By Karen O’Hara
The Obama administration’s plans to move forward with a technology-driven “medical home” initiative as part of overall efforts to reform the nation’s healthcare system is generating speculation about potential long-term impacts on the practice of occupational medicine.
The administration’s support of prevention initiatives as well as studies aimed at improving quality and lowering costs also are expected to have a halo effect.
The federal budget introduced by the Obama administration sets aside a reserve fund of more than $630 billion over 10 years that will be dedicated to financing healthcare reforms, and the president says he is committed to working with Congress to find additional resources.1
“Reforms will affect all medical specialties and practices,” Clarion Johnson, M.D., global medical director for Exxon Mobil Corporation, said during a session on health care reform at the American College of Occupational and Environmental Medicine’s annual conference in April, “Occupational medicine physicians will encounter challenges that reflect on the many settings in which we practice. How proposed reforms look depends on where you are standing, but even a few, if enacted, will make things better than they are now.”
There is a difference in opinion between experts and average consumers about problems with the U.S. healthcare system, according to polls conducted by the Kaiser Family Foundation, experts target unnecessary and troubling variations in care, consumers appear to be more concerned about under-service than over-service, and they are worried about how they are going to pay for the care they receive. In an April survey, a majority of respondents said they or a member of their household have delayed or skipped health care in the recent past.
“These differences between experts and the public matter because key elements of health reform, which elected officials expect to resonate with the public, could get a decidedly less enthusiastic reception than expected if more is not done to close the gap in basic premises and beliefs between experts and the public, Drew Altman, Ph.D., Kaiser Family Foundation president and CEO says in a recently published commentary. Most fundamentally, the challenge is to educate the public about why health costs are rising as fast as they are in the U.S.
According to the Robert Wood Johnson Foundation, a research institution whose mission is to improve the health of all Americans, the key driver of spending—accounting for an estimated one-half to two-thirds of spending growth—is technology, not changing demographics or medical malpractice. Other important drivers of healthcare spending include health status, particularly obesity, and low productivity gains in the healthcare sector. In addition, higher spending does not achieve better outcomes, the foundation reports.3
While there are many proposals on the table, Dr. Johnson said he expects expanded coverage for the uninsured and federally supported insurance plans to top the federal agenda, along with expanded use of communications technology, a greater focus on wellness, and improved incentives or payment for better care.
He noted that Exxon Mobil is a self-insured company, and when it comes to the health and well-being of its employees, there is no room for compromise. Consequently, the company’s ongoing focus is on cost savings and quality. For example, it is working with multiple vendors on information technology solutions, improved care management capabilities through the use of evidence-based medicine, and the development of safer work environments for its employees.
Integrated Coverage
Among the many proposals under consideration, various permutations of the integrated, or 24-hour care, delivery model are likely to be resurrected as part of reform discussions in the coming months, predicts Doug Benner, M.D., an occupational medicine physician who coordinates the occupational health program for Kaiser Permanente, Oakland, Calif. However, while workers’ compensation is on the radar, it is not yet clear how prominent a role it might play given the overall magnitude of the nation’s healthcare crisis, he said.
There are a growing number of integrated disability management programs, but many barriers to a fully integrated healthcare delivery system remain. State-specific regulations and the entitlement mentality inherent to workers’ compensation are two reasons why it is challenging to integrate occupationally focused care with non-work-related medical treatment and disability management programs.
However, despite these obstacles, Dr. Benner says considerable efficiencies and better outcomes can be gained when patients are treated by the same physician or medical group under the same health plan, regardless of the cause of their injury or illness.
“A lot of physicians don’t want to do workers’ compensation,” in part because it is so paperwork-intensive, he said during a presentation in May at a Workers’ Compensation Forum sponsored by the Council on Education in Management. “We need physicians who understand workers’ compensation, return to work, disability, and function.
” Aetna, one of the nation’s leading diversified health care benefits companies, recently reported results from a set of analyses of members with access to integrated benefits compared to control groups without integrated benefits. The most significant finding from the studies showed members with integrated benefits were more likely to take a health risk assessment and enroll in wellness and disease management programs that contribute to healthier behavior and improved health risk.
“When we have a more complete picture of our members and all the benefits available to them, we can have a much greater impact on their health outcomes and on their overall willingness to engage in their health care,” said Laurie Brubaker, head of Health and Productivity Solutions for Aetna.
