Course 1: Adapting to the Affordable Care Act will be a Bitter-Sweet Endeavor
How is the Patient Protection and Affordable Care Act (ACA) likely to impact occupational health? While the answer to that question varies, both supporters and detractors agree on one thing: staying informed about the various requirements of the ACA is essential.
THE PROS
Employers that have occupational medicine clinicians on staff or on contract may opt to expand those services, especially as 2018 approaches and companies begin doing everything they can to stay under the threshold for costs of expensive health plans in order to avoid the so-called ‘Cadillac tax.’ “If you’ve got occupational medical staff within the company or you have a clinic that does occupational medicine, they might be called upon to do a lot more to help keep the plan costs under [that] threshold.
So it is possibly going to ramp-up the scope of their activities beyond occupational medicine,” said Steve Wojcik, vice president for public policy at the National Business Group on Health. According to Mr. Wojcik, the trend over last several years has been that employers of significant size, especially if they have significant concentrations of employees, have been expanding their work-site clinics or ties to clinics within the community. Mr. Wojcik explained that as healthcare costs keep climbing, employers feel that by bringing those services in house or using community-based clinics, they can control both quality and cost better for primary care and preventive services.
THE CONS
For employers, what they’ve seen so far is mainly new benefit requirements, expansion of coverage for adult children up to age 26, new health plan rules and, more recently, fees, assessments, and penalties. “They’ve seen the negative side of the ACA so far in terms of costs, new administrative burdens and additional benefits they have to provide in the way specified by the government,” Mr. Wojcik said. In addition, some employers have had to make or plan for workforce and staffing changes because the ACA is tied to this new definition of full time––30 or more hours per week equals full time for the purposes of healthcare obligations on the part of employers or they pay penalties.
Dr. Robert Orford, a senior consultant with the Mayo Clinic’s Executive Health Program in Scottsdale, AZ, said that it is particularly important that occupational physicians be knowledgeable about provisions of the ACA that will impact their corporations as well as the financial and human impact such provisions are likely to have on their workforce. Dr. Orford noted that while many employers will continue to offer traditional insurance products to their employees, others might decide to decrease their internal insurance benefits and encourage employees to participate in insurance exchanges set up at the state level or by the federal government. “The implications of these changes on the American workforce remain uncertain at this time,” Dr. Orford said. Adapting to the Affordable Care Act will be the subject of course one at RYAN Associates’ 27th Annual National Conference. Dr. Kent Peterson, Rich Williams, Dr. Lee Newman and Chuck McDevitt will serve as faculty. Frank Leone will serve as moderator.
COURSE 2 Benchmarks are the Street Signs on the Road to Success
Benchmarks: Vital Indicators for Occupational Health Programs
Benchmarks are like vitamins––a little hard to swallow but vital for the health of your program. Clear and unambiguous indicators, benchmarks reveal how your program measures up against evidence-based standards of care, productivity, efficiency, and more. There is no way of improving or even monitoring your program’s quality without them.
For example, 60 percent of patients with acute low-back pain will recover within two weeks and return to their full duties in five working days. That’s the standard.
How quickly do low-back-pain patients coming to your clinic return to full duty? Programs need to measure productivity too, and patient waiting times are a good way to gauge your providers’ productivity. According to Donna Lee Gardner, R.N., M.B.A., a senior principal at RYAN Associates, the standard for patient visits is in and out in 45 minutes. How long does it take to process your patients?
Occupational health programs should use benchmarks liberally and creatively to improve not only their programs but the health of the larger workforce. Today there are measures that can help companies achieve a more productive workforce while furthering their bottom line.
“Let’s benchmark what works. Let’s not benchmark things that have worked in the past,” said President and Vice-Chairman of US Preventive Medicine Ron Loeppke, M.D., recently appointed President of the American College of Occupational and Environmental Medicine (ACOEM). “Using medical and pharmacy costs as a benchmark for employee health doesn’t work anymore. Measure rates of employee participation and engagement in wellness programs instead––the greater the rate of participation, the greater the outcome,” said Dr. Loeppke. He added that age and gender-specific screening measures, including colonoscopies and mammograms, are also useful benchmarks.
