A Healthesystems publication

Spring/Summer 2020

Live Better, Heal Better: Employee Wellness in Workers’ Comp


Understanding employees’ overall health is a growing component of workers’ comp. Comorbidities, fatigue, mental health, and other personal health factors can not only impact the effective management of claims, but in some cases the likelihood of injury.

Workers’ comp continues to grow more complex as the scope of care expands to a greater, more holistic view of patient wellness. Health concerns outside of a claim can significantly impact a patient’s recovery from a workplace injury, and addressing these concerns has the potential to lead to greater claims outcomes and cost savings.

Among many insights pulled from a 2020 workers’ comp industry survey conducted by Healthesystems, claims professionals ranked comorbidities and poor worker health the number one program challenge facing the industry, and the third biggest challenge overall. Specific to health risks, comorbidities ranked second, while mental health ranked third.1

Program Challenge to Workers’ Comp1

These findings are consistent with industry research; PricewaterhouseCoopers claims 80% of a person’s health is attributable to health behaviors related to physical environment and socioeconomic conditions,2 and the Journal of Occupational and Environmental Medicine (JOEM) posits that mental health, physical health, job characteristics, and support from work organizations were the most significant determinants of an employee’s productivity.3

80% ipad-image

of a person’s health is attributable to health behaviors related to physical environment and socioeconomic conditions

– PricewaterhouseCoopers2

With a need to improve employee wellness and workplace environments, what key issues do payers and employers face, and what steps can they take to address these issues?


A comorbidity is the presence of an additional, often independent, medical condition co-occurring with a primary condition; in workers’ comp the primary condition would be the workplace injury. In workers’ comp, “comorbidity” frequently refers to a chronic health condition that may be lifelong.


  • list-icon


  • list-icon

    Hypertension and cardiovascular diseases

  • list-icon


  • list-icon

    Chronic obstructive pulmonary disease (COPD) and other breathing disorders

  • list-icon


  • list-icon


Comorbid conditions are impacted by lifestyle choices, including diet, exercise, smoking, drinking, and other substance use, as well as by genetics, socioeconomic factors, and more.


Despite increases to life expectancy, healthcare spending, and improved health outcomes, chronic comorbid conditions continue to rise in the U.S.2 For example:

  • 66% list-icon
    of the population is obese or overweight2

  • 1in3Americans have high blood pressure5

  • 30list-iconmillion +
    Americans are affected by diabetes4


Workers’ comp claims with a comorbid diagnosis have tripled in the last decade, and such claims typically are associated with twice the medical costs of other claims.6

3xlist-iconincreasein comorbid diagnoses in the increase last decade6

Oftentimes, workers’ comp claims must manage comorbidities in order to effectively help injured workers recover, essentially complexifying claims and increasing costs.


Diverse populations face diverse health risks. Certain age and ethnicity groups are more likely to experience particular chronic conditions:


  • 2x
    as likely as whites to visit the emergency department for asthma7



    More likely to have high blood pressure and/or diabetes9

  • 50%
    more likely to die from diabetes or liver disease8



    of people aged 50-64 have one or more chronic condition10


Both are at higher risk for obesity and physical inactivity8,9


When faced with comorbidities, patients may require medications to manage these conditions. However, when coupled with a workplace injury, there is the potential for various drug-drug and drug-disease interactions. Furthermore, the side effects of various comorbid and workplace injury medications may require treatment, and if not managed properly, could lead to polypharmacy, the problematic use of several concurrent medications.

HEART DISEASE NSAIDs, antidepressants list-iconThese drugs can increase blood pressure, increasing comorbid risks
MENTAL HEALTH DISORDERS Opioids list-iconOpioid interact negatively with antidepressants and benzodiazepines used for mental health
BREATHING DISORDERS Opioids, gabapentinoids list-iconThese drugs risks include respiratory depression, which can exacerbate pre-existing breathing difficulties
DIABETES Acetaminophen list-iconAcetaminophen can lead to liver and kidney dysfunction, a risk already present in patients with diabetes
GASTROINTESTINAL (GI) DISORDERS NSAIDs list-iconNSAIDs can cause GI bleeding risks, compounding pre-existing GI conditions


Wellness programs are comprehensive health initiatives designed to maintain or improve wellbeing by encouraging proper diet, exercise, stress management, and illness prevention. When effectively deployed, they have the potential to improve employees’ overall health, which could also decrease medical care costs down the line, and by extension, medical premiums.

