Steve Jobs once said, “I have a great respect for incremental improvement, but I’ve always been attracted to the more revolutionary changes. Because they’re harder. They’re much more stressful emotionally. And you usually go through a period where everybody tells you that you’ve completely failed.”
Change in healthcare, while inevitable, can often be a long, laborious, and uncertain process. Special interests reign, territorialism abounds and the next new thing often strangles the last new thing in its infancy. Given a new national administration committed to change, change is likely to proceed at an unprecedented pace and in ways we can’t predict.
So it has been with occupational health during the past several decades. There are invariably new visions, and often there is only short-term progress associated with these visions before the trail turns cold.
One of eleven courses at RYAN Associates’ 30th annual conference in Boston addressed the future of occupational health. Four sessions offered uncommon insight into where we have been, where we are, and where we are going. Course faculty cited in this story include:
—Dr Karen Huyck
- Dr. Tom Winters, Occupational Health Chief and President, the Occupational and Environmental Health Network in Marlborough, MA
- Dr. Karen Huyck, Assistant Professor, Dartmouth Hitchcock Medical Center and Dartmouth Medical School in Lebanon, NH
- Dr. Madelynn Azar-Cavanaugh, Medical Director of AllOne Health, a Massachusetts-based company with more than 70,000 clinicians that provides a wide array of occupational health, wellness, and population health services to employers.
- A “visionary panel” including Barry Eisenberg (Executive Director of ACOEM), Dr. Barry Magnus (regional medical director at Concentra), John Garbarino (former C.E.O. of Occupational Health + Rehabilitation), and RYAN Associates’ founder and former President, Frank Leone.
Panel members were asked to reflect on what prominent change forecast during recent decades turned out to be less impactful than originally projected and why.
Dr. Magnus zeroed in on the less-than-desirable impact of wellness programs on worker health when included in the occupational health umbrella. He noted that there is a “chronic inability to provide current and prospective wellness employer clients with a meaningful ROI projection.” Dr. Magnus added that “The proper evaluation of corporate wellness programs is based largely on long-term effects which become virtually impossible to measure given the short-term mobility of so many employees.”
For his part, Dr. Winters noted the inordinate power and entrenched position of insurers in effecting change. But, at the same time, he added “The insurance industry is fragmented, thus creating somewhat of a stalemate in terms of progress.”
At a more macro level, Mr. Leone said that current occupational health professionals should “‘beware of the ‘next big thing.’ At various times managed care, workers’ compensation reform, PPMs, PPOs, MCOs, ACOs, and Patient-Centered Medical Home Models (PCMHs) were hailed as the new face of healthcare. Yet in our special interest world, it is difficult to jump on any new bandwagon.”
Panelists cited a variety of other stalled concepts:
- Insufficient progress on service integration
- Fewer for-profit occupational health system/healthcare system joint ventures than initially thought
- An inability of the workers’ compensation system to merge into the larger healthcare system
Given the slow pace of change, it may be time for a reset and a short pause before we identify the next wave of changes.
THE NEXT WAVE
Dr. Winters associated our industry’s likely evolution with significant changes and innovations that are already underway.
“We need to adapt to a changing work environment. There are new job types, emerging markets, more women in the workplace, a proliferation of nanotechnology, and, within five to ten years, the 30-hour work week.”
Dr. Winters continued, “Climate change, for example, is certain to have an increasingly profound effect on workplace health. For example, the effect of climate change can trigger a greater prevalence of asthma, new, more debilitating allergies, and more infectious diseases, and accentuate numerous mental health issues. As a result of climate change, these are likely to all move up on the (occupational health) agenda.”
Dr. Winters cited the obesity epidemic as a foreboding trigger. “It (obesity) alters ergonomic approaches and stimulates a greater prevalence of cardiovascular disease and diabetes. Sitting down issues are stealth and likely to get worse, resulting in more degenerative disk diseases and other related conditions.”
The new occupational health paradigm is likely to move further than these issues. Dr. Winters forecast a wide range of additional changes:
- Circadian disorders borne by shift workers affect mental health and need to be addressed.
- The worker mix is changing: there are more contingent workers and non-employees, resulting in more workers with partial or no health coverage.