“Such leading indicators will ultimately yield lagging indicators,” said Dr. Loeppke. “The health of the workforce is inextricably linked to the productivity of the workforce and the health of the bottom line of the company.” For more information on Dr. Loeppke’s work, see The International Journal of Workplace Health Management, Vol. 1, No. 2, 2008, or www.emeraldinsight.com/1753-8351.htm.
Benchmarking and Outcome Development will be the subject of course two at Ryan Associates’ 27th Annual National Conference. Dr. Ron Loeppke, Ken Eichler, Kim Eidson, Frank Leone, and Roy Gerber will serve as faculty. Deb Borisjuk will serve as moderator.
COURSE 4: Integration, Partnerships, and Expansion of Services Lead Occupational Health Trends
What lies ahead for the field of occupational health? What trends are emerging? And what types of strategies are being developed to help define the next generation of programs?
Integration is one trend industry insiders say has tremendous potential. Combining urgent care clinics with occupational health clinics, for example, is rapidly gaining ground. One industry insider noted that “occupational health used to march to [its] own tune. Now there are a vast number of occupational health and urgent care blended clinics under the same roof. You also get family practice and primary care. There’s a real blending, and it is likely to continue.”
The impact of the Affordable Care Act (ACA) on occupational health is another trend to keep an eye on. As a result of the ACA, a wider variety of screenings will be covered and mandated by carriers. Once you have access to a large volume of people, it is the golden opportunity that occupational health can provide to their parent institution.
Social media is another notable trend the industry is keeping an eye on. Making intelligent use of social media to bring wellness information to young people who rely on cell phones is a strategy that experts say must be embraced, as it is the media this demographic group is comfortable with. “New media,” said Frank Leone, executive director of the NAOHP, “is transforming the way we teach, and in occupational health, it is all about educating and teaching people.”
In addition to staying abreast of trends and developing a strategic vision, according to Dr. K. Andrew Crighton, Vice President and Chief Medical Officer at Prudential Financial, the field of occupational health will need to go beyond subject matter and expertise and exhibit leadership qualities. Crighton said this will require such strategies as:
- Developing and conveying a compelling strategy on how health impacts business
- Possessing in-depth knowledge of your business partners
- Developing communication skills that convey trust and confidence in areas beyond just medicine
Patrick McIntyre, Business Director, Department of Occupational Medicine at Worcester, MA-based Reliant Medical Group, said it will be important going forward to position the occupational health group as a liaison with employer groups to drive additional services and impact employees as well as patients.
Ultimately, he said, it is the employer/company that decides what happens at the worksite. In other words, you have to be able to connect with different stakeholders at a company such as representatives from finance, human resources, safety, wellness, and risk management. “While they are all focused on the same goal––the success of their business––they may have different opinions on the strategies and tactics that they believe will help them achieve success. You need to clearly understand how your services can help them achieve success,” Mr. McIntyre said.
Additions to traditional occupational health services could include employee assistance programs (EAP), chronic disease management (including diabetes, hypertension, and obesity), resources to support wellness programs, organizational development services, and access to primary healthcare services. Mr. McIntyre said that if an organization does not have the ability to provide additional services, they could partner with vendors that provide complementary services that will be viewed as resources by the employer.
Occupational Health Trends and Strategic Vision will be the subject of course four at RYAN Associates’ 27th Annual National Conference. Dr. Dana Headapohl, Dr. Melanie Swift, and Bill Bramble will serve as faculty. Dr. John Braddock will serve as the panel moderator.
COURSE 5: Standards and Protocols are Bread and Butter of Quality
In a field as challenging as occupational health, it pays to stick to the script.
Successful practice managers invariably recognize that industry standards, and the protocols that sustain them, create quality services. Appropriate clinical standards are based on decades of evidence-based research, tweaked and honed by the field’s top practitioners. Fortunately, there are numerous guidelines and standards for practitioners to tap. In 2010, the American College of Occupational and Environmental Medicine (www.acoem. org) published the third edition of its four-volume Clinical Practice Guidelines (acoem.org/practiceguidelines.aspx), which were recently acquired by the Reed Group (www.reedgroup.com/mdguidelines-acoem-treatment.htm). The Occupational Health and Safety Administration (OSHA), (www.osha.gov), has copious guidelines for workplace ergonomics, monitoring of workplace hazardous exposures, and more.