Wellness programs often include wellness screenings to identify health risks and create intervention opportunities to promote healthier lifestyles. This can include the collection of biometric data and the use of health questionnaires.

Approximately half of U.S. employers offer wellness promotion initiatives, and the larger the employer, the more likely they are to have a comprehensive program.11 Wellness programs differ greatly, but often they include information resources, health management tools, campaigns, and other components to carry out health initiatives including:

  • list item icon

    The detection, prevention, and management of chronic illnesses

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    Smoking cessation, which can include counseling and nicotine replacement therapy

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    Promotion of exercise and appropriate dietary recommendations, both for general health and to lower obesity

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    General health education

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    Stress management


Because wellness programs can improve employee health to manage comorbidities, they can help injured workers down the line. But exactly how effective are wellness programs in accomplishing this?

According to a study of 33,000 employees, worksites with a wellness program had an 8.3% higher rate of employees who reportedly engaged in regular physical exercise, and a 13.6% higher rate of employees who reported actively managing their weight.12

Wellness programs are also linked to statistically significant and clinically meaningful reductions in smoking behavior.11 However, not all wellness programs are built the same, and some can be ineffective at improving wellness.

More research is needed to determine which types of wellness programs are most effective and for what health concerns, especially considering that only half of employers have formally evaluated program impacts.11 But a key component to best utilizing wellness programs is tailoring such programs to specific work organizations.


Employers need to take an active hand in forming wellness programs so they can best serve employees, and so they can best maximize employee participation. In one study, of the employees who had access to wellness programs, only 57.8% used them.13

Effective wellness programs approach wellness with a continuous quality improvement attitude and solicit feedback from employees to improve the program.11 Key facilitators of effective wellness programs include:11

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    Broad outreach and clear messaging from organizational leaders

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    Making wellness activities convenient and accessible for all employees

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    Making wellness an organizational priority among senior leaders

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    Leveraging existing resources and building relationships with health plans to expand offerings at little to no cost

Furthermore, research found that employers who use incentives for health screening activities reported significantly higher participation rates than employers that did not offer incentives. Employers that offered incentives saw 69% of their workforce complete health risk assessments (HRA) and 57% complete clinical screenings; employers that offered no incentives saw 29% completion for HRAs and 38% completion for clinical screenings.11


Fatigue can be described as a level of tiredness, sleepiness, and reduced energy that requires increased effort to perform tasks at a desired level. If not properly managed, fatigue can increase the likelihood of injury and long-term health effects.


  • 13% list-icon
    of workplace injuriesare attributable to fatigue14

  • 90%of employersreport being negatively impacted by fatigue16

  • 62%higher risk of injuryfor fatigued workers14

  • 47% list-iconof employers experienced decreased productivity due to fatigue16

icon-image Heart problems

and hypertension can arise from fatigue, increasing long-term risks for adverse cardiac events15

Poor eating habits,

illness, and lack of physical activity can be caused by fatigue17


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    Loss of sleep

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    Night shifts that are counteractive to circadian rhythm

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    Environmental conditions

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    Rotating work schedules that prevent significant rest

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    Excessive time spent on a single task

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    Constant strenuous work demands

Approximately 35% of workers cite lack of sleep as a top impediment to a healthy lifestyle,2 and depending on industry and work environments, this can be much higher.


While employers are greatly concerned with fatigue, only 20% of workers understand the risks of fatigue,18 potentially putting them at risk for workplace injuries and long-term health effects. This is made worse considering:18

  • 43%of workersdon’t get enough sleep

  • 27%of workershave unintentionally fallen asleep on the job

  • 14%of workersdon’t get sufficient time off between shifts

  • 10%of workersdo not get a rest break


While any job can be tiring, certain workers are more at risk than others. Approximately 15 million Americans work full time on evening, night, rotating, or other irregular shifts, and these work schedules can increase the odds of fatigue.17

The following workers see greater risks related to fatigue:

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    Night shift workers are 3x more likely to be injured19

    59% of night shift workers sleep two or more risk factors for fatigue21 less than 7 hours18

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    Over 50% of retail workers, particularly food and beverage workers, have nonstandard shifts or workweeks longer than 48 hours20

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    92% of construction workers and
    94% of transportation workers had 59% of night shift workers sleep two or more risk factors for fatigue21


Whether an employee has a pre-existing condition or is taking medications for a workplace injury, it is important to note that their drug regimen could be increasing fatigue. The following drugs can increase workplace fatigue:

image-icon CNS depressants
image-icon Anticonvulsants
image-icon Benzodiazepines
image-icon Muscle relaxants


Because the causes and work environments that lead to workplace fatigue vary, there is no single solution for addressing fatigue, but there are multiple strategies that can be employed.


