By Anthony Vecchione
Healthcare in the United States has undergone a transformation in large part due to the Affordable Care Act (ACA). Occupational health has also been transformed by the ACA–and by all the new service lines that have sprouted up in programs around the country.
To help explain some of the latest developments in our field, we asked a few industry experts to weigh in on changes we think are particularly relevant and offer tips on how a program might employ them effectively.
Occupational health began as a discreet, clinic-based discipline. However, industry veterans agree the narrowness of that model was not very profitable and the addition of new services has allowed occupational health programs to leverage their relationships with employers by bringing other services to market. “New services will convert an overall effort from potentially breaking even to something that can be very profitable,” said Frank Leone, M.A., M.B.A., president and C.E.O. of RYAN Associates.
Lessons Learned From 9/11
In addition to being a national tragedy, the experience and knowledge healthcare professionals gained from treating first responders and others after September 11, 2001, has had a significant impact on the field of occupational health. Treatment protocols and prevention strategies that were used to combat the environmental diseases that resulted from the September 11 attacks are now being used in workplaces across the country.
“Before 9/11, I did what most occupational doctors did––practice standard occupational medicine, traveling to different factories, consulting, giving advice and performing disability exams, and working on policy development,” said Dr. Marc Wilkenfeld, M.D., chief of Occupational and Environmental Medicine at Winthrop University-Hospital
in Mineola, New York. Now toxicology screenings are an integral part of many occupational health programs, Dr. Wilkenfeld said. While there are certain things mandated by the Occupational Safety and Health Administration (OSHA), some companies are being proactive when it comes to screening their employees. For example, at a workplace where exposure to solvents may be relevant, annual liver function tests are now standard. These screenings, noted Dr. Wilkenfeld, pick up a chemically related disease at an early enough stage for the worker to be protected from serious harm.
“That’s a health benefit from a company point of view. If the worker stays, they get sicker and potentially involved in litigation. Avoiding one case can save millions of dollars and terrible publicity for the company,” Dr. Wilkenfeld said. By preventing one case of lead poisoning or cancer due to exposure, he added, you’re doing the patient and the company a tremendous favor. Dr. Wilkenfeld said that occupational health doctors should seek training in toxicology. “It’s a boutique part of occupational medicine.” Many occupational health programs today are putting time into researching the kinds of industries that generate toxic and potentially toxic environments. For occupational health programs considering adding environmental medicine to their service line, Dr. Wilkenfeld has this advice: “You have to get trained. It’s a very specific field. If you’re an ER doc and go to work at an occupational medical center you’ll do fine. Not true for the practice of environmental medicine. You need training.”
Environmental medicine is something people don’t automatically learn, Dr. Wilkenfeld said. For instance, if someone comes into a doctor’s office and says they were exposed to arsenic, you have to know something about it. Another piece of advice: be 100 percent honest with your clients. Don’t sugarcoat anything. “If you’re worried about chemical exposure in the plant, don’t be concerned about how management is going to react. Ultimately you’re doing them a huge favor by telling them things up front,” Dr. Wilkenfeld said.
Wound Care And Occupational Health: Go Well Together
Crush injuries, amputations, neck, and back wounds are common in certain workplace environments. But they’re not limited to the workplace by any means. Two years ago, West Georgia Worx, a hospital-based occupational health clinic in LaGrange, Georgia, partnered with Jacksonville, Fl.- based Healogics, a company specializing in wound healing, treatment, and prevention. Nick Vlachos, M.D., medical director at West Georgia Worx also oversees wound care and a hyperbaric oxygen clinic.
“The learning curve was quick and I found a needed resource for work-related crush injuries of the hand and foot as well as for burns,” said Dr. Vlachos. Dr. Vlachos said that novel dressings and grafting materials have made it easier for these wounds to be treated in the occupational health setting.
“There is no reason why these same techniques and materials can’t be used at the local occupational health clinic, whether it be private, hospital-based or on-site delivery,” said Dr. Vlachos.
