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  • ACOEM Comments on Healthy Workforce / Healthy Economy: The Role of Health, Productivity, and Disability Management in Addressing the Nation’s Health Care Crisis

    Why an emphasis on the health of the workforce is vital to the health of the economy. 

    INTRODUCTION
    The United States’ health care system is on a collision course with dramatic economic and demographic trends that could bankrupt the nation. In its May 2008 issue, the health policy journal Health Affairs predicted that “if current trends persist, sometime between 2016 and 2020 existing federal revenues will cover only health entitlements, Social Security, debt service, and a smaller defense budget, leaving nothing for anything else, including the environment, education or new health initiatives.” At the same time, the aging and retirement of the baby boomers – the “silver tsunami – is bringing with it an increased burden of chronic disease that threatens the U.S. pipeline of healthy productive workers. The balance between economic net contributors (“workers”) and those dependent on government programs, i.e., Social Security, Medicare and Medicaid is on the verge of a dramatic shift.

    How can the U.S. meet its huge obligations to entitlement programs such as Medicare, Medicaid, and Social Security if the engine that supplies financing – the workforce – is aging and workers have an increasing incidence of chronic disease? Simply providing insurance for everyone in the United States will not solve this problem. Nor will spending more money on the traditional silo of sick-care and late-stage medical interventions.

    The time has come to accept the fundamental reality that the fiscal crisis, the health crisis and the workplace are inextricably linked. The workforce is the engine that drives the economy and supports the health care system. The working-age population is therefore, the key to the future of health care in the United States. The fiscal and social calamity can only be averted by public investment in the health and productivity of working-age population through a new preventive-based paradigm centered in the workplace, with built-in mechanisms for quantifying health and productivity results. 

    A NEW AGENDA FOR PREVENTIVE-BASED MEASURES IN THE WORKPLACE
    The American College of Occupational and Environmental Medicine (ACOEM), the nation’s leading medical organization devoted to worker health and safety, has begun to advance a new action agenda to address these issues. ACOEM believes that more attention and resources should be devoted to health-related services that protect the employability of the working-age population in order to maximize workforce participation and productivity. In addition, government should preferentially invest in high-leverage services that improve the overall health and function of the workforce in order to maintain a proper balance between economic net contributors and net dependent (those dependent on government programs).

    In an environment in which health care costs are skyrocketing, the sensible approach is to reduce the need for care – and the most powerful way to accomplish this is by focusing on evidence-based prevention. A growing body of research demonstrates the connection between preventive practices and lowered total costs – essentially proving the scientific and economic case for prevention. Health promotion and early intervention are clearly effective in improving health and controlling health costs in the workplace; some studies have shown a return of as much as $3 per $1 invested. ACOEM’s members are leaders in this approach – referred to as health and productivity management (HPM) – which has been extensively studied and is yielding positive results for employers.

    Moving the health agenda forward by focusing on prevention in the workplace has the added benefit of addressing the vital issue of America’s global competitiveness. Because worker health and the ability to thrive in the world economy are clearly aligned, both are advanced by a new emphasis on prevention.

    ACOEM’s advocacy is based on four fundamental principles that it believes are critical in addressing the growing health care and budgetary crisis:

    1. Keeping the workforce healthy and productive is essential to keeping the economy strong enough to avert overall health system failure.

    The nation’s health system ills are exacerbating the crushing burden of work disability among its citizens – and the progressive loss of net contributors to the economy. As the final safety net for disabled workers, Social Security Disability Income (SSDI) and Medicare carry the burden of citizens deemed unable to work. Logically, improving health and function as well as making it possible for people to stay at or return to work will both preserve employability and help relieve the impending strain on the SSDI and Medicare systems. A healthy workforce is one of the best indicators of a nation’s overall health.

    2. Public investment in health care should advance beneficial social outcomes, most particularly workforce health and productivity.

    At the national policy level, the health-care debate has focused heavily on the direct costs of health care, how to finance it, who pays for it, and how to cover the uninsured. However, research by experts in occupational medicine has shown that a focus on direct costs is not enough to truly improve the overall health and productivity of the workforce. A more effective approach is to view health as an investment to be leveraged rather than a cost to be justified. The emphasis must be on lowering overall costs by promoting healthier employees and, by extension, healthier citizens; not in merely cutting costs in the short term.