Though most workplaces provide time and spaces for brief rests, the nature of work may require more accommodations to improve the quality of rest an employee can enjoy.

Calm, quiet environments can be helpful. One study found that allowing for 30-40 minute naps during night shifts decreased fatigue burden.16 While this may not be suitable for all workplaces, other research finds that letting workers rest from repetitive tasks by switching duties can help them maintain alertness, decreasing fatigue.21


By strategically scheduling shifts to allow employees 10 hours between shifts so they can get enough sleep, employers can reduce the likelihood of fatigue.20 Staying on a shift pattern for a few weeks before rotating can allow employees to grow used to different sleep schedules, and scheduling consecutive days off allows workers to better enjoy their time off.


Though this depends significantly on work environments, investing in certain equipment or other resources can ease employees’ work burdens. For example, anti-fatigue mats, shoe inserts, and sit and stand stations have been proven to reduce fatigue for retail workers.20 Utilizing similar occupation-specific countermeasures could help reduce fatigue.


It is important to have policies and practices in place to minimize, document, and address fatigue head on. The first step is to create awareness of the risks of fatigue in the workplace, especially as employees are less likely to think of fatigue as a safety issue when compared to employers.21

Simple five-minute safety dialogues between managers and employees can be effective in helping identify fatigue,21 and the resulting conversations can help establish causes and potential solutions for fatigue. Furthermore, documenting injuries, near misses, and other information surrounding fatigue can reveal larger patterns, which can also lead to potential solutions.


Like fatigue, excessive workplace stress may cause workers to develop mental health burdens that impact their wellbeing over time. According to the Centers for Disease Control and Prevention (CDC), poor mental health and stress can negatively impact employee:22

  • list-icon

    Job performance and productivity

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    Engagement with one’s work

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    Communication with coworkers

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    Physical capability and daily functioning

The CDC also claims even after taking other health risks into account – like smoking and obesity – employees at high risk of depression had the highest healthcare costs during a three-year period after an initial health risk assessment.22

Furthermore, mental health issues such as anxiety, depression, catastrophizing (assuming the worst of things) and fear avoidance can impact injured worker care.


A patient’s mental state can severely impact the effects of managed care, keeping them from effectively recovering and returning to work and other routines. Clinical research has found:

Psychosocial factors

can be more detrimental to claims outcomes than physiologic factors in patients following surgery for occupational hand injury23


was the foremost inhibitor of restored function in patients with minor injuries24

Fear avoidance

can lead to higher pain and disability levels and lower return-to-work rates25


Diverse populations face different mental health risks. Clinical research has found:


  • 2xas likely to be diagnosed with depression26


    Higher average stress levels than other generations27



    Likely to experience serious psychological distress than white populations28


While workers may be predisposed to develop mental illness or come into the workplace with pre-existing emotional problems, the workplace itself can be very stressful. Approximately 72% of people have daily workplace stress and anxiety that interferes with their lives moderately.29

While some stress is normal and even beneficial, in some cases workplace stress can contribute to declines in mental health. For example:30,31,29

  • 49 % of employers list-icon agree that the reporting of mental health issues increased in the last five years

  • 48 % list-icon
    of workers have cried at work due to stress

  • 28 % list-icon
    of employees have experienced an anxiety or panic attack on the job


While mental health in the workplace is a serious concern, there is considerable hope. An estimated 50% of workers are more likely to seek help for mental illness now than they were five years ago,31 and there are a wide assortment of clinical modalities to address mental health.

Some ways employers and insurers can promote mental wellness are as follows.


Employees may be worried about discrimination, labeling, or other prejudices when coming forward with mental health concerns. Roughly 59% of businesses believe the stigma of mental health issues prevents employees from seeking help,30 and so it is clear that proactively discussing mental health in a positive light can help employees.

Having conversations throughout a business organization and establishing confidential programs can encourage employees to address mental issues more readily, allowing employers to guide them to available resources. However, this only helps if employees are given the appropriate resources to utilize.


