FAST TRACK ARTICLE
Companies That Promote a Culture of Health, Safety, and
Wellbeing Outperform in the Marketplace
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Raymond Fabius, MD and Sharon Phares, PhD
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Objective: The objective of this research is to test the hypothesis that
companies distinguished by their commitment to their workforce’s health,
safety, and well-being outperform in the marketplace. Methods: To test this,
we analyzed the real-world stock market performance of an investment fund
of publicly traded companies selected on evidence demonstrating their
pursuit of a culture of health, safety, and well-being. Results: This fund
outperformed the market by 2% per year, with a weighted return on equity of
264% compared with the S&P 500 return of 243% over a 10-year period.
Conclusions: Employers, fund managers, and fund investors would be well
served by including strategies that assess a company’s commitment to the
health, safety, and well-being of their workforce when evaluating invest-
ments in their enterprise and portfolios.
Keywords: corporate leadership, culture of health, financial performance,
safety and well-being
T here is a growing body of evidence that supports the concept
that a healthy workforce provides a competitive business
advantage. Unhealthy employees typically spend more on health-
care, a direct cost for most large and mid-sized employers. Even
more costly are the losses in productivity—an estimated $2 to $3
additional dollars for each dollar spent on direct healthcare costs.1
Moreover, companies that focus on health and safety for their
workforce may create a culture that supports a healthy workforce
and increases the percentage of employees engaged and committed
to the organization’s success.2 Additionally, these companies may
become ‘‘employers of choice,’’ allowing them to attract and retain
top-performing talent.
Nearly three decades of research suggest the importance of
corporate culture and financial performance. Early work focused on
the financial performance of companies that demonstrated they
valued employees, customers, and owners3 and the performance of
companies that were well-thought of by their employees, vendor
partners, customers, investors, and society.4 More recent studies
have found the superior stock performance by organizations that
achieve a culture of health, as measured by receipt of various health,
From the HealthNEXT, Newton Square, Pennsylvania (Dr Fabius); Washington
University at St. Louis, St. Louis, Missouri (Dr Phares); and PSG Consulting,
LLC, Plano, Texas (Dr Phares).
Funding: No funding received for this work (self-funded).
Conflicts of Interest: None declared.
Clinical Significance: This research demonstrates that a portfolio of companies
chosen for inclusion in a stock fund because of their approach to their
workforce’s health and safety outperformed the market and improves our
understanding of the value of building and maintaining an enterprise culture
of health through its impact on business performance.
Address correspondence to: Sharon Phares, PhD, 2541 Nassau Trace, Fuquay
Varina, NC 27526 (sharon@jsphares.com).
Copyright ß 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on
behalf of the American College of Occupational and Environmental
Medicine. This is an open access article distributed under the terms of the
Creative Commons Attribution-Non Commercial-No Derivatives License 4.0
(CCBY-NC-ND), where it is permissible to download and share the work
provided it is properly cited. The work cannot be changed in any way or used
commercially without permission from the journal.
DOI: 10.1097/JOM.0000000000002153
456
safety, and well-being awards such as the American College of
Occupational and Environmental Medicine’s (ACOEM) Corporate
Health Achievement Award (CHAA),5 the C. Everett Koop (Koop)
National Health Award,6 the Gallup Great Workplace Award,7 or
being recognized as a high-scoring Health Enhancement Resource
Organization (HERO) company.2 It is noteworthy that the results
from numerous studies uniformly show improved stock perfor-
mance.
For example, a portfolio of companies who had received the
CHAA because of their robust health, safety, and environmental
programs outperformed the Standard &Poor’s 500 (S&P 500) over
13 years (1999 to 2012) and showed a cumulative return for the
CHAA recipients of 78.72% versus –0.77% for the S&P 500.5
Research that followed found that a simulated portfolio of publicly
traded companies receiving high scores on the HERO corporate
health and wellness self-assessment scorecard demonstrated an
appreciation of 235% compared with the S&P 500’s 159% over
a 6-year simulation period.2 Similarly, over 14 years (2000 to 2014),
a portfolio of the 26 publicly traded companies who had received the
Koop award outperformed the S&P 500 Index by 2.35 to 1.00.6
Publicly traded companies that received the Gallup Great Work-
place Award experienced a 115% growth in earnings per share
(EPS), compared with the 27% EPS seen in their competitors over
the same period.7 The positive relationship between award receipt
and stock performance makes sense. These companies likely create
an environment that reinforces conscious and unconscious health
and safety choices and fosters discretionary effort.