Dr. Vlachos said that in many instances occupational wounds are improperly treated. For example, wounds are soaked in Betadine prior to suturing and dressed 100 percent of the time with Bacitracin. Dr. Vlachos noted that there are many other dressing materials that promote growth factors and minimize scarring. “I’m seeing faster healing, less restricted work, and less disfigurement all supporting the employer’s bottom line,”
Dr. Vlachos said. It’s important to recognize that the biggest risk in work-related wound cases is for one or more comorbidities to go unrecognized, Dr. Vlachos said. For example, underlying diabetes, venous and arterial leg disease, smoking, and obesity all delay wound healing.
“The occupational health doctor who delegates his patients to someone else might find that they will have complications because the underlying comorbidities were not [treated],” said Dr. Vlachos. Wound care, Dr. Vlachos noted, is an excellent preretirement specialty for physicians in the occupational health field and for anyone who has been practicing occupational health after leaving primary care. Occupational health doctors said
Dr. Vlachos is constantly referring patients to other specialists. He contends that there are many physicians practicing occupational health in various venues who will never acquire board certification.
“I find that many occupational medicine physicians have very low comfort levels when it comes to treating some common work-related conditions. In particular, conditions that require some additional training or experience, such as back and neck injuries as well as burns and crush injuries of the hands and feet,” Dr. Vlachos said. Dr. Vlachos said he completed the McKenzie courses for neck and back pain. McKenzie (www.mckenzieinstitute.org) is a method of physical therapy and exercise for back pain or neck pain. “I now make it mandatory for my physical therapists to be certified in McKenzie therapy. In no time an occupational physical therapist can become comfortable treating back and neck pain without expensive imaging or long-term pain medication injections.” Dr. Vlachos said the vast majority of these conditions are treated as muscle injuries when in fact they are disorders of the disc. Reducing the derangement mechanically heals the patient, sometimes immediately, he said.
As far as giving advice to other occupational health programs that want to expand or get involved in wound care, Dr. Vlachos recommends partnering with an organization that has experience in this area.
Occupational health physicians must be rooted and comfortable in the treatment of neck and back pain and should not be too quick to order imaging scans, Dr. Vlachos said. He said that occupational health physicians should feel very comfortable approaching patients with the idea that these are disc injuries that are probably going to get better on their own, but the process will be faster with focused therapy.
Virtual On-Site Clinics: Wave Of The Future
Virtual on-site health clinics would have been viewed as strangely futuristic a few years ago. Today they are not only a reality, according to industry experts, but the natural evolution of virtual care.
Carolinas Healthcare System (CHS), an integrated hospital system based in Charlotte, NC, launched a virtual clinic in August 2014. Steve Jones, vice president, of Carolinas Healthcare System Medical Group defines virtual care as a “virtual visit” and on-demand service; program patients must enroll in to access providers.
“We operate all of our own provider coverage for the CHS Virtual Visit product. If you want to take a CHS virtual visit, you log on via an application or webpage and within three to five minutes you have access to available providers who can treat a limited number of acute episodic conditions that are appropriate for virtual care,” said Mr. Jones.
Examples would include seasonal allergies, colds and flu, respiratory infections, skin conditions, urinary tract infections, and pink eye just to name a few. “Today over 65 percent of our virtual visits take place on either an Apple or Android smartphone with a patient satisfaction rating of 4.8 out of 5 stars,” said Mr. Jones.
He explained that it’s a video/audio experience that provides a connection or link-up with CHS providers. It can be accessed via iPhone or Android, iPad or desktop computer. Mr. Jones said over 65 percent of patients access it from their phones. “Today a 10-minute experience with one of our providers is priced at $49.” Urgent care services are also available via a virtual visit. Among the new programs set to launch is health coaching.
“We think it will be more impactful than just a phone call. We’re creating a program whereby you’ll be able to log on through our virtual platform and choose a health coach such as a dietician,” Mr. Jones said.
CHS operates 19 on-site clinics, six are specifically located at their own hospitals in the Charlotte area and intended for their employees. An additional 13 are offered to employers within a 14-county area around Charlotte.
Mr. Jones said the on-site programs have been very successful overall for employers and do help lower their healthcare spending. “It does take the right size company to justify an on-site clinic (OSC). You need a certain number of employees, ideally, you like to see about 1,000 to 1,500 employees who are centralized so that the employee base can utilize the functionality of the clinic effectively,” said Mr. Jones. Down the road, Mr. Jones believes behavioral health will present more opportunities for virtual visits. “As we progress quickly, we will see full primary care services [and] to some degree chronic disease management and follow-up incorporated into a video virtual care programming model.