Only 41% of businesses have a strategy in place to address employee mental health issues,30 and while creating or improving such programs could be costly, if successful in improving mental health they could yield a significant return on investment.

Such programs could involve talks from managers and leaders to employees that encourage self-care. Currently, 53% of managers do not feel adequately trained to spot mental health issues, and 50% of companies don’t provide training to managers on how to identify mental health issues.30 Providing such training could help detect issues early, creating intervention opportunities.

Strategies for different businesses will vary but promoting mental health resources across all appropriate channels can benefit employee wellness.

In the face of intervention opportunities, it is paramount to offer benefit and wellness plans that help employees improve their mental health. Not only is it undeniable that counseling and appropriate drug therapy can help fight mental illness, but telemedicine therapy programs can also improve mental health.

And finally, 66% of organizations do not track or analyze the prevalence of mental health issues in their work environments.30 By documenting such incidents, trends could be deciphered, allowing for larger initiatives that may bolster mental wellness.


While mental health resources may be available in many wellness programs, oftentimes these resources need more promotion. Among employers offering mental health services:30

  • 55% only promoted services reactively or on a oneoff basis as issues arise
  • 43% promoted services proactively via company communications
  • 48% promoted services via company portals or intranet
  • 19% did not actively promote such services


In the event a worker is physically injured on the job, when their doctor clears them to return to work they may often have clear orders on physical limitations, such as not to lift heavy materials, stand for too long, etc. However, if a worker is returning to work due to mental health issues, such limitations may not be clear.

An estimated 68% of employers do not have specific return-to-work strategies for employees on leave due to mental health issues.30 Reintroducing employees to certain mental stressors could cause them to, for lack of a better word, mentally reinjure themselves.


When an employee is returning to work following an injury that involves mental health, it is important to engage the injured worker in various ways. This can include:

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    Workplace reintegration support, which involves sitting with employees to establish arrangements that best suit them

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    Guiding employees to wellness program resources that can benefit them

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    Alternative or reduced duties, or job description revisions

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    Alternative work schedules, including work from home, flex time, and exceptions to time-off policies

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    Understanding how drug regimens interplay with duties, in order to best support adherence to therapy and avoid situations that can conflict with treatment



