• Public Affairs

  • ACOEM Urges Implementation of Affordable Care Act Wellness Provisions

    Phyllis C. Borzi
    Assistant Secretary of Labor
    Employee Benefits Security Administration
    U.S. Department of Labor
    Washington, DC 20210

    George Bostick
    Benefits Tax Counsel
    U.S. Treasury Department
    Washington, DC 20220


    Jacqueline A. Berrien
    Equal Employment Opportunity Commission
    Washington, DC 20507


    Dear Ladies and Gentleman:

    We are writing on behalf of the American College of Occupational and Environmental Medicine (ACOEM) to share our perspective and recommendations on issues affecting workplace wellness programs. Congress made clear when it enacted the Patient Protection and Affordable Care Act that workplace wellness programs can contribute to a healthier nation. We firmly agree, and with this letter would like to offer specific recommendations that can help such programs become an integral part of our national health reform efforts.

    The profession of occupational and environmental medicine (OEM) is positioned at the crossroads of the employer-employee-health system, making it a logical advocate for health system reform through workplace initiatives. Among all medical specialties, OEM physicians have unique training, expertise and perspective to understand the link between health and productivity as well as how to help injured, ill and aging workers remain productive and at work. In addition, the OEM community has a high concentration of physicians trained in preventive medicine, epidemiology and public health. Their focus on population-based health issues as well as individual health is critically important to health system reform. Thus, OEM physicians have a distinct and logical role to play in advocating for prevention-oriented programs that protect and assure the health of employed and productive citizens.

    As the medical society devoted to promoting the health of workers, we believe strongly in the efficacy of evidence-based wellness and prevention programs in the workplace. The evidence clearly demonstrates that these programs can be effective for improving health and productivity if well designed and implemented.

    Why an Emphasis on Workplace Health is Critical to Health Reform  

    There is increasing recognition in the United States that the physical and mental health of the workforce is inextricably linked to the economic health of the workplace. Improved employee health equals improved employee performance, engagement and productivity. Unfortunately, the American workforce is not as healthy, nor as productive, as it could or should be. The
    overall health of Americans is on the decline, with studies showing a dramatic rise in recent years of health risks like obesity and chronic diseases like diabetes, across all age groups.

    At the same time, the aging of the baby boomers – the so called “silver tsunami” – is changing the profile of the workplace and putting new pressure on America’s health care system. In the face of these trends, the United States must find a way to bolster and improve the health and productivity of our national workforce.

    Workplace wellness programs are emerging as a key building block in this new paradigm, helping promote a true culture of health in the workplace. These programs are based on prevention and integrated health management and are aimed at decreasing the burden of illness overall by focusing health management strategies “upstream” from the onset of chronic disease. Rather than simply treating disease, wellness programs seek to keep healthy people healthy and bring people at high risk back from the brink of illness by managing health risk factors and promoting proactive health maintenance strategies.

    With this letter, we would like to offer our perspectives on three subjects of importance to the continued growth and success of the trend towards workplace wellness programs: incentives for participation, program integration, and the use of risk-assessment tools.

    Incentives for Participation

    Workplace wellness programs do not have to be based on outcomes to succeed. In fact, they are more likely to be successful if they encourage employee participation and engagement, providing appropriate incentives that lead to support and buy-in by employee populations. We believe that employers should be able to provide financial incentives to those who choose to participate, with assurance that such incentives will not be considered a violation of the American with Disabilities Act.

    It is not enough to simply incentivize employees, however. If employers create programs to help employees improve their health through behavior and lifestyle changes, the company must also provide resources – ranging from programming to

    facilities – in order to help employees achieve their goals. Demonstrable support from employers helps to create the true culture of health that is needed for workplace wellness programs to take hold and thrive. It is very important that programs be structured in a way that recognizes individuals have different preferences, learning styles and access to technology.

    Integrating Wellness into Workplace Organizational Structure

    While incentives are an important component of wellness programs, they must be integrated into overall wellness strategies by employers. Wellness should be integrated deeply into the organizational structure of the workplace. We recommend the following steps for employers: 

    Incorporate evidence-based preventive medicine services and health education that relies on existing valid sources focusing on skill development that is consistent with employees’ readiness to make behavior changes. 

