In mid-2020, well into the COVID-19 pandemic, the Institute
for Corporate Productivity (i4cp) partnered with Dr. Jeffrey Pfeffer on
research to identify vital organizational stakeholders, their responsibilities,
decision-making criteria, and other key aspects of the healthcare ecosystem.
Pfeffer, a longtime i4cp Thought Leader Consortium member and
the Thomas D. Dee II Professor of
Organizational Behavior at Stanford University’s Graduate School of Business,
has taught at Stanford since 1979 and is regarded as one of the nation’s most
influential business and management visionaries. In addition, he is the author
or co-author of numerous widely published articles, and his 15 books include
2018’s Dying for a Paycheck, a landmark examination of employee
health, stress, and the toxic work environments and management practices that
are leading contributors to those problems.
goal of the 2020 i4cp/Pfeffer healthcare research?
sought to uncover insights to help employers achieve stronger outcomes with
their healthcare programs and ultimately, to contribute to the higher levels of
employee well-being that enable both individuals and businesses to perform optimally.
U.S. employers now pay for or provide half of the nation’s healthcare services,
optimizing the efficiency, effectiveness, and affordability of that care is a
critical imperative—one made even more apparent by the pandemic. But Pfeffer
says employers are still missing the mark when it comes to the well-being of
Recently, Pfeffer sat down with i4cp’s well-being research
lead, Carol Morrison, to discuss the collaborative study and the ongoing
commitment he shares with i4cp to identify and support high-performance strategies
to improve workforce well-being.
has “made everything worse” and exposed the “inadequacies of our systems”
Morrison: In Dying for a Paycheck, you called
attention to the staggering effects of workplace stress on well-being—that of
individuals and the organizations that employ them. In your view, how has
the added challenge of the COVID-19 health crisis affected work-related stress?
Pfeffer: COVID certainly has
made everything worse. Surveys I’ve seen this year—and there have been many by
i4cp and others—are consistent in showing that stress is much worse.
According to the American
Psychological Association, politics and the election became a high-profile source
of stress. Other research by a company that links mental health providers with
organizations’ employees also found that stress has increased this year. Those
are just a couple of examples.
Not only is the stress more
pronounced, but the pandemic has really exposed the inadequacies in many of our
systems. For instance, COVID made it really evident that we have not done very
well as a country with respect to providing enough work/family support. Women,
including talented college-educated women, are leaving the workforce in
enormous numbers. That will disrupt careers, of course, but it also will eventually
create talent shortages.
I have a friend who heads a
company, and she said to me, ‘I am a CEO, but I also run a daycare center. I
run a school, too.’ Because she has a preschooler and a first or second grader
at home, she now has three jobs. And the number of women leaving employers
suggests she isn’t the only one experiencing such overload. So the health crisis
has shown the inadequacies of our work/family support structures.
I think that the pandemic has also
illustrated the inadequacy of the healthcare system in this country. Because we
have an employer-based health system, if you no longer have an employer, you no
longer have health insurance.
So COVID-19 has exposed all the
weaknesses: It has made stress worse, and it has revealed where we are not very
adequate in dealing with situations that confront and seriously challenge people
in their lives.
For an employer who realizes those challenges are
happening, is there a starting place you would suggest? Can they do something right
now to make a positive difference for their workforces?
Sure. A friend of mine runs a
company that connects people with mental health providers, mental health apps,
whatever they need. I think it behooves employers to explore the ecosystems
around work/family support and around mental health. Maybe even insurance
benefits administration, too. In other words, try to do things to find better,
more progressive, more helpful providers.
I think it would also benefit
employers to actually do something which, for the most part, they do not do.
And that is: Evaluate the providers of those health and supportive services and
hold them accountable. Ironically, this is a very important moment for HR. It
is a time in which, I think, companies and their senior leaders understand that
business as usual is not going to cut it. So, along with measurement and
accountability of benefits providers, I think there is an opportunity for HR to
do innovative things—if HR wants to.
practitioners have thought that less is more”
To your point, i4cp research confirms that companies are placing
greater emphasis on employee mental health because of the pandemic (and expect
that to increase in coming months). Have you seen organizations taking actions
to support better mental health that have particularly impressed you or struck
you as being especially innovative?
