By Anthony Vecchione
The synergy between occupational medicine and population medicine is strong and getting stronger. Population health or medicine can be defined in various ways, including a group of people who are associated with a particular provider or healthcare organization, or employment site, or who are part of a health plan.
The American Medical Association’s (AMA) A Primer on Population–Based Medicine (www.amaassn.org/ama/pub/physician-resources/public-health.page) states that a key goal of population health is to reduce disparities in the distribution and impact of diseases and conditions in a population.
According to the AMA, examples of population-based approaches include health promotion screening activities, patient reminders for mammography or influenza vaccines, comprehensive preventive services for high-risk populations, adolescents, and the elderly, and comprehensive chronic illness management programs such as diabetes or asthma.
These goals and initiatives are familiar to occupational health professionals. In its position statement, Optimizing Health Care Delivery by Integrating Workplaces, Homes, and Communities, The American College of Occupational and Environmental Medicine (ACOEM) (www.acoem.org) says, “Occupational and environmental medicine physicians enhance the health of workers through preventive medicine, clinical care, disability management, research, and education.”
It is no surprise that leading experts in occupational health are taking a closer look at how a marriage of occupational medicine and population medicine can benefit the common patient populations they serve.
Mark Russi, M.D., professor of medicine and epidemiology at Yale University and director of occupational health services at Yale New Haven Hospital (www.ynhh.org), contends that occupational medicine is ideally situated to play a major or participating role in population health. “In the end, it is employers who are going to bear the financial burdens of whatever health conditions their employees have,” Dr. Russi said. He pointed out that all the motivations are lined up in the right way and that it makes sense for employers to invest in programs that will help their employees be healthier. “The workplace is an ideal setting to work on things like wellness and disease management, and I think part of the distinction when you start talking about population health as opposed to the traditional wellness programs we had in the past is that to do population health well, you need to understand better the health of your population [so you can] characterize what the risks are among the individuals [in] your large population.”
Members of the National Association of Occupational Health Professionals (NAOHP) often use the association as a resource for research, performance comparisons, and peer networking, which helps us fulfill our mission:
“The NAOHP supports provider-based occupational health programs and professionals in the achievement of the highest quality services, thereby advancing the association to the benefit of the national workforce and the public health of the country. The NAOHP will seek to assist providers in establishing partnership relationships with employers and their workforces to ensure genuine healthcare cost management and individual health maintenance.”
The following summarizes some of our ongoing efforts to elevate the field of occupational health and serve our constituents.
The Yale New Haven Health System includes an integrated occupational health program that is combined with a university program built around wellness and includes everything from smoking cessation to blood pressure monitoring, to weight loss and exercise programs. “People pick and choose from those options. I think it’s important for us to make sure we are offering something for everyone,” said Dr. Russi.
OCCUPATIONAL HEALTH/POPULATION HEALTH, PERFECT TOGETHER
Increasingly, healthcare practitioners as well as health system executives are recognizing the role that occupational health programs are playing in population medicine. “We’re just getting started in this area,” said Chuck McDevitt, vice president and chief information officer at Self Regional Healthcare (www.selfmemorial.org) in Greenwood, South Carolina. “But we believe it’s very important. You spend one-third of your life at work so we believe it’s important to focus on health at work. We’re reaching out to two area employers today and hope to expand that in the future.”
Mr. McDevitt, who defines population medicine as living a healthy lifestyle that includes eating right, exercising, and taking a preventative approach to managing health, believes the changing scenario of the nation’s healthcare system has to be considered when addressing population medicine. “As our focus as a health system changes from a focus on providing services to providing value, we’re going to be working to keep populations healthy while at the same time, we’re working to reduce costs and improve quality of outcomes.” Mr. McDevitt said the focus going forward as the health system moves toward becoming an accountable care organization(ACO) is to work with team members already at risk from an insurance cost
perspective to improve their health.
Mr. McDevitt acknowledged the challenges inherent in establishing an internal population medicine program. For instance, overcoming barriers to care like transportation, medication co-pays, and getting folks to trust that you’re actually trying to help them be healthier. “Another challenge is getting [the employee’s] physician involved in the process. It won’t work if we’re not coordinating care with their primary care provider, or finding them one, and that includes being able to share data, which isn’t easy today.” Mr. McDevitt said his health system is working to build a clinically integrated network where data can be shared between providers, hospitals, labs, and post-acute providers.
REAL-WORLD PROGRAMS THAT WORK
At Dartmouth-Hitchcock Medical Center in Concord, NH, the Live Well/Work Well health and well-being program (employees.dartmouth-hitchcock.org/livewellworkwell.html) gives employees and their families the resources to enable them to enjoy a healthier lifestyle so they can do what they want to do at home and at work.
“We have an extremely robust program. We tout it as a comprehensive integrated health protection and health promotion program which is meant to explain to the world that we understand there’s a relationship between occupational health and general personal health,” said Robert McLellan, M.D., section chief, Occupational and Environmental Medicine at the Dartmouth-Hitchcock Medical Center University. “If you do not live well it’s hard to work well,” Dr. McLellan said. “And if you do not work well,
if your basic occupational health and safety issues are not there, it’s going to significantly impact peoples’ personal health too.”