    • Integrate wellness initiatives with other existing health related programs, such as Employee Assistance Programs.
    • Worksite screening should be voluntary and linked with medical care for follow-up on modifiable risk factors. 
    • Employers should continue to evaluate the effectiveness of their programming to tailor both programming and policies for maximum impact. 
    • Wellness programs should address the needs of all employees at a given workplace, regardless of gender, age, ethnicity, socioeconomic status, culture, job type or physical or intellectual capacity. 
    • Wellness programs should be designed to be culturally sensitive and all-inconclusive and employers should also consider targeted, complementary interventions for their more vulnerable employees specifically designed to engage those who are economically challenged, less educated, or underserved. 
    • Wellness programs should help working families balance work and family commitments and incorporate policies around child care, elder/dependent care, telecommuting, and flexible work schedules. 
    • Wellness programs should encompass multi-modal communication and intervention strategies recognizing individuals have different preferences, learning styles and access to technology.

    To help strengthen the efficacy of such programs, we recommend that health plans and vendors offering workplace wellness programs be accredited by nationally recognized entities using an evidence-based set of requirements to distinguish quality services.

    Use of Health Risk Appraisals (HRAs)

    Employers should provide health risk appraisals on a voluntary basis. Voluntary wellness programs, including financial incentives for completing a health risk assessment (HRA), can provide significant benefits to the individual. The HRA is a key entry point into employee health and wellness programs. The HRA is a widely used, evidence-based tool to identify individuals with and at risk of chronic conditions and to ensure they receive appropriate and beneficial wellness, prevention and disease management services.

    Many employees need some encouragement to complete a long, detailed HRA and to start participating in a program of healthy living. As noted earlier, financial incentives are important and can provide a key motivational trigger. Eliminating the employer’s ability to provide a financial incentive to individuals who complete an HRA or participate in a wellness program would effectively end these programs and the positive results they have produced for workers. We believe that incentives should be used to encourage participation in these programs and should not be tied to health status, biometric results or meeting outcomes from health improvement programs. We agree that HRAs should be able to include questions on family
    history, provided that those questions are clearly identified as being voluntary and provided that the financial incentive for completing the HRA is not conditioned on answering questions on family history.

    We strongly believe that family medical history provided voluntarily should be allowed to guide employees into disease management programs. Workforce wellness programs improve employees’ health outcomes in part because of their ability to identify individuals who would benefit from participation. The family medical history that an employee voluntarily provides plays an important part in the success of these programs. We are concerned, however, that conflicts between the implementing regulations for Title I and II of the Genetic Information Nondiscrimination Act are creating confusion for employers and employees alike. We urge that these conflicts be resolved to ensure that a family medical history, when provided voluntarily, can be used as one basis to identify participants eligible for wellness, prevention and disease management programs.

    Moving the Workplace to a True Culture of Health

    Workplace wellness programs will be effective if well designed and implemented. These programs can reduce the burden of illness and the burden of health risks by closing quality gaps in the management of medical conditions as well as investing in prevention and improving health. They have been proven to work in numerous settings – from large corporations to smaller not-for-profits – when integrated into the organizational structure of the workplace. Creating a true “culture of health” is the optimal outcome for employers who implement worksite wellness programs.

    To get there, we need prioritized investment in evidence-based primary, secondary and tertiary prevention strategies. Preventive strategies that focus either on the individual or the individual’s environment can cost-effectively reduce adverse health conditions, preserve function, or enable employment. Health promotion, health education, safety engineering, hazard recognition, ergonomics and organizational design, nutritional support, prenatal care, immunizations are all examples of primary prevention strategies because they help people stay healthy and productive. Screening and early detection programs, health coaching, biometric testing and pro-active work disability prevention programs are secondary prevention strategies because they can identify and address problems at an early stage when prompt action can be curative or prevent progression. Disease management, evidence-based quality care management, return to work programs and vocational rehabilitation are tertiary prevention strategies because they can limit the destructive and disruptive impact of serious medical conditions on function in daily life and work, can protect or restore productive lifestyles, and can reduce future costs. All these strategies have important roles in comprehensive workplace wellness programs to preserve the function and employability of individuals.

    ACOEM stands ready to work with you as you and your colleagues move forward to implement the wellness provisions in the Affordable Care Act. If you should have any questions or need additional information, please contact Patrick O’Connor, ACOEM’s Director of Government Affairs at 202/223-6222.


    T. Warner Hudson, MD

    Pamela Hymel, MD
    Section on Health and Productivity

    Ronald R, Loeppke, MD
    Section on Health and Productivity