Future of Occupational Health: Where Do We Go From Here?

In a half-day session at RYAN Associates’ 26th annual national conference, leaders in the field spoke about the future of occupational health as a business, a profession, and a medical practice.

William Newkirk, M.D.

William Newkirk, M.D., medical director at UL PureSafety, former director of research at his Maine-based company Occupational Health Research, and the originator of SYSTOC software, created context by first reviewing the history of occupational health in the U.S. following the passage of the Occupational Health and Safety Act.

Fast-forwarding to 2012 and beyond, in sum, he said the Patient Protection and Affordable Care Act will expand health insurance coverage to 32 million uninsured Americans, in turn increasing demand for medical care. In combination with the aging population, the looming physician shortage will worsen. The Association for American Medical Colleges reports that by 2020, the physician shortage will be more than 90,000, with approximately half in primary care, and by 2025 the country will be short 130,600 physicians.

In response, some occupational medicine providers – most notably the nation’s two leading occupational health clinic networks – have been acquired and are being repositioned to take on primary care.

His predictions for the future of occupational health are:

1. The Affordable Care Act will significantly exacerbate the primary care physician shortage, and this shortage will affect how occupational medicine programs are structured. “You will have insurance coverage, but you are not going to be able to find a doctor,” he said. “How are we seeing that play out in our field? We have had a revolution in the last 18 months” marked by the acquisition of Concentra by Humana, Inc., a leading provider of insurance products and preventive services, and of U.S. HealthWorks by Dignity Health, formerly Catholic Healthcare West, a major health system. The intent in both cases is to create local primary care access points. “Within the space of 18 months more than 500 clinics got bought out and converted to use for primary care,” changing the model of care for occupational medicine. Our field is changing dramatically,” Dr. Newkirk said.
2. Many employers will drop their employee health insurance. Instead, their employees will get their health insurance through exchanges, significantly raising the cost of the Affordable Care Act.
3. In a May 2012 report, the Republican staff of the Ways and Means Committee published “Broken Promise: Why ObamaCare Will Force Americans To Lose the Health Care Coverage They Have and Like.” The staff analyzed 71 of the country’s largest companies and found that “these companies could collectively save $422.4 billion from 2014 through 2023 if they eliminated health insurance coverage for their U.S. employees and paid the employer mandate penalty.”
4. Philip Bredesen, former Democratic governor of Tennessee (2003-2011) and author of the book, “Fresh Medicine: How to fix reform and build a sustainable health care system,” analyzed health care costs of the Tennessee state government and concluded: “We can reduce our annual costs by over $146 million using the legislated mechanics of health reform to transfer them to the federal government.” Dr. Newkirk said Gov. Bredesen also has described a new ethos in which employer-sponsored health care insurance is seen as obsolete: “For an entrepreneur wanting a lean, employee-oriented company, it’s a natural position to take: ‘We don’t provide company housing, we don’t provide company cars, we don’t provide company insurance. Our approach is to put your compensation in your paycheck and let you decide how to spend it.’”
5. “If Gov. Bredesen’s vision is correct, the entire fabric of employer-sponsored health insurance could unravel in response to the ACA’s financial incentives,” Dr. Newkirk said. “The question is, how many employers will drop insurance, 5 percent, half, all? Gov. Bredesen says new companies will never even think about it; instead they would pay the penalty. And if you are a small company, you are not subject to the penalty.”
6. Another question to consider: If reducing health care benefit costs is no longer a motivator for employers because they do not provide insurance coverage, what will happen to employer-sponsored wellness programs?
7. Occupational medicine will become increasingly global, standardized, and integrated as large corporations try to control their costs and protect their brands. “I have taught every other year for the last few decades at Harvard to doctors who have finished their master’s degree in public health and their residency in occupational medicine,” said Dr. Newkirk, a Harvard graduate. “When I started, the group was mostly male and English was their first language. My most recent class was mostly female and it had global representation.”
8. Whether jobs and products are in the U.S., China, or other countries, companies recognize that their brand and image matters. “They want to be able to assure consumers that their workers are working at safe plants.” Looking ahead, “there will be a lot of opportunities in occupational medicine, but they will not be in the U.S.,” he said.
9. After a severe recession resulting in significant private sector job loss and a dramatic slow-down in construction, the economy is slowly improving and will continue to do so. The changing nature of industry and the job market will have considerable ripple effects, Dr. Newkirk explained. “If you are a nurse in a hospital doing infection control, you will do pretty much the same thing as always. If you work in a freestanding occupational clinic, you have probably already added urgent care… What you see will depend on where you are.”