I think companies are reevaluating
what they are doing, but it is late. It is a true fact that 61% of the counties
in the United States have not one psychiatrist. So basically we have a system
in which access is seriously limited. And don't even get me started on health
benefits administrators. My general comment to them is that they had better
hope there is not reincarnation!
But HR people are responsible for
this. HR practitioners have thought that less is more. But less is not more.
The idea that you would constrict people's ability to see mental health
professionals belies the fact that mental health is a predictor of physical
We have done a study that shows
the use of an antidepressant prescription—taking antidepressants—is a marker of
depression. You can look longitudinally (which we did, using United Health
prescription data) and see how the risk goes up so that the person taking those
drugs will subsequently be taking drugs for cancer, diabetes, and/or heart
disease. In almost all cases it goes up by about 50%. So mental health predicts
There are empirical realities underscoring
the mind/body connection. If you spend some time looking at the medical
literature, there are two mechanisms for this. One is obvious—if you have
mental health problems you are probably not going to engage in health-enhancing
behaviors. You are probably going to drink more, smoke more, do more drugs, and
Secondly, medical researchers have
also demonstrated connections between such things as stress and depression, and
actual inflammatory responses in the endocrine system.
So HR functions ought to hold
their mental health providers and their health insurance providers more
accountable and stop rewarding them for providing less care. The reason why
health care in the United States is so expensive is because of price and
administrative overhead, not because of overutilization.
Is that part of organizations’ inability or unwillingness
to measure the factors that could tell them whether their well-being programs
are really effective? In our research, i4cp certainly found that too few
companies (less than half) assess either the effectiveness of their well-being
programs or the actual levels of well-being of their employees.
That is exactly correct. People do
what's easy, and it is easy to put barriers into utilization—utilization of physical
health care, mental health care, alternative medicine, physical therapy,
whatever. It doesn't make sense, but they do it.
self-imposed barriers in organizations are unbelievable”
You've recently written (in the Journal
of Occupational and Environmental Medicine) that companies also put
limitations on themselves, consciously or not. What do you think it will take
to move organizations to measure well-being effectively?
I really have no idea. The
decisions that get made on a daily basis are incomprehensible to me. For the
article that you mentioned, it was unbelievable to me that we could go out and
interview some of the most resource-rich, leading-edge companies that are
trying to build cultures of health. Only to hear them say they know that high-deductible
health plans really discourage the kind of health-promoting use of
medical services that they want to encourage. Yet companies are choosing
those health plans. They can't complain about having a high-deductible health
plan when that was their own choice.
Sometimes organizations we
interviewed would also complain that benefits administrators were not
innovative. Yet, again, the companies were the ones choosing which benefits
administrators to use. The self-imposed barriers in organizations are
Your article also noted that many companies aren’t
exactly authentic when it comes to their motivations about offering well-being
benefits and pursuing cultures of well-being. Specifically, you said that many firms
do those things because they anticipate bottom-line business benefits, and not
because they believe that supporting greater employee well-being is the right
thing to do.
And the interesting thing is that
they don’t even get the payoff. Because they don’t do what they need to do—measure,
eliminate barriers to utilization, demand innovative benefits administration,
Do you think that the ruling from the SEC on disclosure
of human capital metrics is a step in the right direction, or that mandated reporting
eventually will help give businesses a positive push toward more disciplined
I think that the move toward ESG (Environmental,
Social, and Corporate Governance) measures puts organizations’ focus
more on people and not so much solely on the physical environmental measures.
That will help because measurement is the first step. It is not the only
step, because we measure many things we don't put much priority on. So without
measurement we will never get better, but measurement by itself probably is not
going to be sufficient.
Will the attention focused on
physical and mental health by the pandemic also serve as a driver for change?
I think so. But it depends upon
how long that focus lasts post-pandemic—whether this is going to be a temporary
thing or whether it is going to change practices. It is hard to say, but I
think that the health crisis has really highlighted the work/family and
physical and mental health areas in which there are huge deficiencies.
It will take time to overcome
those deficiencies. We are not going to create a tremendous number of mental
health practitioners overnight, nor will we create overnight the resources
necessary to provide people the support they need in order to have a job and
have their health.
Historically we have not been very
good at doing things that require time and patience. Sustained attention to
things tends not to be a strong suit for many people, but maybe this will be
different. I hope so.