“When we use guidelines or when we follow OSHA standards, we’re benefiting from the collective wisdom of the experts, and the guidelines that we rely on are evidence-based,” said Dr. Lee Newman, co-founder of Axion Health (www.axionhealth.com) and NAOHP national conference faculty. When it comes to the nuts and bolts of managing a program, standards are elemental. ACOEM has guidelines for program operations and quality improvement. NAOHP Certification is one way programs can ascertain if their practices are adhering to the standards across multiple functions, such as health services, customer satisfaction, marketing, and operations.
Standards and protocols help multi-clinic networks maintain consistency across all sites. AllOne Health (www.allonehealth.com), a large multi-clinic network headquartered in Boston, has broad, standardized procedures for all of their services, including employer services. Because clients have unique preferences for managing their workforce, AllOne clinics need to deliver services according to specifications. “Client A schedules all their employee exams at once, but client B is going to let [their employees] call in and schedule their own exams,” said Deb Talbot, R.N., COHN-S/CM, President of AllOne Health Resources. “We need to be consistent to make sure we deliver the [right] service at the right time.”
Emerging research on work site wellness and safety programs is helping establish a new standard, which Dr. Newman will discuss at the conference. The Centers for Disease Control and Prevention and the World Health Organization have recently established frameworks for best practices for organizations that want to introduce a work site wellness program: (cdc.gov/nccd-php/dnpao/hwi/policy/wellness_pro- grams.htm). Companies can use these best practices as an overall approach and customize them according to the needs of their employees. “Some companies might have a greater need for stress management services, but the basic framework is something that lends itself to being standardized,” Dr. Newman said. At the end of the day, standards and the protocols that allow them to be met are the foundation of successful program infrastructure and quality care. Continually evolving, they are the leading edge of our industry. Occupational Health Standards and Protocols will be the subject of course five at RYAN Associates’ 27th Annual National Conference. Donna Lee Gardner, Jeremy Ford, Robert Dill, and Therese Pacelli will serve as faculty. Dr. Joe Fanucchi will serve as moderator.
COURSE 6: Productivity Management is About Details and Finesse
There is an art to running a profitable occupational health clinic, and when it comes to staffing it, imagination is particularly key. The more innovative you can be in finding the right mix of skills and quantity, the better your clinic is going to perform. According to Donna Lee Gardner, R.N., M.B.A., senior principal at Ryan Associates, the trick is not to over or under hire but to figure out who can do the best job for the least amount of money. For example, instead of sending a physician to a work site call, some clinics employ a certified paramedic for this purpose. Less expensive than a physician, he or she is fully capable of handling any work site injury or wellness task. That’s a creative use of resources.
Some clinic managers have told Ms. Gardner they need a second or third physician or another nurse practitioner for their small clinic. “I ask them why,” said Ms. Gardner. If they are not in a market where workplace injuries are complicated, where a manufacturing sector means a potential for complicated injuries, a provider-heavy staff is unnecessary, she said. In many markets, where injuries tend to be of the urgent care variety, only a single physician may be needed to serve as medical director and provide supervision for a nurse practitioner or physician assistant. “You have to know the market before you can determine what kind of staff you need,” Ms. Gardner said. And you have to know the laws in your state governing advance practice nurses and medical assistants. In some states, medical assistants can’t perform x-rays or draw blood.
But productivity management is also about determining how well your staff is performing against national productivity standards. Technology, work environment, and training all affect the length of time it takes to get a job done. National productivity standards help clinics benchmark for productivity and monitor for ongoing quality. These standards change from year to year, due to innovations in dictation equipment, software, and more. The bottom line is, when it comes to managing your clinic’s productivity, if you know the standards and are willing to be innovative with your use of resources, you are heading in a productive direction.
Occupational Health Productivity Management will be the subject of course six at Ryan Associates’ 27th Annual National Conference. Dr. Bernyce Peplowski, Denia Lash, and Leonard Bevill will serve as faculty. Karen O’Hara will serve as the panel moderator.
