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  • ACOEM Comments on Graduate Medical Education Program

    January 16, 2015 

    The Honorable Joseph R. Pitts 
    Chairman
    Subcommittee on Health, Energy and
    Commerce Committee

    U.S. House of Representatives
    Washington, DC 20515
     

    The Honorable Frank Pallone
    Ranking Member
    Energy and Commerce Committee
    U.S. House of Representatives
    Washington, DC 20515 


    The Honorable Cathy McMorris Rodgers
    U.S. House of Representatives
    Washington, DC 20515

     The Honorable Gene Green
    U.S. House of Representatives
    Washington, DC 20515
    The Honorable Morgan Griffith
    U.S. House of Representatives
    Washington, DC 20515

     The Honorable Diana DeGette
    U.S. House of Representatives
    Washington, DC 20515
    The Honorable Kathy Castor
    U.S. House of Representatives
    Washington, DC 20515

     The Honorable Peter Welch
    U.S. House of Representatives
    Washington, DC 20515


    Dear Chairman Pitts, Ranking Member Pallone, and Reps. McMorris Rodgers, Green, Griffith, DeGette, Castor, and Welch:

    The American College of Occupational and Environmental Medicine (ACOEM) appreciates the opportunity to respond to the Subcommittee’s request of December 6, 2014, for input on the Graduate Medical Education (GME) program.

    We are responding to Question #4:

    Question — Is the current financing structure for GME appropriate to meet current and future healthcare workforce needs?

    Response — The current GME financing structure is not appropriate to meet current and future health care workforce needs. Because occupational medicine (OM) is primarily practiced outside of hospitals, occupational medicine residency (OMR) programs typically have little or no access to GME funds. Occupational medicine is a medical specialty focused on the health and well being of the nation’s workers. OM develops workplace population-health management strategies for workers and their families, provides treatment of work-related injury and illness, creates wellness programs for workers, can provide primary care health services at the workplace and oversees disability management programs.

    Summary of Response to Question #4
    There is broad agreement that OM residency programs have been seriously underfunded for a long period of time, resulting in a shortage of residency trained OM physicians. The United States needs a healthy, able, productive and available workforce to compete in the global economy. The current workforce is aging and is increasingly burdened with chronic illnesses, functional impairments, and work disability, some of which could have been prevented, delayed, or mitigated.

    As the only medical specialty with a designated focus on prevention and care for American workers, with training in clinical practice as well as population management, this shortage has ramifications for the nation’s entire economy. This shortage of OM comes at the same time that there is an increased demand for residency-trained OM physicians to manage health risks and improve the fundamental health of the workforce. America’s chronic disease crisis, combined with an aging workforce, requires new strategies that OM physicians are specifically and uniquely trained to provide. The aging and retirement of the baby boomers — the so-called “silver tsunami” — is accompanied by an increased burden of chronic disease across all age groups that threaten the U.S. pipeline of healthy, productive workers.

    We believe that by striving to keep workers healthier from the moment they enter the workforce to the time they retire, we can dramatically increase the probability that they will “graduate” into Medicare in a much healthier condition.

    Institute of Medicine Report
    The Institute of Medicine’s report, Graduate Medical Education That Meets the Nation’s Health Needs, recognizes the importance of population-based specialties, such as occupational medicine, “Prioritizing the health of populations requires that the health care workforce has skills not only in the treatment of acute conditions, but also in managing chronic disease and multiple conditions, and in disease prevention and health promotion.”1

    The IOM report finds that by linking GME payments to a hospital’s Medicare inpatient volume systematically disadvantages children’s hospitals, safety net hospitals, and other institutions that care for non-elderly patients. Community and population-based specialties, such as public health and preventive and occupational medicine, are similarly affected.2

    Occupational Medicine
    ACOEM represents more than 4,500 physicians and other health care professionals specializing in the field of occupational and environmental medicine (OEM). OM is a primary certificate medical specialty recognized by the American Board of Medical Specialties (ABMS) and is one three specialties in preventive medicine certified by the American Board of Preventive Medicine, the others being aerospace medicine and public health and general preventive medicine.

    Residency training in OM provides a range of skills in population and preventive medicine, epidemiology and disease surveillance, toxicology, biostatistics, and health services administration. Practicing occupational physicians are experts in legal aspects of medicine, such as evaluating causation, determining fitness for work, and applying health and safety regulations in the workplace. They direct preventive programs that promote worker health and reduce workplace hazards. Their expertise as medical detectives is essential for investigating suspected clusters of work-related illness or outbreaks of environmental disease. Specialists in this field are often consulted by fellow practitioners, business leaders, and community organizations to assess occupational or environmental risks and to help interpret scientific evidence.

    OM reduces the demand on other primary care physicians by providing specialized medical services to people of working age. It also provides direct clinical support, especially in cases of work-injury care. While OM health services are primarily directed at workers, it also provides health care to workers’ families, thus extending its impact on population-health. OM specialists often serve as workers’ preferred primary care provider.