In other words, the question is,
will businesses be able to sustain progress that has been made because of their
response to well-being during the pandemic? Will they be able to sustain that
long enough to make a difference? Some will point out that the younger
generation thinks differently, particularly with respect to mental health
issues. They really want mental health support and will choose jobs on that
basis. So that puts pressure on businesses. We will see.
“We need a
much more holistic view, not only of well-being, but of how people live their
In your opinion, how important is it that organizations
pursue the holistic, or whole person, approach to workforce well-being that
i4cp research has featured? (i4cp uses a six-element model that
includes physical, mental, financial, career, social, and community well-being.)
I think it is very important. The
friend I mentioned who is a CEO—and a daycare and school provider as well—said
to me that one of the things COVID has demonstrated is that every day is Bring Your
Child to Work Day. While a child may not be physically at work, their well-being,
what they are doing, and how well they are faring is in your head as a parent.
So basically the idea that somehow
you are going to come to work and your family issues, the well-being of your
children, and what's going on with your spouse or significant other is going to
be left behind is just insane. We need a much more holistic view, not only of
well-being, but of how people live their lives. If someone is ill, or
struggling financially, or a child isn't doing well, you do not leave that at
This is not new. This is what SAS
Institute (a U.S.-based multinational analytics software developer) figured out
close to 30 years ago. The company had hired, trained, and retained many
successful software engineers; its leaders understood that enabling those
engineers to be productive meant that SAS needed to provide support that would
help those employees reduce or appropriately handle family-related concerns.
So the company provided very
generous benefits of all kinds and resources to help employees address the problems
they and their families faced. When challenges arose, as they inevitably did, employees
had the ability to handle them and disruption to their work was minimized.
When organizations take that kind
of action, it means that people can deal with situations so that they don't
have to quit. SAS figured this out decades ago, and it is just astonishing to
me that more companies don't see the benefit of doing this.
Yet, companies don’t. The huge
statistics that we see now about the pandemic driving women out of the
workforce confirms that. And especially when companies talk now about their
commitments to diversity and inclusion, they need to create a work environment
that permits people to survive.
In July of 2020, i4cp partnered with you on a Benefits
Administration survey. In that, you asked HR and business professionals how
engaged their current CEOs and CFOs were in decisions about health benefits—such
things as copays and deductibles, company versus employee contribution levels,
plan design, administration, choice of benefits consultants, etc.
Only 28% of respondents said their CEOs were extremely or
very engaged. Meanwhile, 49% reported limited or no CEO engagement.
For CFOs, the percentages were higher: 41% of survey
participants said their CFOs were very or extremely engaged; a third said their
CFOs showed limited or no engagement.
Given the high costs to organizations for employee
healthcare, what is your reaction to those findings and why it is important for
those C-level executives to be more engaged in benefits-related decisions?
I think they need to be involved
in the right way. As Dying for a Paycheck pointed out—and this is not a
big surprise—the health of your workforce affects things like presenteeism,
absenteeism, missed workdays, turnover, and productivity. So if you really want
a productive workforce you need a healthy workforce—one that is both
mentally and physically healthy.
On the one hand, that is common
sense. On the other hand, there is a ton of data which has accumulated over
decades that demonstrates that. Therefore, you ought to be concerned about
building a culture of health in the workplace. Toward that end, companies are
spending a fortune on healthcare costs because most of the large firms (and
many of the mid-sized ones) are basically self-insured.
So they are spending a fortune on
health benefits, but they are oftentimes administering those programs in ways
that just upset people and create barriers to accessing the benefits companies are
supposedly providing. Essentially that means organizations are shooting themselves
in the foot. So to both produce a culture of health and enable people to take
advantage of benefits that are very important to them, executives should be
much more involved in this.
leaders “have a responsibility”
You’ve reported that some business leaders offer excuses
for opting out—they aren’t willing to invest in well-being benefits for
employees because workers won’t stay with the organization, or they feel that
what employees do on their own time, specifically as it relates to their health
and well-being, is not the business of an employer. What do you say to those
I would quote somebody like Bob
Chapman, chairman and CEO of Barry-Wehmiller [a St. Louis-based manufacturing
firm], who has co-authored the book Everybody Matters: The Extraordinary
Power of Caring for Your People Like Family. He said that when people show
up at your workplace, they have entrusted their well-being, both physical and
psychological, to you, and you have a responsibility.