Aetna offers an Integrated Health Solutions® (IHS) product that includes a risk assessment with questions on work limitations and productivity based on health and emotional conditions. Risk indicators trigger one-on-one wellness counseling to address conditions holistically through other Aetna programs, often before they involve costly acute-care services, company officials said.
“The results suggest that increased coordination of services and member engagement in managing their health condition may be the keys to decreased short-term disability (STD) durations and fewer complications,” Ms. Brubaker said. “Earlier Aetna studies demonstrate that STD claim durations were 3.2 days shorter with integrated health and disability benefits.”
Challenge Breeds Opportunity
Joining Dr. Johnson on the podium at the ACOEM conference, former ACOEM President George Anstadt, M.D., observed: “We are fortunate to be occupational physicians living in America. We are in for a little rough patch, but certainly by comparison, our position is going to improve, and it may even improve absolutely.”
Dr. Anstadt describes the U.S. healthcare delivery system as a triple oxymoron: “It is not about health, it is about disease. It is not about care, it is about competition. And it is a hodgepodge, it is not a system. We have a lot of opportunities here. The system is pretty badly broken, and we are staring down the barrel of a nasty recession. We don’t have a lot of other options other than to fix it.”
Now a medical director with Concentra in Rochester, NY, Dr. Anstadt formerly worked for Eastman Kodak in a number of capacities, including health plan selection. He believes it is important for occupational medicine physicians to recognize the difference between the economics of health care – supply, demand (access), and value (cost and quality) – and the economics of health – the value of productivity and the cost of disability.
“They say you have to follow the money, but you also have to follow health value per dollar,” he told his physician colleagues. “Of the medical specialties, we know more about that than anybody else. That’s the bottom line. We are going to be in the way of some pretty big, important trends here that are going to search out that value.”
Rather than reimburse physicians on a per-visit basis, “we need to move to where we can buy outcomes. That is one of the promises of a digital system where we can look at aggregate data and pay for outcomes,” Dr. Anstadt said. He cited the following as factors likely to influence the future of occupational medicine practice:
- Digital technology
- Evidence-based, outcome-focused medicine
- A preventive approach
- Improved efficiency
- Alignment with large entities
- A greater focus on individual care
Optimistically, he adds, occupational medicine will be perceived as “high value” and even “fun!”
Medical Home
The goal of the medical home is to streamline fragmented healthcare delivery systems by having a primary care physician or clinician coordinate a patient’s healthcare. “The model is centered on patients to make sure they are getting the care they need when they need it, to help them manage that care and understand the importance of being compliant with their medications,” Nancy-Ann DeParle, director of the White House Office of Health Reform, said during a recent press briefing in Washington, D.C. Many large health plans, as well as Medicare and Medicaid, are engaged in or planning demonstration projects to learn more about the quality and cost advantages of medical homes.
“There are very robust demonstrations of (the medical home) going on right now in the private sector,” Ms. DeParle said. “Some insurance companies are doing this already, and they have shown real promise. We hope to move forward with the program in Medicare.”
Meanwhile, large companies are embracing the patient-centered medical home concept. “The comprehensive and coordinated care that the medical home promotes leads to better health, longer lives, higher patient satisfaction, and less expensive care,” said Paul Grundy, chairman of the Patient-Centered Primary Care Collaborative and director of Healthcare, Technology and Strategic Initiatives for IBM Global Well-Being Services and Health Benefits. “The question isn’t whether we should implement the medical home, but how. These standards clearly assess and identify effective medical homes.” The collaborative is a coalition of major employers, consumer groups, patient quality organizations, health plans, labor unions, hospitals, clinicians, and other stakeholders.
Quality Standards
According to Peter Swann, M.D., medical director for Concentra Health Services in the San Francisco Bay Area, occupational health providers need to be aware of the medical home movement for a variety of reasons. Among them:
- It is one of the tenets of national health care reform.
- President Obama has promised appropriate reimbursement for providers who implement the medical home model.
- A number of medical home bills have already been introduced and passed in various states.
- Pilot programs are in place.
- The American Medical Association has endorsed the concept.