1 -Healthesystems analysis.
2 -Action required: the urgency of addressing social determinants of health. PricewaterhouseCoopers. 2019. https://www.pwc.com/gx/en/healthcare/pdf/pwc-social-determinants-of-health.pdf
3 -Stephanek M, Jahanshani K, Millard F. Individual, workplace, and combined effects modeling of employee productivity loss. Journal of Occupational and Environmental Medicine. June 2019. doi: 10.1097/JOM.0000000000001573
4 -National diabetes statistics report 2020: estimates of diabetes and its burden in the United States. Centers for Disease Control and Prevention. 2019. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf
5 -More than 100 million Americans have high blood pressure, AHA says. American Heart Association. Jan 31, 2018. https://www.heart.org/en/news/2018/05/01/more-than-100-million-americans-havehigh-blood-pressure-aha-says
6 -Laws C, Colon D. Comorbidities in Workers’ Compensation. NCCI. Oct 2012. https://www.ncci.com/Articles/Pages/II_research-brief-comorbidities-inworkers-compensation-2012.pdf
7 -Asthma and Hispanic Americans. U.S. Department of Health and Human Services Office of Minority Health. March 13, 2017. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=60
8 -Hispanic Health – CDC Vital Signs. Centers for Disease Control and Prevention. May 2015. https://www.cdc.gov/vitalsigns/hispanic-health
9 -African American health – creating equal opportunities for health. Centers for Disease Control and Prevention. July 3, 2017. https://www.cdc.gov/media/dpk/healthy-living/african-americanhealth
10 -Percent of U.S. adults 55 and over with chronic conditions. Centers for Disease Control and Prevention National Center for Health Statistics. Nov 6, 2015. https://www.cdc.gov/nchs/health_policy/adult_chronic_conditions.htm
11 -Mattke S, Liu H, Caloyeras JP, et al. Workplace wellness programs study. RAND Corporation. 2013. https://www.rand.org/content/dam/rand/pubs/research_reports/RR200/RR254/RAND_RR254.pdf
12 -Song Z, Baicker K. Effect of a workplace wellness program on employee health and economic outcomes: a randomized clinical trial. JAMA. 2019;321(15):14911501. doi:10.1001/jama.2019.3307
13 -Tsai R, Alterman T, Grosch JW, et al. Availability of and participation in workplace health promotion programs by sociodemographic, occupation, and work organization characteristics in US workers. Am J Health Promot. 2019 Sep;33(7):1028-1038. doi: 10.1177/0890117119844478
14 -Uehli K, Mehta AJ, Miedinger D, et al. Sleep problems and work injuries: a systematic review and meta- analysis. Sleep Medicine Reviews. 18(1), 61–73. Feb 2014. doi: 10.1016/j. smrv.2013.01.004
15 -Kales SN, Tsismenakis AJ, Zhang C et al. Blood pressure in firefighters, police officers, and other emergency responders. Am J Hypertens. 2009;22(1):11-20. doi: 10.1038/ ajh.2008.296
16 -Fatigue in the workplace: risky employer practices – part two of a three part series. National Safety Council. 2018. https://safety.nsc.org/fatigue-in-the-workplacerisky-employer-practices-report
17 -Long work hours, extended or irregular shifts, and worker fatigue. Occupational Safety and Health Administration (OSHA). https://www.osha.gov/SLTC/workerfatigue/index.html. Visited on April 13, 2020.
18 -Fatigue in the workplace: causes & consequences of employee fatigue – part one of a three-part series. National Safety Council. 2018. https://safety.nsc.org/fatigue-report
19 -Swaen GM, Van Amelsvoort LG, Bultmann U, et al. Fatigue as a risk factor for being injured in an occupational accident: results from the Masstricht Cohort Study. Occup Environ Med. 2003 Jun;60 Suppl 1:i88-92. DOI: 10.1136/oem.60.suppl_1.i88
20 -Pfirman D, Collins S. Reducing fatigue and stress in the retail industry: workplace solutions. Centers for Disease Control and Prevention – NIOSH Science Blog. Sept 16, 2019. https://blogs-origin.cdc.gov/niosh-science-blog/2019/09/16/retailfatigue/
21 -Fatigue in safety-critical industries: impact, risks & recommendations – final report of a three-part series. National Safety Council. 2018. https://safety.nsc.org/fatigue-insafety-critical-industries-report
22 -Mental health in the workplace: mental health disorders and stress affect working-age Americans. Centers for Disease Control and Prevention. July 2018. https://www.cdc.gov/workplacehealthpromotion/toolsresources/workplace-health/mentalhealth
23 -Roesler ML, Glendon AI, O’Callaghan FV. Recovering from traumatic occupational hand injury following surgery: a biopsychosocial perspective. J Occup Rehabil. 2013;23:536-46. doi: 10.1007/ s10926-013-9422-4
24 -Richmond TS, Amsterdam JD, Guo W, et al. The effect of post-injury depression on return to pre-injury function: a prospective cohort study. Psychol Med. 2009;39:1709-20. doi: 10.1017/ S0033291709005376
25 -Wertli MM, Rasmussen-Barr E, Held U, et al. Fear-avoidance beliefs – a moderator of treatment efficacy in patients with low back pain: a systematic review. Spine J. 2014;14:2658-78. doi: 10.1016/j. spinee.2014.02.033
26 -Depression in women: understanding the gender gap. Mayo Clinic. Jan 2016. http://www.mayoclinic.org/diseasesconditions/depression/in-depth/depression/art-20047725
27 -Twenge JM, Gentile B, DeWall CN, et al. Birth cohort increases in psychopathology among young Americans, 1938-2007: a cross-temporal meta-analysis of the MMPI. Clinical Psychology Review. 2010. doi: 10.1016/j.cpr.2009.10.005
28 -Mental and behavioral health – African Americans. U.S. Department of Health and Human Services Office of Minority Health. Last updated Sept 25, 2019. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=24#1
29 -Highlights: workplace stress & anxiety disorders survey. Anxiety and Depression Association of America. Accessed April 13, 2020. https://adaa.org/workplace-stressanxiety-disorders-survey
30 -2019 DMEC mental health pulse survey. Disability Management Employer Coalition (DMEC). 2019. http://dmec.org/wpcontent/uploads/2019-DMEC-MentalHealth-Pulse-Survey-Results.pdf
31 -2019 Workforce attitudes toward behavioral health: annual report. Ginger. 2019. https://go.ginger.io/final-reportworkforce-behavioral-health-2019
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