Many models exists for the provision of occupational health care to many employers. The most common settings are:
Corporate medical departments and in-plant services, which are sometimes shared among several employers, are described in detail in Chapter 5. They share the advantages and disadvantages of being within the organizational structure of employer and subject to the employer's policies. Union-sponsored occupational health services are uncommon except in New York; there are also a few examples in Canada. Union-sponsored clinics tend to play highly specialized roles within the system and are oriented toward individual workers rather than toward employers.
This chapter will emphasize models for providing services to multiple employers. This may be done within the context of primary care practice on a part-time basis and, indeed, represents an important opportunity for many family physicians, general practitioners, primary care or general internists, and others to augment their practices. This also implies a responsibility, however, to do so conscientiously with preparation and continuing education. Increasingly, institutions such as hospitals, group practices are entering the field and free-standing clinics providing basic occupational health care have appeared in recent years in large numbers. The physician's role in each is slightly different.
The typical primary care physician considering occupational medicine as an emphasis, for a clinic, or as a part-time commitment is well prepared for some medical and surgical functions but not necessarily for others of particular importance to this area of medicine. Table 4.1 lists skills and Table 4.2 lists content areas or knowledge needed for community-based practice in occupational medicine compared to primary care, as in family practice or general internal medicine.
Diagnostic and other cognitive skills are invaluable in clinical practice. Similar skills may apply as well to problem solving in the workplace but only if combined with specific training in workplace hazards and toxicology. Clinical occupational medicine practice often requires the screening of large groups of well persons, frequently applying legally-mandated or employer-required protocols often of questionable utility. The logic and methods of clinical epidemiology are invaluable in the interpretation and proper design of screening programs, which are becoming increasingly sophisticated and problemmatical with the widespread introduction of drug testing and biological monitoring. In all settings, not only in corporate medical departments, occupational medicine practice requires administrative skills beyond office management. To communicate successfully with all parties, including workers' compensation boards, employers, workers, regulatory agencies, and insurance carriers, requires insight into the occupational health care system, an often complex network functioning somewhat isolated from the mainstream personal health care system and subject to its own internal tensions and forces.
Properly practiced occupational medicine should be oriented primarily toward prevention, both by clinical intervention and the periodic health screening of individuals and by the introduction of programs and changes in the workplace that affect workers as groups. In this respect occupational medicine practice, particularly at the higher levels, tends to be less clinical and more administrative. Prevention, particularly on a group level, requires different skills and expertise than treatment-oriented management. These skills and the specialized knowledge must be obtained by the clinician who expects to provide more than routine occupational care.
Table 4.1. Skills Needed in Occupational Medicine Compared to Primary Care Skills in Primary Care Skills in Occupational Medicine ---------------------- ------------------------------- Diagnosis Case Finding Functional Patient Evaluation Disability Evaluation Health Services* Occupational Health Care Organization Clinical Epidemiology* Epidemiologic Basis for Health Promotion and Disease Prevention Periodic Health Evaluation Commitment to Prevention Primary Prevention of Workplace Exposure Clinical Management - - - - - - Program Management and Evaluation * Variable importance, depending on practice and setting. Table 4.2. Content or Knowledge Needed in Occupational Medicine Not Developed in Primary Care Occupational History Toxicology Epidemiology (field studies)* Office Surgery and Orthopedics (plant level)* Occupational Hygiene** Risk Assessment* * Variable importance, depending on practice and setting. ** Understanding for purposes of interpretation and diagnosis, as physicians rarely perform hygiene functions.
If one is considering part-time service in a local plant, a long and detailed tour of the facility is essential with an emphasis on unusual or troublesome work stations. Visits to maintenance, custodial, and representative administrative areas are essential as well, however, and should not be omitted or cut short. Occupations requiring special preplacement tests or periodic screening programs should be observed and their particular physical requirements or hazards identified.
If one is considering starting a clinic or incorporating an increased load of occupational health care services into an existing practice, one must take two preliminary steps. The first is to evaluate the position and capabilities of the practice, including its location and the preparation and interests of the physician associated with it. A clinic or full-time practice in occupational medicine is not likely to succeed unless it is located in an industrial area, is prepared to handle minor trauma, and is efficient in handling workers' compensation claims. The second step is to review the profile of industry in the area. Larger, capital-intensive corporations will generally be more selective in referring cases and may require some assurance of the practitioner's expertise. Small industries, especially in manufacturing or construction, generally look for low costs, trauma care, and minimal waiting time. Certain technologies, such as high-technology electronics, present exotic or uncommon hazards requiring specific and sometimes extensive preparation to manage appropriately.