Many studies have shown that a healthy workforce is more
productive and incurs fewer direct and indirect health costs.8–11
Healthcare represents a high cost to companies, averaging $14,561
in employer-paid costs per employee in 2019,12 with the average
premium for family coverage increasing 54% over the last 10 years,
much higher than either wage or inflation increases in the previous
decade. Since most companies of more than 1000 workers self-
insure,13 reducing health costs can directly impact funding for
additional capital investments and the higher return to shareholders.
Additionally, productivity losses due to illness cost US
employers $530 billion annually.14 Prior research has shown that
for every dollar saved in direct health care costs, employers receive
an estimated $2.30 in improved performance and productivity.15,16
This is bolstered by research that shows companies that score high
on the culture of health assessment scores (CHAS) to quantify
‘‘cultures of health’’ tend to have lower health care cost trends
without the need to reduce benefits or shift more costs to employ-
ees.17
Warren Buffet has called health care cost the ‘‘real corporate
tax’’ because of its escalation over the last many years.18 A recent
study shows that companies who engage in validated ways to
support their workforce’s health, safety, and well-being tend to
see a reduction in health care cost trends.17 Creating a culture of
health is particularly important in a business environment where
healthcare costs are often considered a runaway cost, rising at a rate
two to three times higher than general inflation.
In sum, the evidence clearly points to the correlation of
companies that invest in a culture of health, safety, and well-being
having a competitive advantage. It stands to reason then that
JOEM  Volume 63, Number 6, June 2021
 JOEM  Volume 63, Number 6, June 2021
investors who can identify and score those companies should have
an investment advantage.
Purpose
With this in mind, we set out to test the hypothesis that a real-
world stock investment fund of publicly traded companies selected
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on evidence demonstrating their pursuit of a culture of health, safety,
and well-being would outperform the market over a 10-year period.
Additionally, we hope to clearly demonstrate the financial benefits
for employer leadership, fund managers, and investors in develop-
ing ways to assess and invest in companies distinguished in their
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commitment to maintaining and improving their workforce’s health,
safety, and well-being.
Building a Fund That Focuses on a Culture of
Health
In today’s diverse investment fund market, no fund presently
focuses primarily on companies that demonstrate a culture of health,
safety, and well-being for their workforce. Health impacts all human
performance, but other funds and indices seem to ignore this critical
factor. Most employers state that their workforce is their greatest
asset. Those who invest in their physical, emotional, financial, and
social well-being should provide a better return on investment.
Large business consulting practices such as McKinsey and Com-
pany have even developed products such as the Organizational
Health Index (OHI), designed to help companies improve share-
holder return by making measurable improvements in well-being.19
An appreciation of the years of research showing the connection
between health and organizational financial performance, and an
understanding of how companies that create and sustain a culture of
health are set apart from those who do not lead to the development of
an investment portfolio, called the Health Advantage Appreciation
Fund (HAAF). The HAAF set out to invest in the stock of publicly
traded companies demonstrating a culture of health. The HAAF
approach differs from funds such as the Parnassus Endeavor FundSM
(MUTF: PARWX) and the Calvert US Large-Cap Core Responsible
Index (MUTF: CSXAX). These funds focus primarily on great
places to work at or social responsibility. The Parnassus Endeavor
Fund focuses on companies recognized as good employers to work
for but does not look to health specifically.20
The concept behind the development of the HAAF portfolio
derives from the body of work demonstrating that companies that
nurture a culture of health, as measured by receipt of highly coveted
awards for workplace health and safety, have higher stock perfor-
mance than the S&P 500.2,5,6,7 The HAAF management team
developed a methodology by studying benchmark companies
who have accomplished a culture of health as well as calling upon
learnings from the HealthNEXT (Newton Square, Pennsylvania)
methodology which identified 218 elements in 10 categories that
can contribute to a culture of health and are shown to correlate with
health cost trend.17 These ‘‘Best practice’’ categories include:
 Leadership support and management alignment in promoting a
culture of health.
 Marketing and communications to promote the value of health
and healthy lifestyles.
 Investments in warehousing and integrating multiple sources of
data related to health and productivity.
 Establishing a multi-year strategic health and wellness plan.
 A work environment promoting health such as a smoke-free
campus.
 On-site health activities such as having a workplace health clinic.
 Health and wellness activities and programs directed toward
prevalent risks and illnesses.
 Incentives and benefit design that promote healthy behaviors.
ß 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.
Companies that Promote a Culture of Health
 Promoting and measuring engagement and navigation of health,
safety, and well-being programs.
 Health-related vendor management and integration.
