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A study of the scope of occupational health services.

In order to define the scope of corporate occupational health services as they exist today, a questionnaire was designed and sent to members of the College's Society of Corporate Medical Services. Industries represented in the survey include manufacturing, utilities, transportation, communications, research and development, banking, insurance, and publishing. The emphasis in this report is on data indicating trends in the provision of services.

Rising health care costs, changes in the business climate, and an increasingly restrictive regulatory environment have caused changes in the world

of corporate health organizations. Some companies are increasing their involveme nt in health care through more direct provision; more have scaled back and are contracting externally. Others have shifted focus from occupational surveillance and treatment of work-related illness to a broader role in corporate health management, to ensure quality and value in purchased services.

In order to define the scope of occupational health services as they exist today, a questionnaire was designed and members of the ACPE Society of Corporate Medical Services was surveyed. This group represents the core of ACPE expertise in this area, yet relatively few members of the college are actively engaged in internal occupational health services. For this reason, members were requested to return the questionnaire even if it was not applicable to their practice so this could be noted. In all, 65 questionnaires were returned; 45 were deemed to have information usable for this survey.

Although the main intent was to gather information regarding internal corporate health services, questionnaires were returned by occupational health practitioners who are hospital or clinic-based and who provide a variety of services to small and medium-sized companies. These data will also be reviewed in a selective fashion. We elected not to include information from managed care, peer review, and utilization review companies because, although in some cases they are involved in occupationally related areas, such as disability or worker's compensation, they are not direct providers of occupational health services.

Demographics

Industries represented in the survey include manufacturing, utilities, transportation, communications, research and development, banking, insurance, and publishing. The majority of the internal corporate health providers, approximately 85 percent, would be classified as "heavy industry." There were also two respondents who provide occupational health services to hospital employees but do not contract externally. Five respondents are in hospital-based occupational programs that contract with industry and, in some cases, provide internal occupational services to their own employees. Seven respondents are clinic-based practitioners.

Generally, hospital-based practitioners report to the CEO or a vice president of the hospital. Independent clinics, on the other hand, may have no formal reporting structure. In fact, the medical director may be the president of the company and report to the client.

Of the 31 respondents who deliver internal services, more than 60 percent report to a function classified as human resources, personnel, or a similar type of position. Approximately 22 percent report to an environmental health and/or safety function, with the remainder representing miscellaneous reporting structures.

Respondents were asked if their firms had divisions, other than the corporate health services organization, that provide medical services. Although in several instances different divisions, business units, or sister corporations have their own medical providers and report only on a dotted line to the corporate health organization, no company reported internal competition or specifically indicated external competition from occupational health clinics or local hospitals. As there appears to be a trend toward development of more independent practitioners of occupationally related services, specifically wellness and employee assistance programs, such potentially tailored programs may provide competition for a formerly captive corporate audience.

Figure 1, below, shows that 42 percent serve populations in excess of 25,000 employees. Figure 2, below, shows the breakdown of groups served. Although a fair number of companies indicate that some treatment is rendered to contract employees and/or dependents, generally these services are limited. Contractors on premises may avail themselves of services in the event of an emergency, and some types of health promotion or employee assistance program interventions are available to family members.

More than half the respondents indicate a consistent level of care is provided to all employees, regardless of location or level. Of those that indicate a difference, approximately 60 percent seemed to stratify by management level, the typical example being the executive physical. Understandably, high-hazard environments receive more stringent surveillance, as exposure and safety issues are more critical. There seems to be a movement away from offerings that represent a "perk" for certain employees to a more bottom-line, business-impact-oriented strategy, as demonstrated by increasing client demands and customer choice with regard to health services.

Staffing

Because of a lack of, or inconsistent answers to, questions regarding staffing, little meaningful data could be gleaned from this question. Some indicated a recent decrease in the number of full-time inhouse physicians, with increasing emphasis on part-time contracting for physician services. Some indicated an attempt to decrease costs by enhancing the roles of occupational health nurses and other allied health professionals.

Services

A detailed question regarding types of services and providers did not yield any real surprises (figure 3, above). Although corporate medical organizations are primarily responsible for occupationally related services, such as surveillance and injury management, involvement varies from direct provision of the service to monitoring and oversight of work done by external vendors. Only four companies reported no involvement of the internal medical group in these activities.

As one would expect of an OSHA mandate, the vast majority of companies provide on-site emergency response. Sixty percent of the time, the response is provided by the medical staff, but other groups, such as safety or emergency medical technicians, are directly accountable in some cases. Geographical concentration of populations leads to provision of better services.

Responses regarding provision of nonoccupational illness and injury treatment, as well as comprehensive primary care, show no definite trend. Seven companies indicated that they are providing comprehensive primary care to employees and, in some cases, to family members and retirees. A similar number indicated deemphasis of treatment of nonoccupational illness and injury, with an increasing emphasis on preventive services to control health care costs.

With an increasing emphasis on prevention has come acceptance of the importance of wellness education and health screenings. Enthusiasm for fitness centers as part of wellness programs varies. Sixty percent of respondents provide fitness units inhouse or by external contract. Nonetheless, cost-effectiveness of such endeavors is hard to demonstrate in the short run. In some cases, value added is more readily obvious in terms of morale, although informal polling of companies that have invested heavily in comprehensive facilities indicates many heavy users were "fitness buffs" prior to the use of the programs.