COURSE 8: Industry Leaders Reflect on White-Collar Occupational Health
These days, the term white-collar worker is rather vague. If you go back a century or two, there was a fairly clear distinction between those who worked in factories, mining, farming, etc., with coveralls and “blue collars” and those who worked in offices and wore white collars. Dr. Robert Orford, senior consultant with the Mayo Clinic’s Executive Health Program in Scottsdale, AZ, pointed out that as large chunks of the manufacturing sector have moved to other countries in the last twenty years, the information technology industry has rapidly evolved. The bottom line: the nature of work has changed for much of the U.S. workforce.
There will always be a need for the “patch me up doc (or nurse) and get me back to work” type of occupational health services. However, according to Dr. Orford, when it comes to white-collar occupational health, the recent strategic shift towards group health management and health and productivity management is as applicable to those in office positions as those in more risky manufacturing jobs. From a patient-care perspective, Steve Wojcik, vice president of public policy at the National Business Group on Health (NBGH), said white-collar occupational health programs need to focus on:
- Ergonomics: Including musculoskeletal health, posture, and alignment, as office workers sit at their computers all day. Focus on prevention as much as treatment: taking breaks, stretching, walking, and massage all serve to minimize injuries.
- Vision: Including eyestrain due to staring at monitors. Again, prevention should be the emphasis and should include scheduling breaks and eye exercises.
- Stress: Appears to be the big one. Prevention should include relaxation, exercise, and sleep management programs.
Dr. K. Andrew Crighton, vice president and chief medical officer at Prudential Financial, said white-collar occupational health will need to go beyond subject matter expertise and exhibit leadership. This will require, among other things:
- Developing and conveying a compelling strategy on how health impacts business.
- Possessing in-depth knowledge of your business partners.
- Cultivating communication skills that convey trust and confidence in areas beyond medicine (such as behavior modification).
In addition, Dr. Crighton said it is important to focus on individual and organizational health. “Health is more than just the medical side of the equation.” He suggested expanding the definition of mental well-being to include social and financial well-being. “This will force occupational health leaders to consider broader solutions and partnerships [with] today’s workforce.”
White-Collar Occupational Health will be the subject of course eight at Ryan Associates’ 27th Annual National Conference. Dr. Robert Orford, Monika Valentine, and Dr. Maria Michas will serve as faculty. Mike Schmidt will serve as panel moderator.
COURSE 9: Operational Efficiencies are Oil in the Engine of Success
Achieving operational efficiencies means staying focused on the details. Elements of staffing, billing, outcomes, and quality monitoring are all key to the efficient operation of an occupational health program. The good news is that proven systems for helping practices reach maximum effectiveness, including technologies and protocols, are being employed to maximum benefit every day–from having an appropriate staffing mix to the use of patient flow charts to the avoidance of clinic configurations that force staff to walk farther than necessary for a simple chart drop-off.
Donna Lee Gardner, R.N., M.B.A., senior principal at RYAN Associates, offered a number of efficiency tips. For example, make sure your organization has a defined organizational structure and that it is delineated on a chart that describes who on the staff does what. Plus, each program position should have a detailed job description and competencies that go along with it. If you are hiring a medical assistant, for example, the job description should say something like, ‘We want our M.A. to be able to do breath-alcohol tests,’ and so forth. “Every special activity required in a job should have a competency that goes along with it,” said Ms. Gardner. Also, programs need to make sure they have a process for documenting everything done for a given patient, so the organization can charge for it.
Dr. Steve Dawkins, medical director at Caduceus Occupational Medicine in Atlanta and Macon, Georgia, (www.caduceus24-7.com) said his clinic network uses a system of “float staff” to maintain adequate staffing levels across 12 clinic sites. Float staff are personnel recruited specifically to be moved from one location to another depending on patient load for the day, said Dr. Dawkins. “It’s also is helpful when someone calls [in] sick.” Sometimes, members of the float staff will be working at one particular site when a call comes in that 40 members of the police department are on their way in for drug screens at another clinic. The staff can be quickly moved to the location where they are needed most.
Alan Ayers, M.A., M.B.A., vice president of marketing development at Concentra Urgent Care (www.concentra.com) will speak to conference attendees about additional efficiencies made possible by incorporating urgent care into an occupational heath setting.
Achieving Operational Efficiency will be the subject of course nine at RYAN
Associates’ 27th Annual National Conference. Alan Ayers, Dr. Steve Dawkins, Donna Lee Gardner and Danielle Anderson will serve as faculty and Mary Alice Ehrlich will serve as panel moderator.
