Posted on Thursday, April 05, 2018

When do employers provide accommodations to employees with health problems? Qualitative evidence from Arkansas

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Every year, millions of Americans lose their jobs or leave the workforce because of a health problem (Hollenbeck 2015). They sacrifice substantial income as a consequence, and only a fraction of that lost income is offset by any cash support they may receive from Social Security Disability Insurance (SSDI) or other programs (Schimmel and Stapleton 2012).Introduction

From an employer’s perspective, profits may suffer because these health problems lead to lower productivity and to higher premiums for benefits like workers’ compensation, private disability insurance, and health insurance (Anand and Ben-Shalom 2017). Federal and state governments lose tax revenues and pay more in disability, health care, and unemployment benefits (Ben-Shalom and Burak 2016).

Employees who receive an evidence-based intervention shortly after they realize that a health problem (new or existing) could force them to leave the workforce are more likely to stay in the workforce and less likely to claim public disability benefits (Franche et al. 2005). Employers can play an essential role in early intervention by referring workers with new health problems to the right resources and services, and by providing accommodations, including job modifications and assistive technologies, that help employees stay on the job. However, the extent to which employers offer assistance to workers with health problems is inconsistent. Some employers adopt programs designed to help them retain workers with health problems, but others do not. Furthermore, employers may choose to treat different employees differently in terms of the assistance they offer.[1]

Box 1. Study Background

Who was interviewed?

Fifteen HR professionals and supervisors from 14 employers were interviewed in spring 2017.

Company size ranged from 80 employees to more than 20,000 employees.

A variety of industries were represented, including: health care and social assistance; information and media; manufacturing; finance and insurance; transportation and warehousing; and educational services.

What kinds of cases did employers discuss?

Employers gave detailed information on 50 cases in which an employee developed or disclosed a health problem.

The most common health problems were:

  • Cancer: 7 cases
  • Musculoskeletal conditions: 5 cases
  • Sensory impairment: 5 cases
  • Leg/ knee/foot injuries: 5 cases

These employees varied in their employment outcomes:

  • Stayed at organization: 21 cases
  • Left due to health condition: 11 cases
  • Left for other reason: 4 cases
  • Terminated: 4 cases
  • Status not provided: 10 cases

We interviewed human resources (HR) professionals at 14 organizations in Arkansas in an effort to understand the most important factors influencing employers’ efforts to support and accommodate workers with health problems. The factors we identified include:

  • The availability of resources, including money, staff time, and public resources.
  • The ease (or difficulty) of communication between the affected worker, HR professionals, supervisors, health care providers, insurance companies, and other individuals involved in the employee’s treatment or recovery.
  • The characteristics of the employee and his or her job, including tenure, performance, roles and duties at work, and type of health condition.

Resource constraints can impede accommodations

Employers who had limited access to relevant resources reported more barriers to accommodating and retaining workers with health problems than employers with better access to those resources did.

“We probably spent at least a year working [to accommodate] the individual despite the frustrations and the hardships and all the extra manpower that [were] required. It was creating more work for us than … we really had the time [for].”
-HR director on company efforts to accommodate an employee with a cognitive disability

Financial resources: Employers said it cost them a significant amount of money to cover employer-provided short-term disability benefits, modify work equipment, and bring in temporary workers to cover for employees on leave. Of the 14 employers we interviewed, four reported that a lack of financial resources limited their ability to accommodate employees with health problems.

Staff capacity: Employers told us they spend a great deal of time accommodating employees with health problems. They pointed out that other employers who have limited staff capacity or are not as dedicated to helping out may not expend the same level of effort, especially for workers whose health problems are particularly difficult to address.

Other private resources: Some employers at well-resourced organizations offered additional services and supports to provide timely accommodations, including:

“We don’t have an EAP here. I have felt like people that have [mental health] needs here are underserved.”

-HR director on resources that are lacking at his organization

  • Float pools and temporary workers to reduce the burden on supervisors and other employees when a worker is out for health reasons
  • Employer-provided physicians to suggest appropriate accommodations and improve the flow of communication between employees, supervisors, and HR staff
  • Employee Assistance Programs (EAPs) to help employees resolve their mental and behavioral health problems and overcome other personal obstacles that adversely affect their work performance

Box 2. How the Arkansas Stay-At-Work/ Return-To-Work (SAW/RTW) program helps employers

The SAW/RTW program, which is operated by the Arkansas Rehabilitation Services (ARS) agency at the Arkansas Department of Career Education, supports employers who are working to accommodate employees with health problems. This support takes the form of general ergonomics assessments, vocational counseling, job site assessments, and help developing SAW/RTW plans.