Each company considered for the fund underwent a rigorous
scoring process that looks at corporate performance metrics focus-
ing on key indicators of a commitment to a culture of health
available in the public domain currently and over the previous 3
to 5 years. These metrics include investments such as a workplace
health clinic, having a corporate health officer at the senior leader-
ship level, the company demonstrating leadership via presentations
at health, wellness, and safety conferences, and other activities
focused on the health, safety, and well-being of their workforce that
served as proxies for companies that are committed to nurturing
their workforce. Additionally, the scoring includes companies who
had received prestigious health awards such as the CHAA from
ACOEM21 or the Koop Award from the Health Project.22
Beyond the firm belief in the concept that a commitment to a
culture of health can lead to more robust returns, the fund uses a
systematic, continuous review of information available in the public
domain to identify best practice employers building cultures of
health. Sources include the company’s annual and quarterly reports
and SEC filings, company websites, medical literature, business
news, other media, conference attendees and presentations, key
presentations such as webinars and keynotes by company leader-
ship, and awards, and the presence of comprehensive workplace
health centers.
Due to the level of investment needed to implement many of
the metrics, plus the sophisticated business operations and leader-
ship necessary to earn benchmark status, the portfolio primarily
consists of large-cap S&P 500 companies (Fig. 1), a stock market
index that measures stock performance of 500 large companies
listed on the US stock exchange, and frequently used as a bench-
mark for stock performance. Smaller and international companies
are included to a much lesser extent when public domain informa-
tion reveals their outstanding efforts. However, the resulting port-
folio demonstrated significant diversification by sector with health
care, consumer staples, information technology, consumer discre-
tionary, industrials, materials, financials, telecommunication ser-
vices, utilities, energy, and real estate represented (Fig. 2). The
variety of stocks in the portfolio diversifies the holdings and ensures
that a single holding or sector’s performance does not determine
fund performance.
A few of the fund companies were acquired or acquired
another company outside the portfolio or were part of corporate
mergers during the study period. Mergers and acquisitions can
change the corporate culture. The time leading up to and following
the merger or acquisition completion often increases stock volatil-
ity.23 Investment decisions were made by considering whether
pursuing a culture of health, safety, and well-being was likely to
be continued with focused efforts post-transaction.
The portfolio’s investments were based 75% on the proprietary
score of their culture of health and 25% based upon the ‘‘street’s’’
assessment of the potential for their stock’s appreciation. By consid-
ering outside investment house stock assessments, the fund considers
the company’s business potential and recognizes that a culture of
health alone cannot dictate a quality investment. The fund manager
limited the number of individual stocks in the portfolio to no more
than 40 companies and the fund was re-balanced every 6 months. The
methodology provided assurances that the fund’s growth would not be
unduly influenced by a single high performing enterprise but rather
that the fund’s appreciation would be based on the collective perfor-
mance of the ‘‘culture of health’’ companies.
Companies no longer publicly traded were removed from the
fund when their trading ceased, and monies accumulated by these
investments, as well as dividend payments, were re-distributed during
457
 Fabius and Phares
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FIGURE 1. Fund portfolio equity size and style.
the next semi-annual re-balancing. The dividends were not immedi-
ately reinvested, which would have enhanced appreciation.
METHODS
Using reports generated by a well-known financial institu-
tion’s private banking and investment group, fund performance was
tracked for a decade from the fund’s initiation on January 1, 2009,
through December 31, 2018. The annual and cumulative time-
weighted return of the fund performance was compared relative
to the S&P 500. We looked at the total return (TR), the actual rate of
return of the portfolio compared with the TR for S&P 500 over the
evaluation period, including interest, capital gains, dividends, and
other distributions realized during the evaluation period. Total
return determines an investment’s actual growth over time. While
the S&P 500 TR reinvests interest, capital gains, dividends, and
other distributions immediately, the HAAF portfolio accumulated
interest, capital gains, dividends, and other distributions and rein-
vested them semi-annually. Along with re-balancing, this further
reduced the potential untoward influence of a single stock and
458 ß 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.
JOEM  Volume 63, Number 6, June 2021
allows for a better measure of the collective performance of the
distinguished culture of health enterprises.
Over the 10-year follow-up period, portfolio companies
changed, as noted in the previous section. However, roughly half
of the companies were included in the fund since 2010. The
longevity of fund companies is an indication of their sustained
commitment to a culture of health. The fund engaged in limited
trading, dropping, adding, and re-balancing semi-annually at the
beginning of each year and mid-year.