    3. The workforce will become healthier and more productive through prioritized investment in evidence-based primary and secondary prevention strategies.

    ACOEM defines primary prevention as health promotion and secondary prevention as early intervention. These strategies cost-effectively reduce adverse health, function, and employment outcomes with long-term benefit. Examples of proven health promotion strategies range from wellness and prenatal care programs to immunizations, ergonomics and effective benefit design that promotes participation. Examples of early intervention strategies range from screening and early detection programs to health coaching and work disability prevention programs. It is vitally important to move prevention beyond the medical clinic into other, non-traditional workplace domains – such as human resources and job design – if a new preventive health model is to have significant, lasting impact.

    4. These strategies will succeed only if spending on prevention is considered a priority rather than discretionary.

    Current federal programs “feed” sick-care and starve prevention. The government is forced to allocate most dollars to caring for back-end health care problems, many of which could have been prevented. Additionally, employers and disability insurers are not held responsible for helping people stay healthy and employed, and are often able to shift the benefit costs of employees who become work-disabled onto public programs such as Medicare and SSDI. Unfortunately, the benefit design and administrative procedures in SSDI and Medicare create disincentives to healing and healthy behavior. A prevention model, in contrast, can be driven through prioritization and incentives for health enhancement. 

    ACOEM’S FIVE-POINT ACTION PLAN FOR THE FUTURE

    ACOEM is committed to supporting an agenda for system reform that begins with protecting and strengthening the social and economic engine of the economy – the nation’s workforce. The plan is built on five key action points:

    • Establish a national priority for public investment in programs to assure a healthy, able, and available U.S. workforce. Prevention of disease, impairment, and work disability in the current and future working age population must no longer be seen as discretionary. Prevention must become priority spending because it is a high-leverage investment.
    • Fund programs for prevention and health improvement the same way that Medicare and Medicaid fund care of the sick. Public investment in sick care (especially low-leverage end-of-life care) should not be allowed to crowd out higher-leverage investments in prevention (e.g., health promotion and early intervention programs). At a minimum, funding for delivery of certain services to currently employed people as well as the workforce of the future must be put on an equal footing in the federal budget with existing funding mechanisms for sick-care programs such as Medicaid and Medicare.
    • Go beyond the “medical” definition of prevention to include interventions in other domains that have been shown to improve workforce health and productivity. Reform efforts should include priority investments aimed at increasing the use of evidence-based practices in workplace organizational, management, and safety practices; worksite programs in occupational, personal, and public health; benefits design; economic and social policy; and the delivery of non-traditional services to individuals beyond medical offices.
    • Assure access to evidence-based preventive and early intervention healthcare. Design and fully support health promotion and early intervention medical services that have been shown to be wise investments of public funds – because they keep people healthy, functional, and contributing in the workforce.
    • Align financial incentives that will shift consumers and healthcare providers towards primary and secondary prevention. Design employer-based initiatives that offer employees and their dependents incentives to engage in prevention (wellness, early detection and early intervention) programs. Redesign Medicare’s fee schedules to assure the economic viability of medical practices in which the physician spends time supporting prevention and health management strategies, including health promotion; addressing risk factors and early indicators to prevent progression to disease; preserving or restoring function; and protecting employability. 

    WHY OCCUPATIONAL AND ENVIRONMENTAL MEDICINE?
    The profession of occupational and environmental medicine (OEM) is positioned at the crossroads of the employer-employee-health system interface, making it a logical advocate for health system reform through workplace initiatives. Among all specialties, OEM physicians have unique training, expertise and perspective to understand the link between health and productivity as well as how to help injured, ill and aging workers remain productive and at work. In addition, the OEM community has a high concentration of physicians trained in public health. Their focus on population-based health issues is critically important to health system reform. Thus, OEM physicians have a distinct and logical role to play in advocating for prevention-oriented programs that protect and assure the health of employed and productive citizens.

