—Johann Goethe, 1749-1832
By Karen O’Hara
A healthier workforce is being queued up as one of the significant anticipated lasting effects of national health care reform. The implications of many aspects of the Patient Protection and Affordable Care Act signed into law by President Obama on March 23, 2010, will take years to unfold. However, it is generally agreed that expanded access to health insurance will result in more extensive use of preventive medical services and improved management of acute and chronic conditions in the working population. On a broad scale, “the advantages of simply having access to insurance are obvious,” said John Howard, M.D., director of the
National Institute for Occupational Safety and Health (NIOSH), a research arm of the Centers for Disease Control and Prevention (CDC). “The bill provides coverage to 32 million uninsured people and provides tax credits to about 4 million small businesses to help cover the cost of insurance for their employees. By providing coverage for workers, we can hope for better preventive care and that workplace illnesses and injuries will be diagnosed and managed more Effectively.” In a statement published on the NIOSH science blog,1 Dr. Howard said a provision in the bill of particular interest to the healthcare industry establishes the National Health Care Workforce Commission, which will be comprised of health professionals, employers, third-party payers and labor unions. The commission will be required to submit recommendations to Congress, the Department of Labor and the Department of Health and Human Services to improve safety, health and worker protections for the healthcare workforce.
Dr. Howard also mentioned a number of other provisions relevant to occupational medicine practitioners:
- A mandatory Prevention and Public Health Fund investing $2 billion per year for public health programs (beginning with $500 million in FY 2010, rising to the full level in FY 2015). The funds can be spent on authorized “prevention, wellness, and public health activities.”
- Creation of a National Prevention, Health Promotion and Public Health Council and a National Prevention and Health Promotion Strategy to guide federal investments.
- Authorization for the Community Preventive Services Task Force and the U.S. Preventive Services Task Force.
- Programs targeting prevention and wellness may be funded from the Prevention Fund, by the standard appropriations process, both, or neither.
Authority for the CDC to conduct research and provide technical assistance on employer-based wellness programs is included. For example, the bill directs the CDC to:
1. Provide employers with resources to evaluate employer-based wellness programs and their effect on employees’ health status, absenteeism, productivity, medical costs and injury incidence rates.
2. Train employers how to evaluate employer-based wellness programs utilizing mechanisms such as web portals and call centers.
3. Within two years, conduct a national worksite survey to assess employer-based health policies and programs, followed by a report to Congress with recommendations for the implementation of effective employer-based health policies and programs.
4. Recommendations to boost the size and scope of the healthcare workforce through education, training, and improved access to services.
“Knowing that our field is facing a looming crisis in terms of a shortage of occupational safety and health professionals, I hope that the OSH community will take advantage of (certain) components of the bill,” Dr. Howard said. Those components include a loan repayment program for the public health workforce; public health fellowship programs (including an Epidemic Intelligence Service); and a Youth Public Health Program. According to Dr. Howard, a mandate that insurance companies cannot drop an individual’s coverage when they become sick or discriminate on the basis of pre-existing conditions is “a major consideration for many workers as they contemplate changing jobs or even divulging or testing for a workplace illness.” In addition, “the bill eliminates lifetime limits and restrictive annual limits on benefits in all insurance plans – a benefit for workers dealing with chronic occupational illness or an expensive occupational injury. Another aspect of the bill will make it easier for coal miners disabled by black lung disease to collect benefits,” he noted.
ACOEM Policy Briefing
Prior to the law’s passage, the American College of Occupational and Environmental Medicine (ACOEM) actively lobbied on Capitol Hill on behalf of incorporating preventive medicine principles in the legislation – and its work is just beginning. To a considerable extent, the law supports workplace health promotion and productivity management concepts, but it does not mandate the adoption of them by employers.
“That puts the burden back on OEM physicians and others to take the framework of the law and educate employers on the value of these programs,” said Patrick O’Connor, ACOEM’s director of public affairs, during an April 8 telephonic policy briefing for college members.
A growing body of evidence-based studies clearly demonstrates ways in which workplace health and productivity management help mitigate costs, Pamela Hymel, M.D., ACOEM president, said during the briefing. Corporate medical director for Cisco Systems, San Jose, Calif., where she has helped develop a total health management model for a large workforce, Dr. Hymel says there is a need for additional evidence-based studies that demonstrate the value of specific interventions, which will require encouragement from OEM physicians and a willingness on the part of employers to capture meaningful data.
“There is a great potential for employers who create a culture of health to push forward and reinforce where we are trying to go as a nation,” Dr. Hymel said.
Regarding the future role of OEM practice under the Patient Protection and Affordable Care Act, the picture is far from clear. Interpretation, enactment and enforcement of the more than 2,000 pages of provisions depends to a great extent on federal agencies and a large supporting cast of experts with varying backgrounds and agendas serving in advisory capacities. Mr. O’Connor said he expects the law to create new avenues for OEM physicians to help employers reduce costs while improving workforce health. He foresees a range of opportunities for the delivery of primary, secondary and tertiary care at the workplace that goes beyond traditional wellness offerings and delves much more deeply into disease prevention and management. He advises OEM physicians to be prepared to step up as implementation team leaders in their own organizations and as outside consultants to the industry.
