Employers are painfully aware of the toll chronic illness takes in lost workdays. Now, as they fight alarming increases in health care costs, many want to know how these conditions affect so-called presenteeism, or the reduced performance of employees when they're on the job.

"We're not just worried about absenteeism. We're worried about if, when they are at work, are they fully with us, are they engaged and are they excited about doing their work and working at full potential," said David McKenas, medical director at American Airlines Inc.

In a report published in the March issue of the Journal of Occupational and Environmental Medicine, Dr. Ronald C. Kessler, a researcher at Harvard Medical School, said presenteeism nationwide totals 2.5 billion days each year.

Another report, by the Boston-based Institute for Healthcare Improvement, places the cost of treating chronic conditions at $470 billion a year _ and climbing _ and the cost of lost productivity from chronic illnesses at $230 billion a year.

"Increasingly, an important actor in the health care debate in America is employers, because they're paying for the large health care contracts," Kessler said. "So now employers are very interested in productivity and how health care can help improve the day-to-day efficiency of their workers."

Kessler based his figures on a survey of 3,032 adults conducted by the MacArthur Foundation Midlife Development in the United States. The participants submitted self-reports on their symptoms and productivity levels. Over a 30-day period, 20.2 percent of respondents said they worked less or left early at least one day, compared with 17.5 percent who called in sick at least one day.

"Presenteeism _ when they show up to work but do less _ is more important than absenteeism because for certain illnesses, it's the larger share of productivity loss," he said.

But measuring productivity is a difficult task. It's much easier to note that a worker is sitting at her desk than to say that she's there but only working at 90 percent of capacity, he said.

Work impairments also have a trickle-down effect, he said.

"When I'm at work but only producing at 50 percent and I work in a group, I might be messing up the work performance of five people or 10 people," he said.

Kessler recognizes that his results, based on self-reports, could introduce error. He's working with several major corporations to develop figures in a more controlled setting. Results will be available next year.

Focus groups include Fort Worth, Texas-based reservations agents at American Airlines, where administrators already measure productivity levels.

"Reservation centers are able to track not only activity, such as how much time they're on the phone, how promptly they answer the phone, but they can also track the results of their effort and how much revenue is booked in an eight-hour shift," said John Saylor, manager of American Airlines' employers assistance program. "It's a good opportunity to do research they couldn't do anywhere else."

Kessler said the purpose of his study is not to point fingers at workers with chronic conditions but rather help improve their quality of life.

"Quite a few companies are starting to look at health care as an investment opportunity, as a way to pick plans that will offer a return on the investment," he said.

Health care providers have started to offer numerous disease-specific or disease management programs that feature outreach to employees, newer medications with fewer side effects, education on the benefits of diet and exercise, and training to employers.

Their efforts come on the heels of much criticism of the health care system.

A private organization chartered by Congress to advise the government on scientific matters said in early March that the American health care system is failing to improve the care of patients. The Institute of Medicine specifically recommended that health care providers develop and promote detailed strategies to treat 15 chronic conditions, such as asthma, heart disease and diabetes.

Gerard F. Anderson, executive director of the nonprofit Partnership for Solutions, which works to improve the lives of people with chronic conditions, said it has become easier for employers to design appropriate health benefit packages for those people.

"What they should do is look at what some of the more enlightened companies offer. But one thing we've found in talking with corporate managers is that a lot of people don't ask the right questions about chronic illness benefits because they don't think they can get it," said Anderson, also a professor at Johns Hopkins University.

Aetna Inc., for instance, runs a Healthy Outlook Program for management of asthma, heart failure, diabetes and low back pain. Each program includes individualized instruction and material. Diabetes patients receive videos and workbooks on blood-sugar control, glucose self-monitoring equipment and access to specialized professionals.

"We've found that patients who have information about a disease and manage it have a positive impact on their quality of life. They work better, and employers see that as a good thing," said Andrea Maluso, Aetna's certified case manager in Dallas-Forth Worth.

Aetna's Healthy Outlook Program is free to subscribers. Of the 300,000 subscribers in the area, 9,600 are enrolled in it.

Cigna Health Care offers a similar Well Aware Program for Better Health. It, too, embraces only a small percentage _ 3.5 percent nationally _ of all potential patients with chronic conditions.

"Not everyone is taking advantage of it. Employers may not be telling their workers that they're eligible," said Dr. Richard M. Burton, Cigna's senior medical director.

Alton Anderson, an Arlington, Texas, insurance agent, discovered Cigna's Well Aware program two years ago. He'd been fighting diabetes for 13 years with limited specialized care.

"I'd check my blood-sugar level and get glucose if I needed it, but I never felt like I had a health problem or that I was sick," he said.

A foot blister, however, led to the amputation of his left leg. Now he's more careful than ever to monitor his condition.

Anderson, 62, said Cigna's Well Aware program makes a huge difference "I feel like I've really been able to control my diabetes with the information that they send me and the services that I receive," he said.

While health organizations push for more comprehensive treatment plans, employers are finding ways to enhance their workers' productivity.

J.C. Penney Co., for example, offers two health seminars a month on topics such as diabetes, hypertension, depression and stress for its 9,000 employees in Dallas-Fort Worth. Cigna Behavioral Health and Texas Health Resources Programs run the seminars. Its corporate headquarters in Plano, Texas, features a fitness club, child-care center and medical facility.

"J.C. Penney has always been concerned with the welfare of our associates. If we didn't have the associates running the day-to-day business, running the stores, managing the operation, where would we be?" asked Stephanie Brown, senior public relations coordinator.

AMR Corp., the parent company of American Airlines, operates a 10-room medical facility called Dallas Hope at Dallas/Fort Worth International Airport. A staff of 120 medical professionals caters to the needs of the 31,700 employees in the area.

McKenas said the presence of the clinic has helped reduce lost time. A diabetic who may feel shaky can receive a blood check and glucose, if needed, and assume their normal responsibilities.

Workers injured on the job return to work within five days, compared with 21 days when they're treated elsewhere, McKenas said.

"The whole goal is to return the workers to work as soon as possible, ideally before the mindset of disability comes to fore," he said.

Dallas Hope, operated with a $90,000 monthly budget, also offers workers flu vaccinations, fatigue countermeasures, cholesterol screening and a mobile mammography program.

Texas Instruments provides comprehensive services through an on-site Baylor Health Care Systems clinic. But the company's philosophy is to promote self-responsibility by giving people the tools and heading them in the right direction, said Janet Solomon, TI's Health Benefits and Wellness Director.

"Chronic conditions can still benefit from preventive measures. If you have asthma, you want to prevent an attack. People out many days are people who don't control their asthma," she said.

Kessler said he expects more employers to seek improved care for chronic conditions once they study the bottom line.

"There are things that corporate America is appreciating more. For example, last flu season was the worst we've seen in long time. All of a sudden this flu season, everyone wanted to give their employees the flu shot because they realize the cost of a little flu shot is so much cheaper than having your employees disappear for a week. The same thing is happening with allergies," he said.

Innovative companies have started to link their human resources programs with staff that analyze returns on investment. American Airlines will soon hire an epidemiologist to look at what's causing workers to slow down.

"We have to better study the problem to have the lever to make changes we need to make," McKenas said.

In the meantime, American Airlines continues its research on presenteeism with Harvard Medical School.

"Dr. Kessler is fighting a battle that we long ago accomplished here," said American's Saylor, "and that is to get a company to say if we help our employees become a little more healthy, then maybe our company will be more successful."

(c) 2001, The Dallas Morning News. Reprinted with permission of The Dallas Morning News.