RESULTS AND DISCUSSION
The cumulative time-weighted total return for HAAF com-
pared with the S&P 500 is shown in Fig. 3. The cumulative time-
weighted return for the fund outperformed the S&P 500 throughout
the 10 years studied, returning a 263.83% return on equity on
December 31, 2018, compared with the S&P 500 total return on
equity of 243.03%—a 2% per year advantage for the HAAF.
While other research has been published demonstrating the
success of virtual portfolios of companies who have distinguished
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FIGURE 2. Fund portfolio sector analysis.
themselves through their commitment to workforce health, safety,
and well-being, we believe this is the first article reporting on the
actual results of a portfolio of publicly-traded companies chosen for
their corporate culture of health, safety, and well-being.
Although the association between fund performance of a
portfolio of companies who have demonstrated a commitment to
their workforce’s health and wellness is promising, there is still
work to do. The authors recommend that this study be repeated for
an additional 7 to 10-year period using the same methodology from
start to finish augmented by immediately reinvesting dividends.
Further studies may demonstrate whether our approach holds up
over time and ascertain the impact of changes in economic and
socio-political environments. Additionally, the authors welcome
others to use different methodologies to select the best practice
culture of health companies to provide valuable insights and supe-
rior performance. Lastly, the authors encourage researchers to study
the impact on publicly traded companies in other countries to
ascertain whether the correlation between the ‘‘culture of health’’
companies and stock performance is similar. We are aware of one
such study performed in South Africa that provides preliminary
evidence of positive financial outcomes for companies that support a
culture of health and wellness.24
ß 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.
Companies that Promote a Culture of Health
It should also be noted that in the case of the HAAF,
dividends were not immediately reinvested as are done with the
S&P 500 total return funds, reducing some potential for additional
appreciation during periods of rising stock markets. So it is fair to
say that the out-performance of the HAAF relative to the S&P 500
TR is even more impressive.
Current exchange-traded funds (ETFs) that focus on health
are those that represent healthcare services, not investment into
companies with established cultures of health, distinguished by
caring for their workforce’s well-being in remarkable ways. While
there are funds that focus on socially responsible investing (SRI),
which may incorporate environmental, social, and governance
(ESG) criteria,17 the focus on the workforce’s health and safety
is unique. It perhaps represents an even better investment strategy in
those companies focusing on a culture of health investing directly
into the one asset that every business needs to thrive—the health and
well-being of its people. The closest comparison fund we have
found is the Parnassus Endeavor Fund (MUTF: PARWX), whose
strategy is to invest at least 80% of net assets in companies believed
in providing good workplaces for their employees.25 According to
the fund prospectus, the strategy behind this criteria is that compa-
nies with good workplaces can recruit and retain better employees
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 Fabius and Phares
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and perform at a higher level than competitors in innovation,
productivity, customer loyalty, and profitability. Companies that
provide good workplaces are selected based on ‘‘factors such as
respectful and fair treatment of employees, employee satisfaction
and engagement, pay and benefits, family-friendly policies, and
support for volunteerism and philanthropy.’’26
Companies with healthier workforces experience lower
health care costs, less absenteeism, higher productivity, less work-
force turnover, attract better talent, produce less waste, and experi-
ence higher employee engagement levels. All of these contribute to
a competitive advantage in the marketplace and explain why this
fund outperformed.
The COVID-19 pandemic has taught corporate America the
importance of a healthy workforce. We now know that healthier
employees are less likely to have a severe infection if they contract
the virus.27 Underlying conditions such as heart disease, diabetes,
lung disease, and obesity can set the stage for more serious illness
and more difficult recovery.28 Companies with a benchmark culture
of health and well-being are likely benefiting from a more resistant
and resilient workforce.
Corporate cultures that foster health and well-being become part
of the company’s DNA. Employees both consciously and uncon-
sciously make better and more healthy decisions and likely better
business decisions. They understand that one of their responsibilities
within these companies is to take care of themselves and foster healthful
behaviors within their families and coworkers. The feeling of personal
responsibility, in turn, encourages teamwork and collaboration. As
social creatures, new employees joining a company with a culture of
health are more likely to act in kind and eat a healthy diet, exercise,
drink in moderation, and not smoke just like their colleagues. Suppose
they have a health risk or condition. In that case, they are more likely to
attend to it by establishing a trusted relationship with a primary health
provider and appropriate specialists, adhere to medication schedules,
and follow evidence-based guidelines for care.
Benchmark culture of health, safety, and well-being companies
likely excel in other aspects of management. Therefore, this marker of
investment-worthy companies may be an excellent proxy for orga-
nizations likely to outperform for many reasons. Companies who
invest in health, especially those who are formally ‘‘graded’’ by the
receipt of prestigious awards or investing in recognized corporate
health assessment scores, demonstrate many critical leadership
dimensions that not only help improve the health of their workforce
but likely these leadership disciplines/characteristics spill over into
other critical areas of management and human capital cultivation.