If you think about it, companies
slowly—and by the way, with a lot of legal pressure which, I think, is what
it's going to take for well-being, too—moved away from saying they didn’t care
about the physical environment years ago. And now they believe that they are
stewards of that environment. In fact, many of them are issuing environmental
reports and talking about what they are doing in terms of recycling and
utilization of resources. They came to understand that they have a
responsibility to steward the physical world, which they do.
Companies also have a
responsibility to be good stewards of the human beings who have entrusted their
lives to them. One of my friends calls attention to that by asking: ‘Why do we
care more about polar bears then we do about human beings?’ So companies are
going to be good stewards of the physical environment, but they need to be good
stewards of the human environment as well
The Benefits Administration survey on which we collaborated
also asked respondents to rate the importance of eight criteria in
organizational decisions about which company (or companies) would administer
their firms’ health benefits (benefits administrators were illustrated by
examples including Anthem and Blue Cross Blue Shield).
Of the top five items
respondents rated extremely important, two center on cost, the other three on
access/employee experience (ease of locating providers, ease of administrator’s
website use, market share in employer locations).
What insights do these findings
suggest to you about organizations’ priorities in health benefits decision-making?
I think the
reason why the employee experience and access factors ranked highly Is because
one of the things that HR people try to do is avoid noise. To the extent that employees
cannot get access to the doctors they want, they make noise; and HR doesn’t
like all that noise. So it doesn't surprise me that those features ranked
I would also say
that I think that cost gets too much attention. And if I were going to give
advice, I would advise benefits decision-makers to worry much more about some
of the stuff that didn’t rate highly.
For example, I am
on the Stanford committee for faculty and staff human resources. That is the
committee that oversees our health insurance. The benefits administrators come
in, and for the most part, they do not report on population health. Companies
are paying a ton of money for this. I would hold those administrators
responsible, not just for causing employees aggravation in getting access to
things but, at least to some extent, for the health of the population.
At the end of the
day, my role on the committee is about health and insurance. So I would like to
hear about health. We are offering physical and mental health benefits in order
to produce a healthier population that misses fewer workdays, that is less
stressed, and that is more likely to remain with the employer because they
believe the employer cares about their well-being. That is what we ought to be
assessing ourselves on.
don’t measure their experiences with benefits administrators
The survey asked participants what they were held
accountable for related specifically to their job responsibilities associated
with health benefits. Their top responses:
- Your employees’ opinions about your health
- Absolute level of spending on health
- Mental/emotional well-being of your
Do those factors suggest to you that companies are
holding benefits professionals accountable for what they should be?
I don’t believe it. How can I be
held accountable for the well-being of the people in my organization when i4cp
research has found that most organizations don’t measure that? Of the three
things noted in these findings the one thing that is measured is cost. I don't
think that the other two are typically measured.
My informal sense from talking to
benefits consultants is that most of their clients do not measure their
experience with the benefits administrator. So if you do not measure the
experience with your benefits administrator, and if you do not measure the
physical and mental well-being of employees, then two of the three things for
which benefits administrators are supposedly being held accountable, they are
not accountable for. Because no one has actually gotten any data that would
permit those individuals to be held accountable.
Should they be held accountable
for these things? Absolutely. And it is not that hard. Most companies do
employee surveys. It would not be difficult to put on the employee survey
questions that would assess the employees’ mental and physical well-being and
their experience with their benefits administrators.
When it comes to well-being and benefits, what would you
have business leaders thinking about or doing differently?
Here’s the analogy I make: If you
had a piece of expensive capital equipment, and you had employees who were
systematically not maintaining that equipment or were doing things that would
harm it, you would probably get rid of those employees. You would not let
people destroy machinery you have spent a fortune installing.
I would argue that some of the
most expensive assets that companies have are the human beings they have spent
money to hire, train, and develop. Organizations ought to worry as much about
the maintenance of their human capital as they do their physical capital.
his website for more on
Dr. Jeffrey Pfeffer’s work in employee well-being.
i4cp studies and resources on workforce well-being here.
is a Senior Research Analyst at i4cp