Although most of the employers we talked to were not familiar with the SAW/RTW program, four of them had used the program when employees at their organizations developed health problems. The program had helped these employers:

·Acquire a new telephone headset with a special ringtone for an employee with hearing loss to test out (the employer later bought the headset)

·Obtain a large computer screen to magnify text and reduce glare for an employee with vision problems

·Conduct ergonomics assessments

·Coordinate communication between an employee with impaired hearing, the employee’s audiologist, and the employer to identify equipment that would help the employee hear (the employer ultimately bought the equipment)


All four employers who had used SAW/RTW services were satisfied with the quality of the services and the ease of accessing them. According to one, “The base of knowledge that the ARS experts have helps. It really does.” Another added, “What’s been neat about this is they actually bring equipment out to try. And when something doesn’t work, they come back with more [equipment] and switch it out.”


Despite the many benefits of the SAW/RTW program, participants said they typically relied on ARS for only a few specific problems—for example, “when an employee is in pain at their desk” or “when [employees] need [equipment], and I don’t know how to help.”

Public and nonprofit resources: Several employers singled out the Job Accommodation Network (JAN)[2] and the Arkansas SAW/RTW program (see Box 2) as valuable supplements to their internal resources. Employers appreciated that these services were free and were easy to access.

Communication problems create challenges for employers

When an employee develops or discloses a health problem, a variety of stakeholders can influence the path forward. An employer’s ability to effectively communicate with all other stakeholders is a key factor influencing its ability to (1) understand what accommodations are needed, (2) provide those accommodations, and (3) facilitate the employee’s return to work if an extended absence has occurred. For many employers, poor communication with one or more stakeholders kept them from effectively assisting employees with health problems.

HR staff: HR staff play a key role in ensuring that employees receive timely accommodations to help them stay at work. Several of the employers we spoke with said that if communication between HR staff and other stakeholders was poor in quality or entirely lacking, employees often ended up leaving the workforce before any accommodations had been provided.

Supervisors: Several respondents credited supervisors with playing an important role in identifying employees who were struggling with health problems and helping these employees get the support they needed to keep working. Because supervisors have the most direct contact with employees, they can be crucial to ensuring that communication flows properly so employees can be accommodated and retained. In a number of cases, however, supervisors failed to communicate effectively with HR. Several HR staff expressed their frustration with supervisors who failed to promptly notify them of employees with health needs, and said supervisors needed more training on communicating about and providing accommodations.

“I think the most important thing is … training your managers to recognize what is a disability. Listening for things [employees] say or do, and making [HR] aware of those things, so we are not just blowing it off.”

– Senior vice president of HR describing how supervisors can help workers promptly receive accommodations

Doctors: An employer’s ability to get information from doctors about their employees’ health problems affected the extent to which the employer identified and provided appropriate accommodations. Twelve out of the 14 employers we interviewed required employees who were taking leave or requesting accommodations for health conditions to give the employer notes or paperwork from doctors. Some respondents said they had trouble getting this information from doctors or interpreting the information they did get. However, respondents suggested several ways to overcome the challenges of communicating with doctors: training employees on documentation from a doctor; using a company doctor (if there is one) who can communicate more easily with HR staff and supervisors; and, in rare instances, communicating directly with the employee’s personal doctor.

Insurance providers: When employees are seeking short- or long-term benefits that will help them resolve their health conditions, it is necessary for both the employer and the employee to correspond with insurance providers. In several cases, employers said insurance providers were roadblocks for employees seeking to obtain benefits. They also noted that delays in paperwork processing slowed down an employee’s receipt of short-term benefits.

Employee characteristics make a difference

Box 3. Accommodating workers with mental and behavioral health problems

Employers in the study emphasized the difficulties of accommodating and retaining workers with mental and behavioral health problems. Several employers tried to accommodate employees with these conditions by referring them to employee assistance programs, adapting their work schedules and duties, and providing short-term leave. Still, the majority of these workers ended up quitting or being terminated after an acute incident or relapse.

A few employers also said they had difficulty communicating with workers with mental and behavioral health problems as compared to employees with other health issues. One respondent noted, “I think [employees with mental health conditions] don’t expect [their employer] to be acting in their best interest. So when we call to find out how they are doing, they are really suspicious. It is really difficult to get information back.”

In addition, several respondents observed that some employees with mental health conditions withheld information about their health rather than asking for accommodations because they worried about being stigmatized or losing their job, or they were unaware of accommodations. One HR director noted that supervisor training can mitigate this problem:

“Once we realized [people were leaving without seeking accommodations], we decided to make sure we were training our supervisors about ‘This is how you handle situations like this’… and making sure the departments are communicating with HR more when they see employees may be having issues.”