If one wishes to develop a referral practice in occupational diseases, one must ask where these cases are to come from, who will see them first, and why should they be referred to a particular consultant over another? Consultation practice in occupational medicine today increasingly requires some meaningful credentials and several assured sources of referrals. Occupational medicine is practiced in a fishbowl. Opinions and findings are under review by workers' compensation boards, employers, insurance carriers, and frequently unions. Each is a potential source of or a potential obstacle to referrals. Typically, these parties do not object to a competent opinion, although they may disagree in individual cases. Each, however, is very sensitive to inadequate documentation, incomplete records, and delayed reports and reacts silently by steering referrals elsewhere. In addition, complex cases, which are those most likely to be referred, often go to court or to arbitration. Even when they do not, the suitability of a physician as a possible witness when the possibility exists is often a factor in one's selection to evaluate a case. The physicians' formal credentials in occupational medicine become important in such situations. The testimony of an expert witness with board-certification in the field or at least a fellowship in one of the important organizations (such as the American Occupational Medicine Association) or membership in one of the important selective organizations (such as the American Academy of Occupational Medicine) will usually outweigh that of a witness lacking specific credentials.
Occupational medicine consultation clinics have intrinsic problems that must be addressed in any viable plan. One reality is that they are economically tenuous. Occupational medicine consultation clinics, unlike primary care clinics for occupationally-related injuries, are seldom profitable in the private sector. Rather, the best they can usually achieve is to be self-sustaining on the basis of revenue generated from a mixture of cases that includes a large fraction of patients requiring low-intensity screening and preventive services that cost little to provide. One major reason for this is that the typical individual case referred to a consultant for clinical evaluation is extremely time-consuming and the fees returned by either the workers' compensation board or insurance plans often cover only a fraction of the overhead and personnel cost. For example, the typical patient referred by a general practitioner and seen in one university-based clinic requires between 1/2 hour and 1 hour to interview, 1/2 hour to 2 hours to review past medical records and search the literature, and 1/2 to 1 hour to prepare the consultation report. For this, insurance pays $86.00, approximately three-quarters of what a specialist would bill for medical services provided in 1 hour. Thus, billings cannot support such a clinic and occupational medicine consultation clinics are not a remunerative form of practice. The only answers lie in developing a mix of cases as described, in basing such services at institutions such as universities where physicians are on salary and overhead is subsidized, and possibly by associating such a clinic with a medical facility that also deals with occupational injuries at the primary care level.
It is often wise in the beginning to target a specific industry, employer, or group and to become known as expert in the health problems of a common occupation. Many clinicians have entered occupational medicine practice by taking a particular interest in firefighters, bus drivers, or, increasingly, performing artists. Athletes usually need surgeons but such services can be combined with popular "sports medicine" clinics for amateurs as well. A good way to start in occupational medicine is to assume responsibility for the employee health service of a medium-sized hospital. For their size, hospitals tend to be very conservative employers with rudimentary occupational health services. They are good training grounds for many of the realities of occupational medicine. For example, they require periodic health surveillance of patient-contact personnel, present numerous opportunities for exposure of their workers to chemical, biological, and physical hazards, and, because they are usually unionized, often are involved in collecting bargaining or labor disputes involving benefits. Directing a hospital employee health service is a good way to observe the good and the bad in occupational medicine practice and also provides a "captive" patient base for later expansion of services.
Chapter 13 provides some examples of consultation reports and an example of the standard billing format for consultation services.
Multispecialty group practices are organizations in which specialists in compatible areas of medicine practice in a relationship in which common expenses and resources are shared, whether in a single large clinic or a network including satellite clinics. Group practices were considered a radical departure for medical practice when they began 60 or 70 years ago but have since become an irresistible trend in the United States as practitioners seek increased efficiency and protection from the increasingly hostile world of private practice. Group practices there have grown explosively, both in numbers and size, and have become highly competitive. One element in this competition has been the need to capture groups of patients, as in health maintenance organizations and similar prepaid plans. Group practices in the U.S. have often entered occupational health services in order to "lock-in" large groups of employees that they then expect to use their services for their personal health needs and those of their families.