    Unlike many other medical disciplines, whose practices are limited to a particular city or region, many occupational physicians’ geographic impact is extensive. The unique duality of occupational medicine – combining high quality focused clinical services with population management — expands their sphere of influence. While occupational physicians provide a great deal of direct clinical care, the amplifying effect of their unique managerial and population-based skills markedly increases the footprint of the specialty.

    In 2000, the Institute of Medicine noted that substantially more specialists with formal training in occupational medicine are needed. Federal funding for OMR programs comes primarily from the National Institute for Occupational Safety and Health (NIOSH) and the Health Resources and Services Administration (HRSA). Some additional funding comes from the Veterans Administration and the Department of Defense.

    According to the American Board of Preventive Medicine, the number of board-certified OM physicians has been in a stark decline. Where 121 became board-certified in 2004, there were only 86 in 2013. The long-term outlook for OM is very bleak. Current projections show a loss of 1,655 OM Boarded physicians due to retirement over the next 10 years. Assuming a gain of 764 new OM Boarded physicians over this time leads to a net workforce reduction of 891, or 33% of the current workforce of OM Boarded physicians (those under age 65).

    The Workforce and Medicare
    More than 130 million people are employed in the United States. It is estimated that between 2006 and 2016 the number of workers age 55 to 64 will increase by 36.5% while workers between age 65 and 74 and over 75 will increase by 80%. By 2015, one in every 5 workers will be 55 years of age or older. Older workers typically suffer from chronic health conditions and have multiple health risks. Moreover, the chronic conditions most common among older workers often require more care, are more disabling, and are more difficult and costly to treat than the chronic conditions that are more common in younger age groups. Those workers who remain in the system, increasingly beset by chronic disease, have a greater likelihood of needing to access social security disability and Medicare before retirement age, potentially weakening the nation’s work capacity even more. With appropriate medical care aimed at increasing workers’ ability to physically function, coupled with reasonable accommodations, many workers can continue performing productive services and will not need to access Social Security disability and Medicare prior to retirement.

    Healthier retirees are a key to the sustainability of Medicare. Strategies aimed at bolstering health at a younger age will ensure that workers reaching the eligibility age for Medicare will have less cost impact on the health care system as they move forward in their lives. One study showed that Medicare beneficiaries who participated in various workplace health programs in addition to completing a Health Risk Assessment (HRA) had lower health care cost trends than those who did not participate in any health program or completed a HRA only.3 Another study demonstrated that by preventing 10% of the upward risk transitions that would normally occur once an individual became Medicare eligible, costs would be reduced by $4361 (the average lifetime costs per beneficiary in 2008 dollars).4 investing in the workforce will save money in the long term through reduction of chronic health conditions.

    The workplace is organically connected to the home and to the physical communities in which workplaces exist. Health behaviors and health risks extend across all three environments and cannot be artificially separated. Just as factors in the workplace can affect health and well‐being at home and in the community, activities and behaviors outside the workplace can affect health and productivity on the job. It is an inescapable fact that health impacts work, and work impacts health.

    Research shows that it is becoming increasingly difficult to distinguish individual behavior at and away from work. This makes it more difficult to draw the distinction that individuals can only directly affect their own health through their actions away from work, while employers only directly affect worker health through the workplace environment. The concept of health must be considered in a broader, more holistic context.

    U.S. Surgeon General Regina Benjamin summed it up by saying “We can’t look at health in isolation. It’s not just in the doctor’s office. It’s got to be where we live, we work, we play, we pray. If you have a healthy community, you have a healthy individual.”5

    Thus, the workplace environment cannot be ignored or approached separately in the context of a national health strategy aimed at improving health outcomes and lowering costs. Employees spend more than eight hours of their day in the workplace, and workforce policies influence 65% of all adults.

    OM plays a large role in improving health at both the individual and population levels, bringing prevention strategies to millions of Americans via the workplace. ACOEM believes OM is a key component in U.S. health policy, linking the workplace with the home and the community to create an integrated and comprehensive national “culture of health.”

    Thank you for your consideration of these comments. We look forward to working with the Subcommittee as you move forward with your review of the graduate medical education structure. If you have any questions or desire additional information, please feel free to contact Patrick O’Connor, ACOEM’s Director of Government Affairs at 202/223-6222.

    Sincerely,

    Kathryn Mueller, MD, MPH, FACOEM
    President


    1Institute of Medicine. Graduate Medical Education That Meets the Nation’s Heath Needs. 2014, page 26
    2Institute of Medicine. Graduate Medical Education That Meets the Nation’s Heath Needs. 2014, page 9
    3Ozminkowski RJ, Goetzel RZ, Wang F, et al. The savings gained from participation in health promotion programs for Medicare beneficiaries. J Occup Environ Med. 2006;48:1125-32.
    4Rula EY, Pope JE, Hoffman JC. Potential Medicare Savings Through Prevention and Health Risk Reduction. Franklin, TN: Center for Health Research, Healthways Inc; 2009.
    5Brown E. Surgeon general discusses health and community. Los Angeles Times. March 13, 2011.