Although employers struggled to accommodate and retain employees with mental and behavioral health problems, streamlined communication and proactive outreach appeared to help workers with mental and behavioral health problems stay in the labor force.

Employers’ accommodations of employees did not depend solely on community- and organization-level factors such as resources and communication processes. An employee could be more or less likely to receive accommodations based on his or her personal characteristics, such as tenure, work performance, role in the company, and type of health problem.

“The individual hadn’t been with the company very long. That’s typically when you’re going to see retention not working out, [because you don’t] feel compelled to have to offer as much as you would [to] someone who put in [more] time with the organization.”

-An HR director explains her decision not to accommodate a new employee who developed a back problem shortly after being hired

Tenure: Employees who had been with an organization four years or longer when they developed or disclosed a health problem were less likely than those who had worked for shorter periods to be terminated or leave their jobs for reasons related to their health problem. Employers cited three reasons why they made extra efforts for employees with long tenures: the investment they had already made in the employee, the loyalty demonstrated by the employee, and concerns about how an organization that does not retain long-term employees would be thought of in the community or by other employees.

Work performance: The quality of an employee’s work performance before the onset of a health problem also seemed to affect an employer’s efforts to accommodate and retain workers. Of the 14 employers we interviewed, six cited good performance as a factor that incentivized them to “make more of an effort” to accommodate employees. One respondent remarked, “Once you find that perfect person, you really want to keep them on.”

Physically active versus sedentary work: Employers said it was more challenging to accommodate and retain workers in physically active roles (such as assembly line workers and health care professionals) than it was to accommodate those in sedentary roles (such as financial specialists and clerical workers). An HR director at a health services organization said her “hands were tied” when a worker in a physical role developed a back problem: The employee missed a lot of work and could not do his job from home, so we sent a letter to his physician … We had a series of questions—what job duties can [the employee] not complete, what accommodations, if any, could we make, how much weight can he lift.” When the doctor could not say how long it would take for the condition to improve and could not identify accommodations that could help the employee to stay on in his role, the employee was terminated.

“There was no one thing we could do to accommodate everything. It was too complicated.”

-A benefits administrator describes efforts to accommodate a customer service representative with Stage IV cancer

Type of health problem: The most challenging health problems for employers to accommodate were mental and behavioral health conditions (see Box 3), terminal illnesses, and severe health problems that hindered workers’ ability to perform basic activities of daily living. Conversely, employers described musculoskeletal conditions and conditions that could be addressed with ergonomic adjustments as “low-hanging fruit” because of their relatively low cost and the fact that employees with these conditions tended to have a better ability to identify the technology they needed the employer to purchase.

Implications for policy

Employers need appropriate resources and effective communication strategies to accommodate workers. Policy interventions designed to bolster employers’ resources (like the ARS SAW/RTW program) and advance the flow of information (such as programs that provide case management services for workers with health problems) should help employers who need assistance in these areas, assuming the employers know about them. However, our findings suggest that the employees’ own characteristics also play a pivotal role in whether employers make real efforts to accommodate and retain workers. Even when community- and organization-level factors are the same, employers take different actions for different employees, depending on the employee’s tenure, work performance, role, and health problem.

This has important implications for existing programs such as the ARS SAW/RTW program and recent early intervention policy proposals—such as the Health and Work Service proposed by Christian et al. (2016) and the Employment/Eligibility Services proposed by Stapleton et al. (2016). When early intervention programs require employers to get involved, the designers of the intervention (and those who deliver it) should take into account the different ways that employers treat employees with new health problems. For example, employers may quickly take advantage of new intervention services when an employee with long tenure, high performance levels, and/or a sedentary job develops a health problem that appears straightforward to accommodate, but they may expend less effort when other employees develop health problems, focusing only on maintaining statutory compliance. Policymakers may want to consider strategies for reaching employees—for example, those with short tenure or perceived poor performance—who may be overlooked by employers with limited resource



Anand, Priyanka, and Yonatan Ben-Shalom. The Promise of Better Economic Outcomes for Workers with Musculoskeletal Conditions. New York, NY: Roosevelt House Public Policy Institute at Hunter College, 2017

Ben-Shalom, Yonatan, and Hannah Burak. “The Case for Public Investment in Stay-at-Work/Return-to-Work Programs.” Washington, DC: Center for Studying Disability Policy, 2016.

Burkhauser, R, M. Schmeiser, and R. Weathers. ”The Importance of Anti-Discrimination and Workers’ Compensation Laws on Provision of Workplace Accommodations Following the Onset of a Disability.” Industrial and Labor Relations Review, vol. 65, 2012, pp. 161–180.