- Sen. Max Baucus, the influential chairman of the Senate Finance Committee, has introduced a patient-centered plan and asked for increased payment for primary care services and expansion of Medicare pilot projects.
To be part of health care reform and serve as a medical home, it is likely that occupational medicine programs will need to comply with medical-home standards established by the National Committee for Quality Assurance (NCQA), Dr. Swann said during the ACOEM session on health reform. NCQA is a not-for-profit organization dedicated to improving health care quality. Its Healthcare Effectiveness Data and Information Set (HEDIS®) is the most widely used performance measurement tool in health care.
“Americans are not certain what constitutes primary care, but they do know they want relationships (with medical providers) and this approach heads in that direction,” Dr. Swann told OEM physicians at the conference. “We will be part of health care reform, and NCQA certification will be needed to become a medical home. A lot of the requirements are very data-intensive.”
Dr. Swann noted that the Health Information Technology for Economic and Clinical Health Act (the HITECH portion of the economic stimulus package) allocates at least $19.2 billion for electronic health record (EHR) implementation. Using what Dr. Swann calls a “carrot and stick approach,” physicians could receive $44,000 to $64,000 over five years beginning in 2011 for deploying and using certified EHRs. Under the HITECH Act, to qualify for incentive payments, physicians and hospitals will be required to demonstrate “meaningful use” of a certified EHR technology as defined by the U.S. Department of Health and Human Services (HHS). Those who do will be eligible for higher reimbursement; those who do not will be at risk of reduced reimbursement. The certification process and standardization criteria are being developed. The Certification Commission for Healthcare Information Technology will most likely be the certifying body. Although the incentive-based focus is currently on Medicare and Medicaid providers, Dr. Swann believes occupational medicine reimbursement mechanisms are likely to follow suit. “This is a good time to get on the EHR bandwagon,” he said.
Wellness and Prevention
On May 12, President Obama met with business leaders to discuss innovative prevention and wellness measures they have implemented in their companies as part of ongoing efforts to reduce healthcare costs. “There’s no quick fix. There’s no silver bullet,” President Obama said during the session. “When you hear what Safeway or Johnson & Johnson or any of these other companies have done, what you’ve seen is sustained experimentation over many years and a shift in incentive structures so that employees see concrete benefits” to taking control of their health. President Obama noted that when companies take steps to improve employee health and prevent disease, it is not just the workers who benefit: “Companies see their bottom lines improve. If we can do that in individual companies, there’s no reason why we can’t do that for the country as a whole.”
The president has directed the Office of Personnel Management to work with the Office of Health Reform, the National Economic Council, the Department of Labor, and the Office of Management and Budget to study wellness and prevention plans that have reduced healthcare costs for businesses and improved employee health. He wants these agencies to examine the feasibility of developing similar plans for federal employees.
In response, Christopher Fey, chairman and CEO of U.S. Preventive Medicine, a new member of the NAOHP Vendor Program, suggests his company’s approach, known as the Prevention Plan™, could save billions of dollars by helping Americans avoid expensive medical treatment and improve worker productivity.
“The answer is really quite simple: follow the rules of the clinical discipline of preventive medicine using a personalized approach,” Mr. Fey said. In a letter to HHS Secretary Kathleen Sebelius, Mr. Fey said U.S. companies have medical, dental, and vision plans, but none have a comprehensive suite of preventive services. “Only by providing every American with an integrated program of prevention, early disease detection, and chronic condition management will the health crisis be brought under control and maintained at an affordable level,” Mr. Fey said. Research shows that half of American adults with chronic conditions do not receive recommended care. Under the Prevention Plan, participants receive risk stratification, a personal health record, a dedicated coach/care advocate (as necessary), clinically recommended screenings, early detection tests, and other personalized care tools.
“It’s time to step up and do what the experts tell us – to deploy integrated clinical preventive medicine guidelines for primary, secondary, and tertiary prevention,” he said. “By doing so and using sophisticated data analytics, we can prove outcomes are better and provide the savings the president is looking for.” Because there is a shortage of professionals trained in prevention-oriented specialties such as occupational medicine, occupational health professionals are well-positioned to step into the void. “If you want to predict the future, you have to look at the trends, and there are just not enough prevention-trained people out there,” said Dr. Anstadt, who noted that primary care doctors often refer patients to OEM physicians to take advantage of their expertise.