Dr. McLellan, an associate professor of medicine at Dartmouth’s Geisel School of Medicine, said the difference between clinical medicine and population medicine is that clinical medicine is focused on the patient in front of you without as much attention paid to all the patients who may not be in front of you. For example, in a clinical practice, a family doctor may have seen you three years ago and not have seen you since. In traditional clinical practice, it doesn’t really matter because the physician’s responsibility is only to the patient in his immediate care. In contrast, population medicine or population health is different. “The concern is for an entire population who is attributed to you, with responsibility
and accountability financial and healthwise, whether or not a particular patient has ever graced the door of [your] examination room.”
Occupational health programs fit well into the population medicine scenario in several ways, Dr. McLellan said. For starters, occupational medicine is fundamentally a preventive medicine specialty and its practitioners have expertise in both clinical medicine and population-based medicine or population health. “As a preventive medicine specialty, there’s a focus on the determinants of health, that means
what are the factors in a population that impact the health of that population,” said Dr. McLellan. “In the workplace of course, how hazardous is the work? How safe is the work? And more generally, what is the diet available to the population? How easy is it for the workforce to be physically active during the workday?”
Dr. McLellan, the lead author of ACOEM’s Optimizing Health Care Delivery by Integrating Workplaces, Homes, and Communities (http://www.acoem.org/uploadedFiles/Public_Affairs/Policies_And_Position_Statements/Optimizing%20Health%20Care%20Delivery%20Position%20Statement.pdf) pointed out that occupational medicine in many settings acts as a public health officer for the employee population, just as the public health officer oversees the general health of the community by paying attention to the drinking water and the quality of the food. “Public health officers ensure that there’s adequate care and measure the health of that
community population. So do many occupational medicine physicians in a similar public health officer way measure the health of the employee population to ensure a protective environment, promotes health and assures adequate care.”
CHALLENGES THAT LIE AHEAD
What advice would you give to an occupational health organization seeking to adopt a population medicine approach to employee health? “Work with area providers and hospitals to partner on a program rather than compete,” Mr. McDevitt advised. It is hard enough to get folks to comply and to get data on patients, and that goal is a lot easier with a partnership. He said he would also like to see individualized care management of the chronically ill, particularly in the area of medication management.
Dr. McLellan of Dartmouth-Hitchcock said there are considerable challenges to consider when an organization is contemplating an internal population medicine program. “One of the big issues that all employers deal with is around privacy and confidentiality.” He acknowledged that many employees assume and expect their employer to be concerned about hazards they may encounter at work, to protect them from those hazards, and to take care of them if they get injured.
However, said Dr. McLellan, some employees may be concerned that an employer is poking into their business if they begin deploying health risk assessments that ask about personal risk factors.
“The employer is required by law to maintain appropriate privacy, but there is a big trust issue around that privacy. That is probably one of the most important issues to deal with in the early stages of a program like that.” A second major challenge is that you can build the best program in the world with all kinds of services and yet if people do not engage in them the resources will be useless. “Figuring out how to incentivize, motivate, and engage people in the services that have been made available to them is another huge challenge.”
Yale’s Dr. Russi agrees there are challenges facing occupational health programs seeking to adopt a population medicine approach. “We’re getting to the point where most of us who are trying to do this need to take the next step. Wellness programs have been offered for years and years. The next step is biometric screening and helping employees identify what their health risk factors are and then trying to provide them the tools to work on them.”
Dr. Russi said that Yale New Haven’s occupational health program undertook biometric screening for its health system this past summer. “We were successful in screening 50 percent of our complete work population and we incented people to do that. We actually deducted $500 from their insurance premium if they took part in the screening.”
Yale employees now have their own personalized confidential health-risk assessment, Dr. Russi said, and a wealth of information they can get to help them modify their own risk factors. In addition, employees have access to smoking cessation, weight-loss programs as well as disease management programs for employees that have an established illness. “We started a pilot program for people with diabetes so they are adequately informed about their disease and understand the medications they take.” The ultimate goal is to inform people about their own health risks and offer them things like biometric health screening and follow-up programs that allow them, in a very personalized way, to modify their risks.
However, said Dr. McLellan, some employees may be concerned that an employer is poking into their business if they begin deploying health risk assessments that ask about personal risk factors.
“The employer is required by law to maintain appropriate privacy, but there is a big trust issue around that privacy. That is probably one of the most important issues to deal with in the early stages of a program like that.” A second major challenge is that you can build the best program in the world with all kinds of services and yet if people do not engage in them the resources will be useless.
“Figuring out how to incentivize, motivate, and engage people in the services that have been made available to them is another huge challenge.”
Yale’s Dr. Russi agrees there are challenges facing occupational health programs seeking to adopt a population medicine approach. “We’re really getting to the point where most of us who are trying to do this need to take the next step. Wellness programs have been offered for years and years. The next step is biometric screening and helping employees identify what their own health risk factors are and then trying to provide them the tools to work on them.”
Dr. Russi said that Yale New Haven’s occupational health program undertook biometric screening for its health system this past summer. “We were successful in screening 50 percent of our complete work population and we incented people to do that. We actually deducted $500 from their insurance premium if they took part in the screening.”
Yale employees now have their own personalized confidential health-risk assessment, Dr. Russi said, and a wealth of information they can get to help them modify their own risk factors. In addition, employees have access to smoking cessation, weight-loss programs as well as disease management programs for employees that have an established illness.
“We started a pilot program for people with diabetes so they are adequately informed about their disease and understand the medications they take.” The ultimate goal is to inform people about their own health risks and offer them things like biometric health screening and follow-up programs that allow them, in a very personalized way, to modify their risks.
