—Anonymous Q&A
At RYAN Associates’ 25th Annual National Conference, three panelists who attended the first annual national conference in 1987 reflected on occupational health’s past, present, and future as a business enterprise and a clinical practice. The panel was moderated by RYAN Associates’ Founder, President, and CEO Frank Leone, who also shared his observations. The following is an edited transcript of the session.
The panelists are:
William Newkirk, M.D.,
Medical Director, PureSafety, Nashville, Tenn. Dr. Newkirk is a board-certified occupational medicine physician with more than 30 years of experience in the field. He formerly was the chief researcher at his company, Occupational Health Research/SYSTOC, which was recently acquired by PureSafety. He is considered a visionary in the industry, particularly with respect to forecasting, medico-legal issues, and information management system development.
Sue Stock, O.T./R,
Manager, Occupational Health Services/CARES Employee Assistance Program, Sparrow Health System, Lansing, Mich. She entered the field in 1985 and developed one of the first hospital-based occupational health programs in Michigan.
Rich Williams, M.A.,
President, Advanced Plan for Health, Irving, Texas. Mr. Williams has been in the employer health business since 1974. A former hospital CEO, he is an expert on medical home and accountable care organization models. Early in his career, he was one of the first to apply sales concepts in health care through his company, Health Sell.
Q: When you think of the evolution of the field of occupational health, what stands out in your mind as the most positive change that has occurred in the past 25 years?
Mr. Williams: To put it in perspective, when I first got involved in 1974 it was called industrial medicine, and my biggest challenge was to get the physician in the clinic to stop smoking while he was doing a physical exam. He looked at me like I had three heads. The professionalism and advancement of the field have been dramatic. The certifications, the types of people who have gone into the field – they are extremely professional and a lot smarter than the average bear when it comes to occupational health as well as health care in general.
Ms. Stock: I agree about the caliber of the people. The core occupational health program components that were out there 25 years ago have not changed: communication, case management, attention to detail, and customer service. However, employers are more sophisticated now, and technology has significantly changed our efficiency and effectiveness in dealing with employers.
Dr. Newkirk: If we look at the numbers we are really doing a much better job with disability management – disability days are way down – and prevention. The problem, of course, is that our achievements kill revenue in the clinic, so we have been putting ourselves out of business.
Mr. Leone: There has been a basic, core re-definition of what occupational health is all about. Back in 1987, the definition of occupational health was managing work-related injuries as a condition. In 2011, so many organizations saw it as a very significant part of a wide range of services that can be provided at the workplace. In a sense, occupational health has gone just so far as a stand-alone entity. But on the other side, it is a vehicle or platform for all of the other things that can be pulled in with it.
Q: Looking back, what has been your greatest disappointment?
Dr. Newkirk: Personally, when I think about the first RYAN conference, I remember how stupid I felt when I walked into each class because I did not know a whole lot about OSHA and all sorts of other things. As far as disappointment, I feel more stupid today, because there is even more to know. Professionally, the greatest disappointment is the loss of manufacturing. The exciting thing in the ’80s was going into places where they were making shoes and shirts, and visiting plants where regular people were doing regular jobs. Now the shoe and manufacturing plants in the area where I was practicing (rural Maine) are closed.
Ms. Stock: A disappointment I have is the continued lack of (senior leadership) acknowledgment of the value of occupational health to the hospital or health system from the standpoint of the employer relationship, direct financial contribution, and downstream revenue. All of those things are really important.
Mr. Leone: My greatest disappointment is that for many years I was lecturing that the next great thing was going to be real movement toward performance-based, incentive compensation for staff in provider-based occupational health programs. That simply has not been the case. We have not gotten to the point where reimbursement is based on outcomes. We may get there someday, but in 25 years we have not.
Mr. Williams: In 1987, the same year as RYAN Associates’ first conference, I spoke to the American Hospital Association about corporate health as the next great activity; it still hasn’t happened. Health systems get into their silos, and if you are part of a health system, that is a problem. If you are not part of a health system, you have a tremendous opportunity to do the kinds of things I think we should be doing – to be the employer’s health adviser. You only have to look at the Humana purchase of Concentra to see how important our skills are.
Q: What strengths do you see occupational health professionals effectively leveraging to accomplish their objectives?
Dr. Newkirk: You only have to look at the Humana purchase of Concentra to see how important our skills are. Our medical model is the model that is going to be adopted by everyone. We know how to do it. We know how to look at a case and understand the cost. We are going to see general medicine adopting occupational medicine techniques across the board.