Kay Campbell

PROSPECTS FOR NURSING

Kay Campbell, EdD, RN-C, COHN-S, executive director of the American Association of Occupational Health Nurses (AAOHN), said she believes leadership training and education are the best ways to sustain the nursing profession and propel it forward. As an educator, business consultant, and expert on population health management, Dr. Campbell has a unique perspective: “Occupational health nursing is alive and very well, so we are very excited about the future.”

Referring to an influential study, Dr. Campbell said the Robert Wood Johnson Foundation (RWJF) and the Institute of Medical (IOM) launched a two-year Initiative on the Future of Nursing in 2008 with the goal of producing an action-oriented blueprint to address the loss of older nurses to retirement and a shortage of schools and faculty to train new nurses. A committee produced “The Future of Nursing: Leading Change, Advancing Health” in 2010, and later worked with AARP on some pilots projects.

Among key observations and recommendations contained in the report:

1. Nurses should be allowed to practice to the full extent of their education and training in the state(s) in which they work. Statutes are needed to remove restrictions that create barriers to practice, Dr. Campbell said.
2. Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. “Traditional task-oriented, segmented teaching approaches need to be broadened,” Dr. Campbell noted. “If you have been in nursing, you know it is disjointed. People get frustrated when they should be thinking about the skills sets they need to do their job, and more importantly, have passion around that job.”
3. There should be more residency training options for nurses to increase the percentage who attain a bachelor’s degree to 80 percent by 2020 and double the number who pursue doctorates. This would likely give nurses greater opportunities to fill perceived gaps in leadership roles in industry and healthcare settings, she said.
4. Nurses should be full partners with physicians and other health care professionals. “I am speaking here today as a result of collaboration,” Dr. Campbell said. “It’s the way of the future. We all must collaborate to learn and prosper.”
5. Effective workforce planning and policy-making require better data collection and information infrastructures: “This will allow patients, clients, and employees to have better health care.”

The AAOHN offers a number of leadership, education, and hands-on training opportunities to its members through its Academy and other sources. It also encourages members to be politically active, contribute to management teams, boards, and community groups, and serve as professional mentors. “We need to be full members of the health care team and the delivery system,” Dr. Campbell said. “We need to be seen as leaders. All nurses need additional information presented in new ways.”

Expertise Shortage

Dr. Campbell also cited a report which examined the status of occupational health and safety as a profession. The National Assessment of the Occupational Safety & Health Workforce was conducted in 2011 to help the National Institute for Occupational Safety and Health (NIOSH) determine how to best utilize training funds. Survey respondents included employers and OH&S training providers.

According to the findings, future national demand will significantly outstrip the number of OH&S professionals with the necessary training, education, and experience to provide a broad range of OH&S-related services. At the time of the survey, there were about 48,000 OS&H professionals in the U.S. workforce, dispersed as follows:

• Safety professionals – 59 percent
• Industrial hygienists – 15 percent
• Occupational health nursing – 9 percent
• Occupational medicine – 3 percent

Employers are expected to hire more than 25,000 OS&H professionals within the next four years to fill an average of about 5,000 positions per year, 71 percent of them in safety. “There are a lot of jobs out there, they just may not look like the jobs you are used to seeing,” Dr. Campbell said. “The same old leadership skills thing just keeps popping up. Employers who were surveyed said they need OH&S professionals who know how to think strategically and how to collaborate to make things work better.”

When asked about the role of occupational health nursing, employers said they depend on nurses for direction on wellness and health promotion. They also expressed a need for expertise in case management, transitional work programs, conducting health and safety assessments, analyzing workplace hazards, and preventing workplace accidents. The survey results also indicated a need for additional training in leadership skills and knowledge of local, state, and federal regulations and compliance issues, Dr. Campbell noted. “For occupational health nurses, it’s all about communication and education…the ability to talk with workers, consult with senior management, engage with different cultures, teach, do technical writing, understand industry and how the jobs are done,” Dr. Campbell said.

On a global level, AAOHN is looking at ways to form alliances with nursing organizations in other countries. It also is collaborating with the World Health Organization on the potential development of the first international occupational health nursing center. “The future is bright. We just need to make sure we have the skills that are needed for the next 20 or 30 years,” Dr. Campbell said.