Group practices often set the tone for medical practice in their communities. Group practices introduce occupational medical services into the community at a high level of visibility. An organization known as the Center for Research in Ambulatory Health Care Administration, based in Denver, is presently developing a model demonstration program in occupational medicine for its principal client, the Group Practice Management Association. This activity may provide new or improved approaches and preliminary data for evaluation and should be watched carefully.
Historically, multispecialty group practices have done well in providing occupational health services and it is an unusual group that does not have at least some of its members physicians involved on a routine basis. One key to this success has been the availability of physicians and ancillary health professionals in major specialties under one roof. This eliminates the need for referrals outside the group. It provides the depth needed to handle most problems within a given standard of medical practice yet remaining within the group itself where attention can be paid to controlling costs. A wide scope of medical expertise is usually available within the group itself, without the need for referral to outside clinicians who may not be subject to the self-imposed controls on cost and utilization present within the group. The group often offers the latest diagnostic equipment, extensive laboratory and x-ray facilities, a pharmacy, and sometimes its own hospital. The group usually also has access to other facilities as needed for acute care. After hours, employees may be seen for injuries at nearby hospitals. Serious problems requiring hospitalization are usually handled by group physicians with admission to any of the large metropolitan hospitals. Increasingly, groups are opening their own urgent care centers as well, providing the type of care prviously available only in emergency rooms with the advantage of continuity of supervision and access to medical records by group physicians.
Multispecialty group practices do have certain disadvantages, however. They have usually developed as providers of personal health care and often do not perceive occupational medicine as a high priority until competition becomes intense. Then, they often rush into developing services without appropriate preparation. Group practices tend to enter the field by either creating within themselves new services staffed by physicians recruited for the purpose or by using the personnel they have on staff already, whether qualified or not. The latter is often a dangerous strategy, however.
As the occupational health service develops, it frequently finds itself subordinated to personal health services whenever decisions are made regarding allocating resources, recruiting staff, marketing, and opening satellites.
Indeed, for this reason it is advisable to keep the administrative structure of the occupational health service as autonomous as possible within the group even at the expense of some duplication. Administrators who are not sensitive to employer's concern over lost time may see no need to expedite registration and waiting periods. One of the major criticism of group medical facilities by employers is that because occupational injuries are no more important to the group than non-occupational injuries, an injured employee may have to wait longer to be treated because the injured employee will be competing with non-industrial injuries for available physician time. Groups suffering financial problems or poor cash flow may also be tempted to shift overhead expenses onto the apparently lucrative occupational services contracts, raising costs to employers and destroying the attractiveness of the group-based option.
In Canada, multispecialty group practices are much less common because the health care system does not encourage them. There is no trend apparent incentive for them to grow rapidly in the near future. However, where they exist they are often trend-setters and often provide at least a limited range of occupational medicine services.
Hospital-based occupational health services are increasingly popular in large metropolitan institutions in the United States. The incentive for hospitals to do this, within the American system, is to cultivate a patient base likely to enroll in their health maintenance organizations and to use the hospital and its outpatient clinics for their personnel health care. Some hospitals do a very credible job providing specific occupational health services but other more develop their programs as a marketing device, often merely as an extension of their emergency rooms, with little real commitment of resources or quality assurance. University teaching hospitals have had additional reasons to become involved for educational purposes but also respond as do community hospitals to the economic realities.
In 1986, a survey conducted by the American Hospital Association found that 8% of responding institutions had some form of external occupational health service and another 12% were planning to introduce such services. In San Diego, 6 hospitals offered such services in 1984 compared to none in 1974. Most of the services are rudimentary, either an extension of emergency room care or an isolated community outreach program. A few, however, are well-developed and comprehensive in their provision of services. Pacific Presbyterian Medical Center, in San Francisco, has provided an extensive service for a number of years. Many academically-oriented medical centers which have offered such services in the past did so as part of training programs in occupational medicine, including the University of California at San Francisco, Harvard, Johns Hopkins, Mount Sinai School of Medicine in New York, and the University of Toronto. More recently, however, community hospitals have entered the field in large numbers. The MedWork Program of Decatur Memorial Hospital in Illinois is an example of an extensive service emphasizing community service. Most hospitals have promoted their services through selective business contacts rather than media advertising. Several hospitals are using occupational health services to build up "wellness", or health promotion programs and virtually all use the services to increase utilization of other hospital departments such as radiology, clinical specialties, and laboratories. More hospitals are charging on a fee-for-service basis than provide services under contract but somewhat under half use both, as appropriate to circumstances.