Mr. Leone: The occupational health practitioner understands that it is all about environmental causation and appropriate return-to-work outcomes. That mindset is out there, and the real world is catching up to that mindset. This is a discipline whose time has come.
Ms. Stock: Our strengths are the communication model, the networking, the case or care coordination that we have used so positively over the years in terms of keeping track of and moving the patient through the system. These are all skills that will be valuable in the future.
Mr. Williams: I agree: that care coordination is going to be the key, and we have the critical thinking habits right now. In terms of evidence-based protocols, when you switch from what you do now in occupational health to broader employer health, those rules are a given. They have been proven for 40 years. You can measure them, follow them, and be successful.
Q: What are the most significant operational, clinical, or leadership shortcomings you have observed in occupational health programs? What suggestions do you have to address those shortcomings?
Ms. Stock: We need to foster the development of formalized leadership skills among our mid-line staff. We may send them to a half-hour or hour-long session, but there is more we can do. When I was working for a community college in the Business and Community Institute during a hiatus from health care, I learned that you can find resources in your area through workforce development organizations. You can bring formalized business leadership training, conflict resolution, and customer service training to your organization, many times at no charge in grant-supported situations. That will be a great opportunity, especially as we move clinicians into leadership positions.
Dr. Newkirk: The biggest clinical shortcoming is that we don’t know what we are doing. Our ability to apply evidence-based medicine to occ. med. Has really been limited. We don’t have answers to even the most fundamental questions. We think we do, but when we look at the data we really don’t. All we do is parrot what our teachers taught us, and so on.
Mr. Williams: As a group, we are stuck in the box. Remember about 20 years ago when the word “paradigm” became popular? We didn’t change the paradigm, we just talked about it in concept and how things could be different. While the professionalism is fantastic, the way we think about what we do remains pretty much the same. We need to listen to clients and see what they want, not just with the things we do today but with things that are going to happen in the future. To combat shrinking revenue, you have to do something different to exist.
We need to foster the development of formalized leadership skills among our mid-line staff.
Mr. Leone: A common shortcoming is the inability of any healthcare organization with an occupational health program to define its mission and the value of what it is doing, both internally and to the community, in a way that everybody on the team understands. Too many people just come to work and do what they do in their own narrow world. They fail to recognize occupational health makes so many contributions to their parent organization and that the value can be very significant. The more that it is defined and embraced, the more it becomes a self-fulfilling prophecy of success. Another shortcoming is rampant negativity, which is the mindset of our country right now, unfortunately. We have gone into more than 700 organizations providing consulting services in the past 25 years, and about 80 percent of the time we are psychologists, and 20 percent of the time we are consultants. There are negativity issues. There are turf conflicts. They are allowed to fester and endure rather than being nipped in the bud and resolved to allow positive forward movement.
Q: How do you envision the role of the occupational health practitioner evolving in the next decade? What do occupational health professionals and programs need to do in order to best position themselves for this anticipated change?
Mr. Williams: In the next 10 years we will have to move from being specialists to being generalists. It’s the concept of being the employer’s health adviser, regardless of the topic. Being a generalist is really a giant leap, and in the end, it is going to be the critical success factor for a program. Again, to position yourselves, you need to listen to your customers.
Dr. Newkirk: When we started this, essentially what you did in occ. Med. has a cute name like MedQuick or WorkHealth. You went out to companies and explained the notion that if you returned people to work more quickly, you would save them money. Then you would try to get the doctors who were putting people off work not to do that. Since there were a lot of injuries out there, you could run a business. Ten years from now it is going to be incredibly more complex. First, the revenue stream from injuries is going to dry up. You are going to have to be much more diverse, and get much more involved in prevention and in the workplace. There are going to be fewer jobs available for providers. You are going to really have to know what you are doing.
Mr. Leone: This is something that is going to be generic to health care, but especially apropos to what is and will be going on in occupational health: the practitioner’s role is going to evolve to much more of a coordinator role, with the practitioner dealing with the full patient care continuum from prevention, to acute care, to long-term rehabilitation. It will encompass the ability to coordinate care among a large number of different kinds of practitioners and specialists, understanding how and when prevention fits into the equation. You need to start thinking in those terms now, emphasize management of the full patient care continuum for multiple constituencies, and learn and grow as you go along.