    ACOEM is positioned to serve as a central facilitator and convener in the employer-employee-health system interface, working toward health system reform with partners ranging from not-for-profit health organizations to government and the corporate sector. (See Appendix 1 for a more detailed description of ACOEM and OEM.) 

    This statement and accompanying appendix were developed by the Health, Productivity, and Disability Management Special Committee co-chaired by Ronald Loeppke, MD, FACOEM, and Jennifer Christian, MD, MPH, FACOEM. The document was approved by the ACOEM Board of Directors on August 27, 2008.

    APPENDIX 1

    What Is OEM

    Of all the specialties, occupational medicine enjoys a unique vantage point as a preventive medicine specialty focused on the workplace and those who work. Occupational medicine plays a key role in recognizing and preventing hazards and reducing the burden of work-related illness and injury.

    • Occupational and environmental medicine enjoys a unique vantage point as a preventive medicine specialty focused on enhancing the health, safety and productivity of workers through workplace initiatives. OEM physicians deal with the crucial intersection of work and health. Historically, the specialty has had its primary focus on health concerns due to work, but as times have changed OEM has been broadening its focus to include work concerns due to health.
    • As population health experts, occupational medicine physician leaders are well-prepared to assist in development of evidence-based strategies to guide public investment to maintain and enhance the U.S. working age population’s health, function, and ability to participate in the workforce.
    • As practicing clinicians, occupational medicine physicians bring unique commitments and capabilities for delivering key services at the front end – developing programs that will prevent, minimize or delay work disability – and at the back end to assess fitness, identify suitable work and accommodations, and monitor both health and performance.
    • Practicing occupational medicine physicians have broad general medical expertise plus additional expertise in one or more specialized areas.
    • As resources for employers, occupational medicine specialists have the skill sets and societal positioning to implement workplace programs that will maintain the health, function, employability, and productivity of workers.
    • Since occupational medicine is a sub-subspecialty of the American Board of Preventive Medicine, most residency trained occupational physicians have been trained to anticipate, recognize and evaluate workplace hazards, and to work in conjunction with industrial hygienists, toxicologists, and safety engineers to protect workers from illness and injury, which are major causes for people to leave their jobs and receive disability benefits.
    • In addition, occupational medicine physicians have also traditionally used the workplace as a focal point for health promotion or “wellness” activities with a variety of incentives to encourage employees to make significant lifestyle changes and engage in health-enhancing behaviors.
    • Many occupational physicians have even broader skill sets because they serve as expert resources in the stay at work and RTW process after illness or injury. They have developed useful functional/vocational expertise as a result of having to answer questions, resolve issues, and work with professionals in other disciplines in order to resolve health-related employment situations.
    • Occupational medicine’s new and unique specialty arena: the intersection of medical, functional and vocational expertise is important.
      • Medical expertise is required because of the need to understand the current and future impact of the underlying pathology on a person’s state of health, vitality, and anatomical or physiological integrity – and how to minimize that impact.
      • Functional expertise is required in order to understand the person’s current level of self-sufficiency – their ability to function in daily life and accomplish particular things or tasks independently – and how to improve that ability.
      • Vocational expertise is required in order to understand the current impact of functional limitations on global ability to work or employability – and how to minimize that impact.
    • Thus, among all specialties, OEM physicians have unique training, expertise and perspective to understand the link between health and productivity as well as the importance of work, the hazards that workers face, and how to help injured, ill and aging workers to remain productive and at work. 

    What Is ACOEM? 

    The American College of Occupational and Environmental Medicine (ACOEM) is the nation’s largest medical society devoted to promoting the health of workers, their families, and communities through preventive medicine, clinical care, research, and education. ACOEM represents approximately 5,000 physicians and other health care professionals specializing in the field of occupational and environmental medicine (OEM). ACOEM members practice in diverse settings including large industry with multi-plant operations, medium and small-sized companies, private practice, hospital-based OEM programs, government agencies, and academia. 

    ACOEM is a recognized leader among medical professional societies for its commitment to enhancing worker health and productivity; preventing work-related illness and injury; and advocating effective and outcome-oriented medical care.  As a member of the American Medical Association’s House of Delegates, ACOEM works closely with other primary care disciplines including family practice and internal medicine.