ACA upside: Obamacare could boost occ health
Law emphasizes prevention, workplace wellness
On the surface, Obamacare and occupational health don't seem to have much overlap. But rip aside the controversy over the health insurance exchanges and medical benefits, and employee health professionals may find themselves in a familiar realm of preventive health.
In fact, the Affordable Care Act gives EHPs a unique opportunity to become involved in their hospital's containment of health care costs. After all, occupational health differs from other medical specialties because of its emphasis on prevention and population health, says Kathryn L. Mueller, MD, MPH, FACOEM, professor in the Department of Physiatry and the School of Public Health at the University of Colorado Anschutz Medical Campus in Aurora.
"It's an opportunity for growth, for the occupational medicine foundations of how we provide treatment to be expanded into the realm of overall medical care," says Mueller, president-elect of the American College of Occupational and Environmental Medicine (ACOEM).
The Affordable Care Act pushes payment systems towards rewarding functional outcomes rather than fee for service. Improving function is the laser focus of employee health, as EHPs seek to reduce disability and get employees back to work as quickly as possible, she notes. Occupational health professionals also have experience analyzing workers' compensation and injury data and seeking ways to reduce health costs — skills that are similar to those promoted by the ACA.
"We look at the population and say, 'How do we improve the overall health?' That is unique [among medical specialties]," Mueller says. "Those values are the same ones you would use to manage chronic disease."
Employee health can play a direct role in helping employers lower health care costs, says Craig D. Thorne, MD, MPH, vice president and medical director of Employee Health & Wellness for Erickson Living, long-term care communities based in Baltimore, MD. Erickson provides health clinics for employees. (See related article on p. 6.)
"Onsite employee health can be more cost effective, you can provide work-related and non-work-related care, and we can remove some of the barriers to finding care," he says.
ACOs look for better outcomes
The new paradigm for medical care is the "accountable care organization," networks of doctors, hospitals and other health care providers who receive bonuses or incentives for keeping a population healthy. There are about 500 ACOs — at least one in every state — and the number is growing. About half of them operate under Medicare and the other half are private.
ACOs will focus on improving the care of people with chronic illnesses, such as asthma or diabetes. But they won't just look at numerical values, such as A1C scores, says Mueller. The ACOs will seek to improve function — something employers are particularly interested in, since it relates to productivity and absenteeism.
"It's designed to promote a change in culture focused on value outcomes," says Mueller.
This coincides with a push in occupational health to integrate injury prevention with health promotion. This is especially important as the workforce ages and copes with chronic conditions, says Sheila Fitzgerald, RN, PhD, director of Occupational and Environmental Health Nursing at the Johns Hopkins Education and Research Center for Occupational Safety and Health in Baltimore.
Obesity, in particular, has a dual impact. Obese workers are at greater risk of injury, and they have a higher rate of chronic diseases such as high blood pressure and diabetes. (See related article on p. 7.)
"Businesses have [financial] incentives to provide programs that help their employees remain healthy," Fitzgerald says.
While most employee health departments don't provide a full range of medical care to employees, they are a key part of health education and prevention programs, such as annual vaccinations. They help manage disability accommodations and the Family and Medical Leave Act and often coordinate wellness programs. They interact with employees through pre-placement exams and annual contacts, such as TB testing or fit-testing.
Yet they are rarely a part of committees that make decisions related to insurance and employee medical costs.
"It's going to require aggressive activity on our part to be sitting at the right places, talking to the right people, because we haven't always been included in these discussions," says Mueller. "That's the challenge."
Worksite wellness gets a boost
Even with health insurance exchanges that are not subsidized by employers, the workplace remains a focal point for health improvement.
The Affordable Care Act places worksite wellness at the center of a "national public health strategy," according to a report1 in Preventing Chronic Disease, a journal published by the Centers for Disease Control and Prevention.
"One of the genius strokes of the Affordable Care Act is looking at the workplace as a perfect venue for encouraging healthy lifestyles," says Laura Anderko, PhD, RN, Robert and Kathleen Scanlon Endowed Chair in Values Based Health Care at the Georgetown University School of Nursing & Health Studies in Washington, DC. "It saves money, but it also keeps people healthy, keeps them at the workplace, and reduces insurance costs."
The ACA provides grants for small businesses to start wellness programs and it is funding a new Work@Health program administered by CDC. Six hundred employers of all sizes will participate in training sessions to learn how to implement a comprehensive workplace health program. (More information is available at www.cdc.gov/workathealth/get-involved.html.)
Meanwhile, the Affordable Care Act allows employers to increase employee incentives to participate in wellness programs.
Incentives rise for healthy habits
Employers may offer incentives, such as a premium discount, of up to 30% of the total cost of employee-only health care coverage (both employer and employee contribution). The incentives can be even greater if employers include programs to prevent or reduce tobacco use. Incentives for non-smokers or participants in smoking cessation programs can rise to a maximum of 50% of the total health coverage cost. The previous limit for wellness incentives was 20% of health insurance premiums.
The law has some fine print. Different types of wellness programs may involve different incentives. In "participatory wellness programs," employers may reward employees who participate in a wellness program that has no specific goals or requirements. For example, they may reimburse the cost of fitness club membership, reward someone for attending an educational session, or offer an incentive to take a health risk appraisal that has no further requirements for attaining health outcomes.
The rule's incentive limits apply to activity-only and outcomes-based wellness programs. An employer can provide a discount on health insurance premiums to employees who perform certain activities (such as following a diet or participating in an exercise program) or the employees who reach a certain goal (such as losing weight or lowering blood pressure).
To guard against discrimination, the law requires employers to offer an alternate pathway to a reward if an employee cannot perform the activity or attain the goal for medical reasons. For example, if an employer offers a reward for a walking program, and an employee can't participate because of a medical condition, the employer either needs to provide another wellness option or waive the requirement for that employee.
"[The outcome or activity-based program] must have a reasonable chance of improving the health of, or preventing disease in, participating individuals, and not be overly burdensome, not be a subterfuge for discriminating based on a health factor, and not be highly suspect in the method chosen to promote health or prevent disease," the law states.
Editor's note: The rule on wellness incentives, which becomes effective on January 1, 2014, is available at www.federalregister.gov/articles/2013/06/03/2013-12916/incentives-for-nondiscriminatory-wellness-programs-in-group-health-plans.