Ms. Stock: Diversification – getting into areas such as travel medicine and onsite services – through a general health model is where we all need to go. One important thing is to use the resources that are available. The NAOHP has numerous resources and provides opportunities for all of you to network.
Q: Conceptually the bundling of appropriate services for employers makes sense, but tactically it can be difficult to orchestrate given that the typical healthcare organization is beset by competing priorities and budgetary constraints. What can be done to move collaboration and service integration to the next level?
Dr. Newkirk: It depends on the organizational structure. If you are in a hospital, good luck because I have never found a more risk-averse group of managers. They are scared about losing their jobs and they don’t have the resources to do what they need to do. If you are clinic-based, then your institution has no interest in preventing injuries, because it runs contrary to financial incentives. The challenge going forward is convincing someone above you that preventive services at the worksite are a good idea. The people who can convince management of the value of prevention are the ones who are going to survive.
Ms. Stock: Outside of the cost savings for the organization, you have to prove that you can produce a good piece of revenue. We are in that situation right now, so stay tuned.
Mr. Williams: Bill’s assessment is accurate: most middle managers in hospitals are totally risk-averse. That is what they teach you in hospital administration school. What I say to hospital managers is: Where is your bottom line for your total business? In 99.9 percent of the hospitals in the United States, it is the commercial employer business. They are just starting to see that business is going to be eroded and they are going to have to do something about it. You can be in a position to fill that void. Part of it is the salesman in me, but part of it is the reality that if your organization does not have that business, it is in trouble. If you are hospital-based and you compete with a free-standing clinic, watch out. They are going to (bundle services) because it makes business sense.
Mr. Leone: For every dark cloud there is a silver lining: Yes, there is risk and adversity but there are also parochial interests tied to bottom-line results. If there is a crack in this shell of adversity, it is in putting forth good, tangible return-on-investment value propositions to the people who are making the decisions. You are more likely to achieve success coming from the bottom up than from the top down. If you go to individual product lines – whether it is sports medicine, travel medicine, wellness, women’s health, whatever the case may be – and persuade the principals who are involved that allegiance with occupational health would be in their best bottom-line interest, then when you go to senior management with a request, you are increasing your odds of getting favorable action. You are more likely to achieve success coming from the bottom up than from the top down.
Q: What would you say to someone considering a career in occupational health?
Mr. Leone: There is not a more noble profession than health care. You are not making widgets. You are out there affecting the lives of large numbers of individuals every day. The character of the people you are working with is exceptional, and that really makes a difference. Occupational health represents a choice. It is evolving, and in many respects still on the ground floor with the potential to affect many people.
Mr. Williams: This is the future of health care in the employer market: the right spot at the right time, and you can do anything that you really want to do. It may not be where you are today, but you will be able to do it in this profession as you move into it. You are going see some dramatic movement in the employer market in the next five years.
Ms. Stock: It is a great time to get in or stay in the field. Working in the hospital has given me the opportunity to develop relationships with businesses outside of the hospital, and it is really a chance to be creative and to develop negotiation and conflict resolution skills. If you want it to be a stepping stone to another career, it provides a great opportunity to branch out.
Dr. Newkirk: The field in terms of numbers of professionals is in decline and a lot of jobs have disappeared, so I would not go to somebody and say this is a fabulous opportunity because there are so many more positions for doctors and nurses being created. But I would say that you would never be bored because you will never scratch the surface of what you need to know. You will be dealing with legal issues and medical issues…every day will be challenging. The other pitch I would make is that the social benefit is enormous to the extent that you can make jobs more viable and safer.
Q: What word or phrase best describes the most important trait of an occupational health practitioner of the future?
Mr. Williams: Professional activism on behalf of your clients to get them a result and build your practice.
Ms. Stock: Three Cs: communicator, collaborative, and changing.
Dr. Newkirk: You need to be smart: You have to know what you are doing and be smarter than your competitors. You also need to be wired, technologically speaking.
Mr. Leone: Balance. There are a million different circumstances and situations. You need to be nimble, not rigid.
Q: What are your final words of advice?
Mr. Williams: Stay positive and look for opportunities. Don’t be afraid to take advantage of those opportunities.
Ms. Stock: If you want to move forward, consider what everyone else is doing. What tools can you take home with you? Continue to network after the conference and learn from other people you meet here.
Dr. Newkirk: When you get up in the morning and feel stupid just realize we all feel that way.
Mr. Leone: Live your dream. Set the bar high. Remember that crisis breeds opportunity Latch on to the opportunity side of things.
