2015 Ushers in an Era of Change

By Phyllis Hanlon

The Affordable Care Act (ACA) is reshaping the nation’s healthcare system in innumerable ways, some positive, some negative, and some that remain to be seen. One positive effect, deduced by The RAND Corporation (www.rand.org), is that 9.3 million more American adults had health coverage between September 2013 and March 2014. Certainly, in the midst of so much change and challenge, opportunities have arisen, especially for occupational health providers.

At the National Association of Occupational Health Professionals (NAOHP) 28th Annual National Conference in Philadelphia, a panel of experts weighed in on what the ACA could mean for the profession in the coming years.

That the number of Americans living with chronic conditions is on the rise today is not news. The prevalence of obesity, for example, is increasing by 25 percent annually. One study (http://journals.lww.com/joem/Abstract/2007/07000/Health_and_Productivity_as_a_Business_Strategy.4.aspx) found nearly 80 percent of medical spending goes toward healthcare and medications for chronic conditions. Furthermore, the American workforce is aging. By 2015, one in five workers will be over 55 and an older workforce faces more health challenges. (https://journals.lww.com/joem/fulltext/2012/04000/optimizing_health_care_delivery_by_integrating.20.aspx)

While these statistics are noteworthy, the U.S. Census Bureau has even more alarming news, according to the conference panel. Although the country is experiencing a dramatic increase in the 65 and older set, the number of physicians available to care for them is not keeping pace. The current physician shortage is estimated at 62,000.

Over the next ten years, the shortfall is predicted to be 130,000. This situation will impede access to healthcare but it will also provide opportunities for occupational health professionals. (http://journals.lww.com/joem/Full-text/2012/04000/Optimizing_Health_Care_Delivery_by_Integrating.20.aspx)

Employer Woes

According to Dave Weir, president of the University of Pittsburg Medica Center’s (UPMC) WorkPartners (www.workpartners.com), baby boomers comprise the largest employee demographic block but use more healthcare services than any other sector of the population. So, this aging workforce may come up short when it comes to health coverage, as some employers, in reacting to premium hikes, taxes, and fees, revamp their benefits packages. In 2013, 83 of the nation’s largest corporations participated in a Business Group on Health Survey (www.busi-nessgrouphealth.org) in which employers projected a 7.2 percent increase in the cost of providing benefits. Fifty-three percent of respondents said they planned to increase their employees’ share of the premiums and 39 percent intended to raise deductibles.

Additionally, Mr. Weir spoke of the hidden costs that employers face when their workforce is unhealthy. For every dollar spent on worker medication and pharmacy costs, the employer absorbs $2-3 of productivity costs from presenteeism, absenteeism, and disability. On the other hand, these challenges could motivate employers to invest in the health of their workforce, and that means more opportunities for occupational health providers.

Occupational health programs can help keep the costs accompanying workers’ compensation claims down through the use of biometric screenings, health risk assessments, pharmacy outreach, a 24/7 nurse line, employer-driven wellness programs, and clinical engagement programs like patient-centered medical homes.

For example, Mr. Weir said UPMC WorkPartners instituted a comprehensive health and productivity program that relies on service integration. The wellness and health management component includes health promotion, lifestyle coaching, condition management, a wellness portal, incentive design, and population analysis. Meanwhile, onsite health services include urgent care and a mobile medical unit. Employee assistance comprises short-term behavioral health counseling, return-to-work assistance, and more.

Seventy-five percent of doctors’ offices now have care managers and UPMC WorkPartners has connected rehabilitation with health coaches through an electronic health record system. “You need to engage the patient and the doctor. Different medical professionals have to work together to manage a patient’s condition,” Mr.Weir said. “You also need to look at the whole person when devising a treatment plan. Traditionally, programs have been [in] silos but now [they] need to become integrated.”

Workforce Evolution


Dr. Arlene Guzik, assistant medical director and vice president of operations at the Florida-based Lake-side Occupational Medical Centers, thinks the ACA is creating fertile ground for occupational health providers to demonstrate how their services can help employers contain costs and support employee health.

She said the workforce in recent years has undergone a metamorphosis. “The days of working for one company for your entire career are gone,” she said. Today’s workplace has more women, dispersed generations, ethnic diversity, contract and older workers. In addition to assisting employers with health and wellness programs, occupational health professionals are a resource for employees who have challenges navigating the complex system, e.g., finding specialists, making appointments, and gaining access to medical records, according to Ms. Guzik. Acting as advocates, occupational health professionals can assist these individuals as they work to improve their health.

Although some companies operate without a formal on-site occupational health program, Ms. Guzik pointed out that alliance with a community partner is necessary but not always effective. “That partner might not know what the employees need,” she said. Companies that choose to offer an internal occupational health program that addresses workers’ compensation and offers urgent, episodic, and primary care help ensure workers remain healthy and on the job.