Mary Stroupe

HEALTH INFORMATION AT FOREFRONT

In the world of health information management, the future is now, said Mary Stroupe, president of Integritas, Inc., producers of Stix and Agility EHR software for use in occupational health programs, employee health departments, and the rapidly expanding on-site and mixed-use clinic markets. Speaking at RYAN Associates’ national conference, Ms. Stroupe covered a number of related issues: “All of the elements are inter-connected, but we can only talk about one at a time,” she explained.

The second phase of the American Reinvestment and Recovery Act certification and health information exchange (HIE) implementation is approaching. The first phase, which is still underway, involves the establishment of electronic medical records (EMRs) by independent providers, hospitals, and health systems; phase two focuses on the ability to share data among providers and organizations.

“With the next wave of ARRA certifications for software in 2013, providers will need to demonstrate they can send and receive data through HIEs. It is already happening and will become more and more ubiquitous,” Ms. Stroupe said. “Data structures and relationships are needed to properly secure and protect data.”

Key issues to consider in 2013 and beyond include:

APPLICABILITY

If you are exclusively offering occupational medicine services and don’t plan to exchange data, why should you care about these requirements? According to Ms. Stroupe:

• Patients will be asking for electronic copies of their work-related health records so they can aggregate them into their own personal health record.
• Employers will expect providers to satisfy their employees’ requests to exchange information with ambulatory electronic health records.
• When employers are paying the bills, they see advantages to using a system that helps avoid duplication of services and effort.
• Any certified record needs to produce data in a way that can be shared.

MATCHING PATIENTS AND SERVICES

Within any information system, a patient typically needs to be related to an employer, a payer, to family members, and to a provider treatment site. It quickly becomes more complicated when a patient has multiple employers and/or insurers or when multiple diagnostic and treatment sites are involved.

“When you overlay all of the services you are offering – wellness, urgent care, workers’ compensation – on top of that, you have to make sure the correct services are delivered to the right person. If you decide to expand your services, you need to make sure you have a database that can handle the expansion” and its relationships with other provider databases, such as lab or radiology, Ms. Stroupe said.

“If you are taking care of your own employees, the relationships become even more complex because you are acting as both the provider and the employer. For your own employees, there is quite a bit of sensitivity about not using their Social Security number as an identifier, but you will need it for workers’ compensation. You have to be able to identify patients in multiple ways.”

An information system also has to be able to verify a provider’s identity. Ms. Stroupe said providers should expect two-factor identification systems to be built into practice standards and become commonplace. Systems already in use typically involve a combination of a unique user code, “smart” card, or bio-ID such as an iris scan or fingerprint.

PRIVACY AND SECURITY

Privacy means who can see and release information; security is how data is protected. Compliance with national privacy and security standards is recommended. “The heart of the matter with regard to privacy and security is that employment-related information is an employment record, not a medical record,” she said. “You need to be able to distinguish between employment data and protected health information,” for example, clinical lab results versus a bill for services rendered. Health risk (wellness) data and urgent care treatment records are protected health information and subject to the Health Insurance Portability and Accountability Act.

Note: “A hospital EHR does not distinguish between employment-related and protected health information. From a data management standpoint, this is one of the biggest issues to come to grips with if you are expanding beyond employment-related services,” she said. “You also need a separate EHR for internal employee health information that does not belong in an ambulatory care electronic record.” However, some data, such as allergies and immunizations, should be shared in accordance with national standards.

INTERFACES

Hospital-affiliated clinics often are required to interface with hospital mainframe billing systems, adding another layer of complexity. One trend to watch in freestanding clinics is the use of registration kiosks or hand-held devices that allow patients to register and even pay by credit card. The patient-entered data automatically go into the clinic’s practice management or EHR system, significantly expediting workflow and other activities, such as medication dispensing.

HEALTH INFORMATION EXCHANGE

In terms of the future, Ms. Stroupe said, “what we are working toward as a country is analogous to the ATM (banking) network, enabling patients to access their health information from virtually anywhere. In the interim, state exchanges are evolving, most notably in Indiana and around the Chesapeake Bay. National standards dictate practices for data capture, maintenance, transmission, and sharing across multiple systems via secure networks.

In closing, she offered these recommendations:

• Have an information system that forwards your future.
• Build the case for why you need an EHR and practice management system to address complex needs.
• Be on the forefront in your organization with regard to onsite clinics…you already have the relationships with employers.
• Be conversant with what is happening with EHRs and why you cannot use the ambulatory EHR for your occupational medicine and employee health data.
  
  “What we are working toward as a country is analogous to the ATM (banking) network, enabling patients to access their health information from virtually anywhere.”