Popularity of employee assistance programs has increased dramatically in the past 10-15 years, even for small and medium-sized employers, as emphasis has shifted from substance abuse alone to a more comprehensive array of counseling services. Only two companies with internal corporate health groups reported no such programs. In 16 of 29 cases, the employee assistance program is an integral part of the medical/health services group. In six it is provided by an internal group other than medical, frequently because of bargaining unit agreements. External vendors deliver counseling services in seven instances.

Analysis of relationships with industrial hygiene and safety revealed five cases where both are provided by the medical group itself; three companies provide safety programs internally, through a nonmedical group, but contract for specialized industrial hygiene needs. One company has a safety program, but no industrial hygiene/toxicology, and one claims to have no such programs at all. The remainder of the 21 companies report that their programs are provided by internal groups parallel to and frequently in conjunction with the medical staff.

With the advent of the Americans with Disabilities Act, focus on job accommodation is clearly increasing. All companies claim to provide this service, but, in the majority of cases, it is done by human resources personnel with medical input. For almost a third of respondents, reporting is to the medical group itself.

Disability Management

The 31 corporate respondents in general indicated significant involvement in all types of disability management (figure 4, below). While slightly more emphasis is placed on consultation and monitoring of occupational illness and injury, when it comes to addressing tough cases, the medical staff is involved in all cases. The least common responsibility was actual certification of benefits. Even with regard to nonoccupational disability, however, this function was performed by the corporate health staff in over half of the cases.

Disability Insurance Status

Figure 5, below, shows that respondents, typically large corporations, are generally self-insured, with a slightly stronger tendency to be both self-insured and self-administered for occupationally related illness or injury.

Medical Benefits Design Role

Informal data suggest that, historically, companies rarely tapped the expertise of inhouse health professionals in designing medical benefits. As shown in figure 6, page 46, more than half of the respondents have a consultative role in benefit design. However, they lack decision-making authority. Another 15 percent are involved as team representatives in plan development or post-design, and a quarter of the respondents report having no role whatsoever. Of the four respondents who have total responsibility for plan design, only one is in a corporation in the classic sense; the others include an insurance company, a hospital, and an armed forces health services command. The corporation is a JCAHOambulatory care facility that provides total health care services for employees, nonemployees, and their families.

Changes in Scope

The role of the occupational health organization has evolved significantly in recent years. Cost pressures, liability concerns, and regulatory activities have had dramatic impacts on the way health care is delivered in the corporate world.

There is growing emphasis on disability case management and efforts to minimize medical claims and productivity losses, while ensuring quality of care. Much attention is also geared toward a drug-free workplace, as screenings become more commonplace and substance abuse cases are monitored more aggressively. In addition to managing existing health problems, many companies are allocating resources toward preventive care and wellness programs, thereby educating people to take personal responsibility for their own wellbeing.

In light of the current regulatory climate, such as the new Americans with Disabilities Act (ADA), corporations are focusing on activities that ensure compliance with new standards. For example, today's occupational health professional recognizes the importance of performing standard preplacement assessments, providing valuable consulting on job accommodation issues, participating in job description/design, and evaluating work restrictions. OSHA surveillance is also more prevalent, and strict attention is being given to infectious disease control, particularly in response to the OSHA's bloodborne pathogen standard.

Other areas of increased emphasis include quality/risk management, computer automation, repetitive strain injuries and spinal care, employee assistance programs, international or field support, reproductive health, credentialing, involvement in managed care, and unbundling of cost. Although results are sporadic, some respondents indicate recent reductions in clinical staff and/or contracting out of nonoccupational illness/injury and physicals.

As corporations look for innovative ways to alleviate medical costs, they have come to rely on internal health services for consultation on legal matters, administrative issues, benefits strategies, and other far-reaching concerns. Likewise, as the occupational health organization strives to deliver high-quality, cost-effective, value-added services, they have become more customer-focused.

Survey participants were asked to rate the value-added aspects of corporate health programs in a number of areas. Although, on average, more respondents emphasized the importance of controlling health care costs and demonstrating concern for employee welfare through such programs over provision of consulting expertise for the corporation or ensuring quality community care, there was no consistent trend. Some felt that saving employee time off the job or ensuring regulatory compliance were top priorities.

Similarly, it is not possible to draw any supportable conclusions from responses to the question regarding perceptions of top managements opinion. Some were less enthusiastic overall about management appreciation of services.

The final area explored by the survey concerned the perceived need or desire for additional education or training. There is a clear desire for management training, specifically conflict resolution, negotiation, and marketing. Other areas mentioned by several respondents include worker's compensation and disability management, including ADA; business training, specifically financial management and cost containment; and quality management methodology. Several respondents were interested in more involvement in benefits design. Many also felt a clear need for further formal training in preventive medicine and occupational health.

Although this survey did not provide any statistically analyzable data, it does demonstrate some thought provoking trends in this specialty. Suggestions for future work include more detailed interviews with some respondents and a survey of roles and responsibilities of corporate medical directors. As ACPE does not have a large representation from this group, the American College of Occupational and Environmental Medicine members could provide more valuable data on this subject.
COPYRIGHT 1993 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1993, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

Article Details
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Author:Comstock, Marcia L.
Publication:Physician Executive
Date:May 1, 1993
Words:2132
Previous Article:Reporting quality of health care to the board.
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