The American Hospital Association report concluded that involvement of hospitals in occupational health provided many benefits for hospitals, among them:
Industrial medicine clinics are free-standing facilities, not associated with hospitals or multispecialty group practices, serving many employers, usually in a well-defined geographical area such as a town or an industrial park. They are usually independent operations with a small professional staff, limited facilities, and streamlined procedures designed to facilitate the management of acute injuries and the rehabilitation of temporary disabilities. Their patients are generally drawn from local employers with whom they often have contracts for services, emphasizing episodic care of injuries or illnesses on an acute basis and periodic health evaluations as mandated by law or by company policy. Their revenues are generated primarily from workers' compensation fees for the former and third-party payments from the employer for the latter. In a few cases, industrial medical clinics have grown quite large and diverse. In general, however, they are more likely to grow by establishing satellites or spin-off clinics and by creating larger health care systems composed of several clinics.
Although not a new phenomenon, industrial medical clinics have become prominent as a provider of occupational health services only in recent years. With changes in the workers' compensation system and in the health care system in general, they have been attractive models for entrepreneurs interested in providing direct health care services in settings with low overhead. This had led to a perception of industrial medical clinics as having little regard for the quality of care provided and little commitment to preventive services, which are typically more expensive and have less appeal for employers seeking to contain short-term costs.
Indeed, the very term "industrial medical clinic" is problemmatical. Such organizations are typically so identified by the operators themselves, in spite of the disfavor with which the term "industrial medicine" is held by the specialty of occupational medicine. Very likely, the retention of the term "industrial" is often a defensive position, since seldom does the staff include specialists in occupational medicine. Also, "industrial" may be seen as showing an affinity for the employer where "occupational" suggests some consideration of the workers' point of view. In most cases, however, it is likely that the name is either a holdover from past practice or that the founders did not themselves consider the difference.
The proliferation of "industrial medicine clinics" has led to major changes in occupational health services. It has made services easily accessible to small businesses and has consolidated into a viable practice format services previously rendered by private practitioners. The operation and staffing of these clinics are of concern, however. These clinics are intensely competitive and frequently bid against one another for contracts to provide care to the employees of corporations and public agencies. This had led to isolation and secrecy that has impeded professional dialogue and sharing of case information. The frequent lack of involvement by occupational medicine specialists in these clinics is disturbing, since it suggests that prevention and knowledgeable consultation is subordinated to episodic acute care, an impression candidly confirmed by some experienced practitioners. Such concerns and the entrepreneurial style of many of these facilities have raised doubts over the quality of care rendered in many cases. In the absence of evaluable data on treatment and outcome, these doubts cannot be readily rebutted. We are aware of a few exemplary industrial clinics and of individual physicians doing credible clinical work at otherwise undistinguished clinics. The closed and secretive nature of many, particularly proprietary, clinics makes objective evaluation exceedingly difficult. No broadly recognized accreditation body exists for this sector of health care. Industrial medical clinics may be the largest sector of medical practice to exist outside of a formal or informal network of communication, representation, and peer contract influencing quality assurance.
The rise of the "industrial medicine clinic" over the last two decades has been almost entirely overlooked in the medical literature as a topic for investigation. Now the dominant occupational health care provider in many communities, the industrial medicine clinic is itself coming under pressure from competitors. Corporate and in-plant medical services are not keeping up with the growth of industry, and no class of health facility has matched the growth of industrial medical clinics except urgent care centers. Whatever their limitations, industrial medicine clinics have clearly proven themselves to be an economically successful format thus far. On the horizon is a posibly formidable competitor, however. The urgent care centers are growing at an even more rapid rate and offer a convenient alternative for the provision of episodic acute care and routine general services. Such centers have a broader base of patients and are usually supported by the financial and marketing resources of much larger organizations. Even if occupational health services compose only a small fraction of the total volume of services provided by urgent care centers, their share of the market for such services may become considerable in a very short time. The absence of even a nominal claim to special expertise in occupational health care on the part of these centers is disturbing, however, if they are to play a major role in the future.