COURSE 10: A Healthy Workforce is a Performance Driver in Business
Today, more and more employers are seeing the value of investing in their workers’ health. In a 2008 study in the International Journal of Workplace Health Management, Ron Loeppke, M.D., ACOEM president and NAOHP national conference faculty, wrote, “Today’s reality is that health is a performance driver. Progressive employers are showing the way to ultimately controlling healthcare costs is by investing in their most important asset – their people (or human capital) – as ‘corporate athletes’ and improving their health and well-being.”
Dr. Loeppke’s research, as well as that of Dr. Dee Edington, shows that workforce wellness is inexorably linked with productivity and profit margin. Moving workers from high health risk categories to medium risk or even low risk has significant bottom line implications.
Meanwhile, regulations coming online next year in the Affordable Care Act (ACA) are set to take advantage of this connection by giving employers new ways of incentivizing employee participation in wellness programs. But what kinds of wellness programs work best? How do employers engage their workers in voluntary programs without seeming overly self-interested?
Ken Bush, director of occupational medicine at North Carolina’s Wake Forest Baptist Health, is creating wellness programs for the 3,500 employees of the Forsyth County government. “You are talking about fire fighters, sheriffs, environmental services,” Mr. Bush said. “It will be a Total Worker Health model.”
The question remains, how do you motivate people to change behavior to adopt healthier lifestyles? “There is no cookie-cutter model,” said Mr. Bush. “We as managers are so engaged in our process and program; we don’t stop and ask, ‘Where is this person at?’ We are only going to have a couple of opportunities with employees. If you miss it, you may not get another for another year.”
Mr. Bush said companies were moving from R.O.I. to V.O.I. (Value of Investment). “It’s more about the value . . . we prevented that heart attack but how do we track that? How do you measure the monetary value of something that hasn’t happened?”
Having access to on-site wellness services and programs is something that you can’t easily put a dollar value on, Mr. Bush said. It just makes sense. Employee wellness programs are a leading edge of the population health movement. This course will provide the latest information on research and give examples of models that are helping to improve the health of the U.S. workforce.
Integrating Wellness Services will be the subject of course ten at RYAN Associates’ 27th Annual National Conference. Dr. Lori Rolando, Ken Bush, and Yale Miller will serve as faculty. Kelley Maier will serve as panel moderator.
“Things have changed a lot, especially borne by merging affiliations of multiple healthcare facilities and the expanding of services offered under the occupational health umbrella.”
COURSE 11: Legal Issues are Many and Varied in Occupational Health
Occupational health programs face an array of legal issues today––rules and regulations that are accessories to modern advances in efficiency, fairness, and, hopefully, cost-containment. Whether it is new affiliations and partnerships, acquisitions, the blending of occupational health and urgent care, electronic health records (EHRs), Accountable Care Organizations (ACOs), or the Health Insurance Portability and Accountability Act (HIPAA), occupational health executives need to be aware of the myriad of legal challenges and their possible repercussions.
“Compared to 28 years ago, things have changed,” said Frank Leone, M.P.H., M.B.A., executive director of the National Association of Occupational Health Care Professionals (NAOHP). Mr. Leone said that 28 years ago, when you talked about legal issues in occupational health, it usually meant complying with Occupational Safety and Health Administration (OSHA) standards or workers’ compensation rules.
“Things have changed a lot, especially borne by the merging affiliations of multiple healthcare facilities and the expanding of services offered under the occupational health umbrella,” said Mr. Leone.
HIPAA is a huge issue when it comes to the employer-worker-clinician relationship. Why should occupational health programs pay attention to HIPAA privacy rules? Regarding medical records, for example, there are strict laws and confidentiality issues that employers must adhere to. According to HIPAA, employers have access to some protected health information if the disclosure is required to comply with laws relating to workers’ compensation. HIPAA also allows disclosure per the requirements of state or federal regulations.
Clinicians need to be mindful of confidentiality when recording patient information in occupational medical records. Occupational health clinicians regularly keep personal health information such as medical conditions not related to work separate from exposure records. However, certain OSHA standards require employers to obtain written opinions from clinicians performing required medical-surveillance examinations. These standards typically state that “the employer shall instruct the physician not to reveal in the written opinion specific findings or diagnoses unrelated to occupational exposure,” according to the U.S. Department of Labor.