Christian, J., et. al. “A Community-Focused Health and Work Service (HWS).” In SSDI Solutions: Ideas to Strengthen the Social Security Disability Insurance Program, edited by J. McCrery and E. Pomeroy. West Conshohocken, PA: Infinity Publishing, 2016.

Franche, R.L., K. Cullen, J. Clarke, E. Irvin, S. Sinclair, and J. Frank. “Workplace-Based Return-to-Work Interventions: A Systematic Review of the Quantitative Literature.” Journal of Occupational Rehabilitation. 2005: 15: pp. 607–631.

Hollenbeck K. “Promoting Retention or Reemployment of Workers After a Significant Injury or Illness.” Washington, DC: Center for Studying Disability Policy, 2015.

Schimmel, J.H., and D. Stapleton. “The Financial Repercussions of New Work-Limiting Health Conditions for Older Workers.” Inquiry, vol 49, 2012, pp. 141–163.

Shier, M., et. al. “Barriers to Employment as Experienced by Disabled People: A Qualitative Analysis in Calgary and Regina, Canada.” Disability and Society, vol. 24, 2009, pp. 63–75.

Stapleton, David, Yonatan Ben-Shalom, and David Mann. “The employment/eligibility service system: a new gateway for employment supports and social security disability benefits.” In McCrery J, Pomeroy E, editors. SSDI Solutions: Ideas to Strengthen the Social Security Disability Insurance Program. West Conshohocken, PA: Infinity Publishing. 2016.

This issue brief is the fourth in Advancing Policy to Support Workers with Disabilities, a Roosevelt House series edited by Professor Purvi Sevak that aims to objectively synthesize research that can inform policymakers and other stakeholders of the potential impacts of a range of policy changes on employment of individuals with disabilities. Research to support the series is funded by the Rehabilitation Research and Training Center on Employment Policy and Measurement, housed at the Institute on Disability at the University of New Hampshire, with partners at the Association of University Centers on Disability, Hunter College, Kessler Foundation, and Mathematica Policy Research. The Center conducts research and knowledge translation activities to improve the employment outcomes of people with disabilities.


This series is funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (U.S. Department of Health and Human Services) under cooperative agreement 90RT5037. The findings and conclusions are those of the authors and do not represent the policy of HHS or NIDILRR. The authors declare that they have no competing interests and retain sole responsibility for any errors or omissions.

[1] The Americans with Disabilities Act (ADA) and other federal and state regulations have important implications for employers of workers with health problems. For example, the ADA requires employers with 15 or more full-time employees to provide reasonable accommodations to qualified individuals with disabilities, unless doing so would cause “undue hardship” to the employer. Although the literature indicates that the ADA and state anti-discrimination laws significantly increased accommodations to workers with disabilities (Burkhauser et al. 2012), other studies suggest that discrimination and other employer attitudes are still barriers to workers who are struggling to find and keep jobs after experiencing health problems (Shier et al. 2009; Kaye et al. 2012).

[2] JAN, a free online resource and consulting service for employers and individuals with disabilities, is funded by the U.S. Department of Labor’s Office of Disability Employment Policy.

Katie Morrison is a health analyst at Mathematica Policy Research, where she supports research on employment and health policy initiatives aimed at individuals with disabilities. She recently worked on a study examining the impact of a $1-for-$2 benefit offset on the earnings of Social Security Disability Insurance beneficiaries. Katie has her Masters in Public Policy from Georgetown University.

Rayna Thornton is a program associate at Mathematica Policy Research where she supports researchers in studies on employment policy and individuals with disabilities. Rayna has her B.A. in Economics from Spelman College.

Alix Gould-Werth is a researcher at Mathematica Policy Research whose primary research interest is social programs and policies designed to improve the economic circumstances of people with low incomes, including through examining employer-employee interactions. She has a special interest in Unemployment Insurance, Temporary Assistance to Needy Families, disability benefits, and reforms to the criminal justice system. She has a Ph.D. in Social Work and Sociology from the University of Michigan.

Yonatan Ben-Shalom is a senior researcher at Mathematica’s Center for Studying Disability Policy, with expertise in policies and programs related to the employment and income of people with disabilities—especially those who acquire disability in adulthood such as workers and veterans. From 2013 to 2016, he directed the Stay-at-Work/Return-to-Work Policy Collaborative, a project funded by the Office of Disability Employment Policy at the U.S. Department of Labor. The Collaborative focused on advancing policies and programs that promote positive job-retention outcomes for workers who experience a medical condition that increases their risk for labor force exit. Dr. Ben-Shalom has served as principal investigator for numerous studies funded by the Social Security Administration and the National Institute on Disability, Independent Living, and Rehabilitation Research. He has a Ph.D. in Economics from the Johns Hopkins University.