An ACOEM task force will continue to have a voice as the reform law goes into effect, Mr. O’Connor said. The task force, led by Ronald Loeppke, M.D., a longstanding proponent of evidence-based health and productivity management programs, has adopted a five-pronged approach:
1. Evaluate and disseminate clinical evidence that demonstrates the value of health and productivity and disease management.
2. Develop the steps required to put evidence-based recommendations into action.
3. Identify exactly what is needed to create a culture of health at work, understanding that some employees require ongoing encouragement to sustain healthy lifestyles.
4. Ensure that health and productivity management program recommendations are consistent with federal laws such as the Family and Medical Leave Act, the Americans with Disabilities Act, the Health Insurance Portability and Accountability Act, and the Genetic Information Non-discrimination Act (GINA), as well as state laws and regulations.
5. Clearly demonstrate costs and return on investment associated with workplace wellness and health promotion to employers.
“ACOEM is focusing on this five-pronged approach moving forward as the federal government begins implementation of workplace health reform,” Mr. O’Connor said. “Another issue we are gong to be working on – and it’s going to be really difficult but we see real merit in it – is reimbursement for services such as vaccinations that may be provided at the worksite.
“We spent some time on this issue during the Congressional debate and will continue to do so over the next two to three years.”
On a separate but related front, Mr. O’Connor said ACOEM will continue to seek interpretations of GINA and the ADA to lift barriers to providing workforce health risk assessments (HRAs) and other wellness interventions without violating employee protections enforced by the Equal Employment Opportunity Commission (EEOC).
For example, there has been resistance at the EEOC to the concept of using incentives to encourage employee participation in wellness programs on the grounds such programs infringe on employee rights. However, there is language in the reform act that allows employers to offer employees a 30-50 percent discount off the cost of insurance coverage for participating in wellness programs and meeting certain criteria, such as not smoking or losing weight.
“The hope is that incentive provisions in the act will be used by the Obama administration to convince the EEOC to go forward with regulations that find wellness provisions are not a violation of the ADA,” Mr. O’Connor said. “We also hope provisions in the new law will enable us to go back to federal agencies under Title I of GINA to get some loosening of EEOC provisions regarding HRAs. Time will tell.”
As a cause célèbre, Mr. O’Connor said workplace health promotion and disease management will continue to be a “heavy lift” for ACEOM, in part because consensus is lacking.
“There is no general agreement on what is meant by or what is embodied in disease promotion programs,” he said. For example, “there is concern from the American Heart Association, the American Cancer Society and other organizations that there is a potential for discrimination in workplace health promotion and disease prevention programs. There is more work to be done to bring all stakeholders to the table, including occupational medicine, to sit down and talk about what constitutes effective workplace health promotion and disease prevention programs.”
View from the Trenches
Brian Harrison, M.D., an ACOEM fellow and director of Health and Productivity Management for Affinity Occupational Health, Menasha, Wis., said he was asked by Affinity team members for his opinion on the impact of reforms relative to employer-sponsored wellness programs shortly after the reform law was passed. Although he views the law “as a negative overall,” Dr. Harrison assured his staff that Affinity Occupational Health will retain its competitive edge.
“The work we do remains essential,” he said. “By continuing to expand our presence at workplaces now, we secure a better future for ourselves, our clients, and our part of the world.” He expects the reforms to increase employers’ costs, which could, in turn, diminish their investment in wellness. But for Dr. Harrison, the most important question is: How will reform affect the way health insurance premiums are set? “Most of our clients are fully insured, and their rates are experience-based,” he explained. “This has been their strongest motivator to sponsor wellness. They have wanted to control claims experience and get better rates. If that mechanism is changed, such as basing rates on the solvency of a national program or an insurance exchange, then employers will no longer be motivated by the effect of their own claims history.”
Dr. Harrison says he finds the success or failure of wellness initiatives depends on individual and employer motivation, with money considered the most widely accepted motivator. “Financial motivation of both individuals and their employers will be strongly influenced by how insurance rates will be set,” he said. “Namely, will my efforts to stay healthy, both individually and as a corporation, decrease my insurance rates? If people no longer pay for health care directly, or by experience-based premiums, then motivation declines. Being healthy doesn’t decrease taxes.” Additionally, Dr. Harrison is “skeptical” that self-insured, small-to-medium-size companies will be able to remain self-insured because they will likely find it difficult to comply with all the requirements the Secretary of Health and Human Services is expected to promulgate to meet the new law’s intent. Self-insured companies that opt to get into insurance exchanges would have decreased flexibility in terms of their wellness programming, he said. Meanwhile, insurance companies may be motivated to sponsor wellness programs at client companies, which could diminish demand for provider-based services.