It’s early on. As programming continues to develop, you’ll see more of these services.” For other occupational health programs considering a virtual on-site initiative, Mr. Jones urges them to take a marketplace approach; and look at virtual care as a way to connect their providers to local employers. They might also want to consider having an occupational nurse at those locations or setting up virtual programming for those Employers.
He also suggests setting up injury management services. A lot of employers are still looking for ways to connect those virtually. Over the years, Mr. Jones said that occupational health has not been a total revenue source for a lot of groups. Blending urgent care services and virtual care might be a direction to consider.
Workers’ Compensation/Health And Wellness: A New Model
Berynce Peplowski, M.D., sees it, workers’ compensation costs are increasing and quality is growing uneven. The problem, said Dr. Peplowski, medical director of U.S. HealthWorks, is that we aren’t consistently improving the health of our population in comparison to other nations.
“Yet we continue to spend more money. I believe we should bring what we do on the healthcare side to workers’ compensation and wellness and offer a package for employers and payers that’s outcome-driven and value-driven in an alternative payment model,” said Dr. Peplowski.
What she means by the alternative model is shared risk, such as capitation consistent with what we are seeing in the Affordable Care Act (ACA). “The thing that differentiates this from Obamacare is that we would be integrating the workers’ compensation and wellness along with the health plan, all of which would be specific to the work site,” Dr. Peplowski said.
Right now, occupational health is still operating within the old-school, fee-for-service, Medicare model that has people getting paid more for doing more. In a shared risk model, Dr. Peplowski
argues, there would be accountability for outcomes. “Important outcomes in workers’ comp are measures such as getting people back to work,” she said. In the current system, there’s no accountability. For example, if a doctor is treating someone for a back injury today, and the patient gets another injury subsequently or never returns to work, the provider experiences no consequences.
“That model did not work for Medicare or workers’ comp. At the end of the day, what really matters for workers’ comp is to have employees back at work, making enough money to take care of their families. That’s the accountability piece that hasn’t been present,” Dr. Peplowski said.
The win-win for everyone is the sustainability of the economy. This benefits the worker, the employer, the providers, and the community, she said. In addition to a value-driven, outcomes-based alternative payment model, Dr. Peplowski said there also needs to be “transparency of metric.” And that is true for every patient and every case, with no exclusion of outliers. All parties, including workers, need to be able to review return-to-work outcomes, recidivism, narcotic prescribing, medical costs, margins, and total claims costs.
Travel Medicine
Travel medicine has played a role in occupational health for a long time but it’s a bit more prevalent today, and perhaps should be even more prevalent because there is such a close connection. Travel medicine is a specialty that helps international travelers prevent and
manage health issues that arise while overseas.
Typically when you think of travel medicine you think of inoculations and warnings. Mr. Leone said a good travel medicine program should consist of counseling on how to avoid becoming ill and what to do if you fail. In other words, what resources are available to the foreign traveler?
While most occupational health programs could sustain a travel medicine program, the key is to have personnel with special training and a strong, interest in the field.
It’s no surprise that urban areas are more likely to have people who travel on a regular basis, and as a result, travel programs are more valuable in these settings. “If you’re located near a major airport between Washington D.C. and Boston, you’re going to have a lot of international travelers, much more so than if you’re based in Wichita,” said a senior industry analyst.
Also, in large urban areas, it’s important for travel medicine personnel to be aware that employees who are traveling aren’t just doing it professionally. It is not uncommon for someone who is from Africa but works in New York to fly home to visit family.
Finally, the industry veteran said, that when there is an outbreak of a disease in some part of the world, such as the recent Ebola outbreak, it is important that it gets on the master roster of the travel medicine person so they know what kind of inoculation should be administered.
A medication kit should always be provided to a traveler going to an unusual place, one that includes the appropriate medication to combat common ailments including traveler’s diarrhea and dysentery.
As occupational health evolves within this rapidly changing healthcare landscape, industry experts urge occupational health executives to spread the word about the innovative new things they’re doing. Initiate outreach initiatives to employers, and let them know about the fringe services available to them. In order to achieve their optimal potential, occupational health programs must incorporate supplemental services into their service portfolios for employers.