- The emergence of autonomous vehicles will decrease the prevalence of DOT physicals. • Data overload, as a result of more cameras and sensors, can vastly increase stress-related conditions.
- The treatment of many mental health conditions will change as our society uses fewer pharmaceuticals such as anti-depressants and as pharmaceutical solutions are replaced by more functional jobs and supportive managers.
According to Dr. Winters, the workplace setting of many occupational health professionals will also change. “There is likely to be a decrease in corporate-based occupational medicine professionals and a proliferation of more highly specialized consultants.”
Dartmouth-Hitchcock’s Dr. Karen Huyck emphasized the need to use occupational health to “ignite” a transformation of American healthcare from a “sick-care” system to a “healthcare” system. Dr. Huyck noted that there is an inexorable link between occupational medicine and an organization’s ability to develop functional Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs). For example, a classic ACO is based on physicians and other practitioners coming together to provide care that increases value and enhances quality while minimizing costs. Such a structure is at the core of occupational health practice.
For their part, PCMHs stress a whole-person approach to providing care which should be the heart and soul of every occupational medicine practitioner’s mission. “You will need the connection to an employer base for ACOs and PCMHs to be successful,” stressed Dr. Huyck.
“Work affects health and health affects work,” said Dr. Huyck. Workers need to come to work healthy and a central role of an occupational medicine physician is to enhance the health status of both individuals and populations.” Dr. Huyck appears bullish on occupational health, “The potential leverage available to a single occupational medicine physician can affect the well-being of tens of thousands of individuals.”
Dr. Huyck also emphasized the “psychological health of the workplace.” She noted ten primary health risk factors that can and should be addressed at the workplace that are associated with an increase in chronic disease: back/neck issues, depression, fatigue, chronic pain, sleep problems, high cholesterol, arthritis, hypertension, obesity, and anxiety. Dr. Huyck noted that these risks are inherently interrelated; that is, the incidence of one condition stimulates the development of others, yet many practitioners tend to view them in isolation if at all.
“(We) need to tie occupational medicine to workplace safety more definitively. Traditionally, there is little to no linkage of the two while considerable evidence has emerged that a healthy worker is a safer worker.”
—Barry Eisenberg
HOW WE NEED TO CHANGE
What, then, do we need to do to manage change as we move forward?
Mr. Eisenberg, executive director of ACOEM, noted the “need to better tie occupational medicine to workplace safety. Traditionally there is little to no linkage of the two while considerable new evidence has emerged that a healthy worker is a safer worker. We need to associate both work-related and non-work-related incidents with a worker’s ability to work effectively.” Dr. Eisenberg cited the oft-stated notion that someone who reports to work on Monday after incurring a softball injury over the weekend may still be unfit for duty.
The lack of certified practitioners is a significant impediment to keeping occupational medicine out of the mainstream.
“Few realize that only 4,043 physicians have been certified since 1949. We gain about 90 new board-certified occupational health physicians a year while losing about 200-300 a year due to retirement and other factors. Given that our nation still incurs about 4.5 million injuries per year, we can conclude that occupational medicine is still a supply-dominated specialty.”
What will it take to bring more certified occupational health physicians (and other practitioners) into the fold?
OneCall’s Dr. Azar-Cavanaugh stressed the need to generate greater specialty awareness at the basic level. “During grand rounds, I learned that half [of physicians] have not heard of the specialty, and only a few knew occupational medicine was a specialty. We need to come together to at least get occupational medicine on the medical school curriculum.” Others noted that occupational medicine was often not even on the list that would-be residents could match up to.
“If occupational medicine continues as it is currently defined, it is destined to languish, if not perish.”
Frank Leone noted, “If occupational medicine continues as it is currently defined, it is destined to languish, if not perish.” The specialty needs to redefine itself by actually renaming it. There is a precedent, noted Mr. Leone, “ACOEM was once labeled “ACOM” until the specialty realized that “Environmental’ should be included in the title. A redefinition/ renaming needs to pull together a new vision of occupational medicine that integrates multiple specialties.”
The dream will endure. In the words of beloved Civil War-era abolitionist Harriet Tubman, “Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.”
The pieces for a new and considerably more impactful world of occupational health are within our grasp. We need to think big, learn from the past and advance a powerful vision of occupational health as an integral part of the new healthcare dynamic.