The industrial medicine clinic is characterized by certain basic features: a central facility serving multiple client employers, expansion of medical staff with primary care providers, an emphasis on medical care with less involvement in prevention, close attention to market trends, and a relatively small nursing and support staff.
Two respected early examples of groups specializing in occupational practice are the Detroit Industrial Clinic, P.C. (1920) in Southfield, Michigan, and The Occupational Medical Clinic, Ltd. (1961) in Phoenix, Arizona. The experiences of these prototypes have not been studied systematically but some conclusions can be drawn from the successful operation of these and similar operations.
In general, the independent industrial medicine clinics rely on a medical staff and an administrative staff. Line responsibility for administrative functions is vested in a full-time administrator, who establishes systems for financial oversight and billing, supply, and personnel. Medical functions, however, are coordinated and supervised by a chief of staff who oversees a full-time medical staff which may consist, in a large clinic, of occupational physicians, general surgeons, and primary care practitioners, nurse practitioners, and a part-time affiliated but external or rarely even resident staff of specialists.
A small number of clinics provide industrial hygiene services on a fee-for-service basis. Such services usually do not fit in well with the medical orientation of the clinic, however, and are seldom well utilized. Likewise, mobile clinic vans and contract in-house nurse practitioner services are often considered. The relatively low-risk industries that form the principal client base of these clinics usually do not support such elaborate and expensive activities.
The specific services provided by industrial medicine clinics often include physiotherapy as well as medical evaluation and treatment. Physiotherapy tends to be intensive, in part because the goal is to return the worker to the job as quickly as recovery can be attained and in part because frequent visits to a physiotherapist are useful in monitoring progress. When the worker is sufficiently improved, the physiotherapist can alert the physician at once, without the delay between doctor's appointments that would otherwise result. Because fees for physiotherapy are much less than for medical services, this is more cost-effective and efficient for the insurer, whose primary concern is to return the claimant to work as soon as possible.
Employers are naturally anxious to minimize the time an employee spends out of the workplace. Access to radiology and laboratory facilities must be expedited and waiting time minimized. Record handling is best performed by an administrative staff fully conversant with OSHA disclosure guidelines. Special record formats and questionnaire instruments and the appropriate training of ancillary supporting staff such as clinic nurses and aides, can relieve the physician of routine low-yield activity.
American Hospital Association. Profile of Hospital Occupational Health Services. Chicago, American Hospital Association, 1986.
Begin C, Demers L. Quebec's multi-instititional health arrangements. Health Management Forum (Toronto), Winter 1986, 31-42.
Conrad DE, Parker-Conrad JE. Hospital-based occupational health programs. AAOHN (American Association of Occupational Health Nurses) Journal 1987; 35:251-253.
Cullen MR. Occupational Medicine. A new focus for general internal medicine. Arch Intern Med 1985; 145:511-5.
Freshnock LJ, Jensen LE. The changing structure of medical group practice in the United States, 1969 to 1980. J Am Med Assoc 1981; 245:2173-2176.
Guidotti TL. The private sector and occupational health. Health Management Forum (Toronto) Summer 1987; 8(2):26-34.
Guidotti TL. Desirable characteristics of the teaching occupational medicine clinic. Journal of Occupational Medicine 1984; 26:105-109.
Guidotti TL. Interaction between a medical group and a school of public health: A case study of a productive affiliation. American Journal of Preventive Medicine 1985; 1:30-35.
Guidotti TL. The general internist and occupational medicine. Journal of General Internal Medicine 1986; 1:201-202.
Huston P. Group practice: poised to flourish - at last. Medical economics 1983; 212-229.
Moxley JH III, Roeder PC. New opportunities for out-of-hospital health services. New England Journal of Medicine 1984; 310:193-197.
Rosenstock L, Heyer NH. Emergence of occupational medical services outside the workplace. American Journal of Industrial Medicine 1982; 3:217-223.