These might include effective strategic planning, leadership
460 ß 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American College of Occupational and Environmental Medicine.
JOEM  Volume 63, Number 6, June 2021
FIGURE 3. Relative perfor-
mance—HAAF compared with
S&P 500. HAAF, Health Advan-
tage Appreciation Fund.
engagement, program/product management, program/product inte-
gration, measurement and evaluation that are objective and verifiable,
sustained commitment to excellence, employee engagement, train-
ing, retention, and advancement. It is also likely that companies with
an influential culture of health may also be indicative of companies
that have a more general culture of aligned goals between the firm and
its employees. For this reason, establishing a method to identify
benchmark culture of health companies may be an excellent way for
fund managers and investor to identify enterprises worthy of invest-
ment, and provide another metric which employer leadership can use
to demonstrate company value to the investment community.
LIMITATIONS AND CONCLUSION
This article features the performance of only one fund for one
10-year period, which invested in a finite number of companies.
Additionally, our method of selecting portfolio companies has
considerable subjectivity, and depends on publicly available infor-
mation that may be incomplete or subject to error. The results are
also not generalizable to firms with small capitalization, those not in
the S&P 500, and non-US companies.
As this study further supports the merits of investing in
companies committed to a culture of health, it may be prudent
for the investment community to assess this commitment as part of
the process to decide the merits of investing in any company. If one
were to consider the investment into a promising company with an
exciting business model but whose workforce carried a significant
illness burden that the company was ignoring—rethinking the
investment might be prudent. There might come a day when all
companies published their culture of health score like they provide a
credit score. With the pressure of the investment community, all
companies would compete for being the healthiest. This market-
place approach might go a long way to mitigate the health care
crisis, leveraging market forces.
Corporate leadership is responsible for capital appreciation
and providing quality returns for its investors. Company executives
should leverage this research to support their investment in their
workforce’s health, safety, and well-being. Fund managers and fund
investors would be well served by including strategies like the
Health Advantage Appreciation Fund’s approach when evaluating
investments in their portfolio. However, several changes would
make this an easier task. The investment community should demand
more transparent reporting of the workforce’s aggregate illness
burden and measures that evaluate the extent to which publicly
traded companies deploy resources to manage the health and well-
being risks and conditions within its workforce. Companies say their
 JOEM  Volume 63, Number 6, June 2021
greatest asset is their people. However, today the investment
community has no idea if employers put the necessary focus on
the health, safety, and well-being of their workforce as they do to
invest in the ‘‘health’’ or upkeep of their machinery and other capital
assets. The investment community demanding more information on
a workforce’s health can create a virtuous circle of improvement.
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Suppose a culture of health gains the attention of the investment
community. In that case, its importance may gain recognition by
company leadership, and potentially additional employee health
investments will be made. It is even foreseeable that all publicly
traded companies will provide the investment community their
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culture of health score one day.
In a country where 62% of individuals with employer-based
insurance has at least one chronic condition,29 companies that create a
culture for a healthier workforce have a competitive advantage. Any
investor who invests without knowing how the enterprise invests in
their workforce is missing an essential component of company
financial health and performance. However, now it is not easy to
obtain this information. Investors can easily read reports that outline
publicly traded companies’ commitment to workplace safety and
environmental sustainability. Still, no such reports exist on a wide-
spread basis for company commitment to a corporate culture of heath.
We also consider the possibility that companies that focus on their
workforce’s health and safety build a culture of health and a culture of
trust. This trust between employer and employees engenders engage-
ment and commitment to the performance of the company. Trust is not
a ‘‘nice to have’’ in the workforce; it is as necessary as optimal health
for employees and organizations to perform at their best.30
Building a culture of health is a significant undertaking and
requires long-term vision, investment, and commitment, but this
undertaking may be vital to business and investment success. A
portfolio of companies chosen for inclusion in a stock fund because
of their approach to their workforce’s health and safety outperformed
the market. Of course, this association does not necessarily imply
causation. Companies that focus on their workforce’s health and
safety may also use best practices in many areas of business manage-
ment. Thus, excellence in health and safety may be a proxy for a
culture of excellence in various domains. The literature, however,
increasingly links the health of a workforce to business performance.
More research is needed to improve our understanding of the value of
building and maintaining an enterprise culture of health and its impact
on business performance. The authors encourage corporate leadership
and the investment community to support this research to guide their
asset allocations and augment their success.
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