Workers’ Compensation


The ACA’s impact on workers’ compensation is still emerging, but Dr. Maria G. Michas, MD, MPH, FACOEM, who practices at US Health- works, among other programs, speculated about its potential effects. If the legislation performs as intended, employers should have healthier workers who recover faster. Additionally, better healthcare invariably means less cost shifting, fewer false claims, and reduced workers’ compensation expenses. On the flip side, patients may experience delays in care due to the physician shortage, which could also mean extended disability duration and delayed return to work. Employees with higher deductibles and co-pays may be more inclined to file workers’ compensation claims, and that too would push up an employer’s workers’ compensation costs.

Chronic conditions cost employers up to $93 billion a year in insurance claims and have increased notably, according to Dr. Michas. Fifty percent of Americans have a chronic condition and approximately 80 percent of healthcare spending can be attributed to caring for them. Plus, roughly $800 billion a year is spent on wasteful, redundant testing. “Health status affects work performance and productivity. Occupational medicine [aims for] a quick return to work, so it seems in line with the mission of the ACA,” Dr. Michas said.

Dr. Michas predicted that blended programs will continue to multiply. “Occupational medicine [mixed with] urgent care will be the norm. Larger occupational medicine programs will become urgent care centers and take on higher-level workers’ compensation claims. Telemedicine in remote areas will increase,” she said. The American Telemedicine site predicts that 48 percent of Medicare patients will use telehealth options instead of going to the emergency room. As more elements of the ACA are implemented, Dr. Michas expects occupational medicine providers to act as coordinators while educating the working population about health plans and how to access their benefits.

Opportunities Abound

Craig D. Thorne, MD, MPH, MBA, FACP, FACOEM, vice president and medical director of Employee Health and Wellness at Erickson Living, is optimistic about the industry’s prospects in the ACA era. Two elements of the ACA in particular present huge opportunities for occupational health professionals who design and promote work site programs: 100 percent coverage for preventive services and incentives for wellness. Dr. Thorne suggested beginning with an assessment of current work fitness and disability prevention and management efforts and moving on to on-site employer-sponsored fitness and wellness programs. Tie rewards to healthy behaviors (e.g., the completion of HRAs, biometric tests, nutrition and weight management classes, flu clinics, tobacco cessation programs, and, last but not least, reaching goals).

Maximum permissible rewards under health-contingent wellness programs have increased to 20 to 30 percent of the cost of health coverage. Rewards for programs designed to prevent or reduce tobacco use can be as much as 50 percent of the cost of coverage. “When designing a program to promote health and prevent disease, it must be non-discriminatory, not overly burdensome, and employees need to know about this opportunity,” he added.

Dr. Thorne emphasized the importance of helping employers devise a plan for reducing chronic conditions and risk factors and their associated bottom-line impacts. He pointed out, though, that financial indices should be tracked, but increases in health scores should also be recorded.

As healthcare advocates, occupational medicine practitioners should develop relationships with community medical facilities and act as liaisons between workers and these entities by, for example, finding appropriate primary care providers or specialists, scheduling appointments, obtaining estimates on common procedures, and helping resolve insurance claims. “We can find centers of value and steer patients to urgent care clinics in their area,” Dr. Thorne said.

Occupational medicine professionals can address mental and behavioral health issues too, Dr. Thorne said. Through Employee Assistance (EAP) and Work/Life Programs, they can help employees locate licensed experts for marital conflicts, parent-child issues, stress and anxiety issues, and can address other problems such as drug and alcohol abuse, eldercare, childcare, financial and legal matters. 

Erickson Living uses a SMART (Specific Measured Attainable Relevant and Time) strategy when it comes to the health and wellness of its employees. Dr. Thorne explained that SMART’s goals are to enhance the overall physical and mental health of its staff. “Wetie SMART goals to bonuses,” he said. “We’ve also developed quick tip guides for complex tasks like workers’ compensation reporting and case management, data management, and root-cause analysis for injuries.”

The company issues monthly productivity reports that include all wellness efforts–– smoking cessation education and a number of enrollees. The report also provides vendor referrals to nurse health coaches and health advocacy services.

Dr. Thorne emphasized that occupational health services are more important than ever due to the ACA’s emphasis on affordability and quality. Occupational health providers can help reduce health inflation for the government and payers and perhaps even help employers avoid added taxes by providing cost-effective care in the workplace. Though access continues to be a problem, occupational health providers can help employees get more timely medical attention.

The employer mandate to offer health insurance to all full-time employees or risk penalties is bound to encourage employers to invest in wellness and prevention. This means there will be more opportunities to provide chronic condition management and care coordination. Dr. Thorne strongly believes in measuring and rewarding progress, which incentivizes providers to strive for true outcomes vs. fee-for-service reimbursement. “You need to customize goals to each provider’s individual performance,” said Dr. Thorne.

Real reform starts with increased access to health and a focus on prevention and early intervention, said Dr.Thorne. This in turn sets the stage for on-site programs. These healthrelated activities will help to increase the productivity and competitiveness of workers. When workers understand how best to use their health benefits and get rewarded for engaging in their own health and wellness goals, they will optimize their health status. When all is said and done, the ACA could be a win-win for the American public and the occupational health professional.

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