An important question that occupational health decision-makers need to ask is ‘Do their EHR vendor’s products meet legal requirements?’ In 2011, the American College of Occupational and Environmental Medicine (ACOEM) welcomed the inclusion of occupational health data in a national standard for the meaningful use of EHRs. Concerned about legal issues, ACOEM advised The National Institute for Occupational Safety and Health (NIOSH) to advocate that EHR vendors develop software functionalities that meet the legal demands for data privacy, surveillance, and communication inherent to occupational health.
Finally, because occupational health clinicians work with a variety of records, OSHA recommends that these professionals understand the differences between these records, the confidentiality issues involved, and the specific rules related to them. Clinicians, for example, are familiar with personal medical records that include documentation of personal healthcare, routine preventive care, acute-illness care, and care of chronic diseases. Laws that affect information collected in medical records include HIPAA, the Americans with Disabilities Amendments Act, and the Genetic Information Nondiscrimination Act. Occupational health programs must also understand the individual state laws governing the privacy and confidentiality of personal medical records.
Legal Issues in Occupational Health will be the subject of course eleven at RYAN Associates’ 27th Annual National Conference. Dr. Al Osbahr, Dr. Jonas Kalnas, and Octavia Williams-Blake will serve as faculty. Barbara Enochs will serve as a panel moderator.
COURSE 12: Prior-to-Hire Functionality Tests Reduce Workplace Injuries
According to Indiana’s Worker’s Compensation Institute, on-the-job injuries cost the U.S. economy 170 billion dollars annually (www.iwci.org/comp-clues&item=282). No wonder employers want sensible prevention strategies.
Post-offer tests and pre-work screens are a straightforward way of reducing workplace injuries by ensuring your top pick for a job is physically capable of performing the tasks of the position. These evaluations are objective, scientific, and crafted based on detailed job descriptions, including careful ergonomic measurements.
Yet many employers don’t take advantage of them. Functional, post-offer tests have been around for decades. Today, however, employment law only allows a person’s ability to perform the essential functions of the job they’ve been offered to be used as hiring criteria, said Susan Isernhagen, P.T. and co-founder of DSI Work Solutions. These evaluations, sometimes called post-offer, pre-employment screens, can also include a medical evaluation––the results of which are subject to HIPAA privacy laws. Agility tests are non-medical and can be performed prior to a bona fide job offer, but post-offer tests are performed after the offer of a job. The applicant is guaranteed the job if she can perform its essential functions.
For example, a job applicant can’t be denied the job if he/she cannot run up a flight of stairs if the job doesn’t entail running up a flight of stairs.
“If the job only requires a 50-pound lift, and the worker was tested with a 50, 75, and 100-pound lift, if he passed 50 and did not pass 75 or 100 . . . you can’t deny them the job as only the 50 pounds was job-related,” said Ms. Isernhagen.
The Americans with Disabilities Amendments Act (ADA) provided a reasonable accommodation component to these tests for those who fall under the definition of disability. That is, if a worker has a disability and can perform a job’s essential functions with a reasonable accommodation––like a slip-sheet for hospital nurses or a pallet being placed waist-high instead of on the floor––then the accommodation allows the person to perform the essential functions, according to Ms. Isernhagen.
There are companies, like DSI Work Solutions (www.dsiworksolutions.com), that specialize in analyzing jobs to help employers create detailed job descriptions with actual measurements. Job-specific tests are designed from these descriptions. When it comes to avoiding workplace injuries, productivity losses, and higher than necessary medical and pharmaceutical costs, the usefulness of detailed job descriptions and tests cannot be overstated.
“Half of it is knowing what the job requires,” Ms. Isernhagen said. “But you can’t know that if you don’t have a job description.” The other half is a legally compliant job test.
As the benefits of prior-to-hire functionality testing come to light, more employers will be taking advantage of the efficiency and wisdom they bring to business.
Prior-to-Hire Functional Examinations will be the subject of course twelve at RYAN Associates’ 27th Annual National Conference. Dr. Steve Crawford, Terry Lawson, and Brent Webber will serve as faculty. Trena Williams will serve as a panel moderator. Conference course overviews were written by Anthony Vecchione and Isabelle T. Walker.