However, no matter what impact the reforms ultimately have, Dr. Harrison believes employers will remain strongly interested in health-related productivity management. “We are better positioned than other types of providers to sell programs that measurably impact absenteeism and presenteeism,” he said. “Another way we are favorably positioned is the connection between wellness and workplace safety. The health insurance reform law doesn’t affect workers’ compensation, and employers still have motivation to control workers’ compensation costs. Wellness is increasingly seen as important in that regard.”
Workers’ Comp In-Play
In a recent entry on the Workers’ Comp Kit Blog, a discussion forum for employers, Karen Wolfe, president of MedMetrics, LLC, a web-based workers’ compensation medical analytics company, supports the position that occupational health clinics will continue as the best treatment option for workers as practice patterns in the group health world continue to evolve. “Occupational medicine clinics have doctors who specialize in treating workplace injuries and their accessibility will not be affected by the health care reform law,” said Ms. Wolfe, a nurse, former software developer and longtime NAOHP member. “Outside of occupational medicine, doctors’ practice patterns for treating injured workers will be a question of accessibility and availability, probably with longer wait times for appointments and referrals.”
Ms. Wolfe cites studies that show a growing number of physicians are leaving private practice and going to work for hospitals, health systems and large multi-specialty groups, primarily driven by high operational costs and reimbursement challenges. She believes health care reform will accelerate the movement away from private practice and toward corporate-based medicine, in turn tightening access and creating opportunities for treatment alternatives such as increased use of nurse practitioners and physician assistants.
“The bottom line is doctors’ treating practices are changing and will continue to change with or without health care reform,” she said. “Doctors working as employees of a corporation will follow corporate practice standards that define time spent with a patient, as well as time allocated to completing forms and communicating with families or employers. “The silver lining for workers’ compensation is those who can access occupational health specialists for injury treatment will notice no change. Accessibility and the quality of care should remain constant. As for those seeking injury treatment elsewhere in this new healthcare environment, the story could be different.”
Joe Paduda, principal, of Health Strategy Associates, a consulting firm specializing in group health and workers’ compensation managed care, and author of Managed Care Matters, an industry blog, agrees the likelihood that workers will be healthier may be the most significant long-term impact of reform. He reasons that if a greater number of underlying conditions and co-morbidities are addressed in a larger segment of the population under group health plans, workers’ compensation insurers won’t have to pay as often for the treatment of non-work-related conditions in order to resolve a claim. In addition, Mr. Paduda forecasts:
- A decreased need for hospitals to cost shift to workers’ compensation to make up for revenues lost due to treating the uninsured; conversely, there is a possibility of increased provider cost shifting to workers’ compensation to cover cuts in Medicare reimbursement.
- A much stronger and tighter focus on managing group health, Medicaid and Medicare by major managed care companies, which will likely result in less interest in, and resources dedicated to, workers’ compensation, which represent less than 3 percent of national health care spend.
- A nominal, if any, decline in claim frequency as a result of broader coverage. Research shows uninsured individuals are not more likely to file workers’ compensation claims because other factors such as morale, employees’ pay level and immigration status appear to have more influence on filing than does coverage.
- Group insurers and health plans will invest heavily in medical management, data mining, analytics, chronic disease management and electronic health record technology.
In an article published last summer in Business Insurance4 industry experts expressed uncertainty about the impact of health reform on the workers’ compensation insurance industry. Harry Shuford, chief
economist at the Boca Raton, Fla.-based National Council on Compensation Insurance, told reporter Joanne Wojcik that major health reform issues “don’t have much relevance” to workers’ compensation. “If you’re trying to figure out how to reform the U.S. health care system, you’re probably going to focus on the big things first,” he said. “Work comp and bodily injury, liability, etc., are all very small. So, they would be tertiary issues to address.”
On the other hand, Dave North, president and chief executive officer of Sedgwick Claims Management Services Inc., Memphis, Tenn., said while the legislation does not feature specific references to workers’ compensation, “You can’t fundamentally alter the national health care system and not affect workers comp. “If you look back at the national dialogue that occurred at the start of the Clinton era, we saw in this country significant changes in health care in the years following, and there was no legislation passed. The heightened dialogue and awareness alone caused significantly positive health care reform for employers,” Mr. North said.
In an April 6, 2010, Risk & Insurance article, Peter Rousmaniere, an industry observer and writer, also notes that workers’ compensation is only superficially referenced in the legislation. “None of the leading proponents in the House or Senate sought to include workers’ compensation in their health care reform bills,” Mr. Rousmaniere writes. “But the legislation may in fact have an indirect and marked effect on workers’ compensation” because of changing employee, employer, vendor and medical provider behavior. In the same article, Gary Anderberg, practice leader for analytics and outcomes at Broadspire, a third-party administrator, says his “biggest near-term concern is that much of the work that needs to be done in workers’ compensation medical management will languish in the doldrums as health care reform sucks up all the available air and energy for the next two or three years.”
