incentives for employers may diminish, the incentives to keep people well under managed care