Richard Donze, DO, MPH
Director, Occupational Medicine Services
In meetings and hallways conversations with physician and administrative colleagues in hospital settings, I repeatedly hear references to the current buzz about healthcare "value" and "pay for performance." The first term/concept refers to balancing quality of care and efficiency, where ordering more tests and administering more treatment than necessary in the name of quality can be inefficient and too expensive, while too much emphasis on efficiency and cost can mean not doing enough or what's necessary for high quality. High value healthcare is that elusive sweet spot between those two extremes, as it attempts to do what's necessary but just that, thus automatically ensuring optimal efficiency. Pay for performance is just what it sounds like: federal and commercial health insurers providing rewards or imposing penalties based on the apparent or measured value.
Such colleagues have asked me if those concepts are part of the dynamic in my clinical environment where we treat work-related injuries and illnesses and perform fitness-for-duty physicals. Sure, I tell them, except we lump them both together and use a different descriptor: we call it "practicing Occupational Medicine." That's right folks: The model for improving quality and controlling costs by encouraging more appropriate ordering and practice behavior by providers has been right under our noses for decades as the alternative healthcare universe known as Occupational Medicine. Occ Med providers coming out of conventional medical training and practice have to develop these sensibilities and behaviors more or less organically, in response to the environment, the way fish coming onto land had to trade fins and gills for legs and lungs. We couldn't survive without them.
Just looking at the names of the health insurance entities is enough to demonstrate that Occ Med is truly an alternative healthcare universe: the names you typically see are Liberty Mutual, Travelers, Hartford and Zurich rather than Blue Shield, Aetna, United, or Medicare. Sometimes the employers may even self-insure and use a third party administrator to manage their claims. Another major distinction is that attention to quality, efficiency and pay for performance are nothing new, but have always been fundamental to Occ Med practice. Employers all demand high quality care for their workers, since it simultaneously fulfills their moral/ethical responsibility as it also usually leads to one of their most important outcomes -- getting injured employees safely back to work.
Sure, the employers-insurers would rather we not order too many MRIs or orthopedic consults, but if those measures ultimately result in an earlier return to work they might be considered good investments since they help keep down the costs to replace wages, backfill with other staff, etc. If providers and employers both recognize that what's best for the employee is ultimately best for the company (even though the employee doesn't always recognize it) , the clinician can often have the freedom to find the most efficient means to that end. The most expensive order we write is the one that keeps employees out of work, so we tend to only do that rarely, as when the injured folks needs bed rest. Everyone who can walk into the office can usually do something at work.
If we are good clinicians and stewards, we get our fee-schedule-based reimbursement from the workers comp carriers (in Pennsylvania, this number is well north of Medicare rates and rises every year), hopefully gain the employers' trust and get to keep them as clients (the ultimate pay for performance incentive), and maybe get a shot at another prominent source of revenue in Occ Med -- the physicals, whether mandated by OSHA, DOT or the employer's self-imposed policy -- which are fee for service, out-of-pocket expenses for the employers. This is where I have to translate for my hospital associates, as they are generally unfamiliar with the concept of "cash." I tell them it's a neat system: you send a bill for the service you provide and the employer sends back a check without an insurance company intermediary. Pretty amazing, eh? We have to price these non-workers-comp services competitively, but at least we get a chance to try to cover our costs and enjoy life outside the usual healthcare economy.
Could or should the Occ Med way become the way of the general healthcare world? Occ Med practice is certainly not perfect; we have our own unique challenges, such as those low back pain patients that just don't get better no matter what we do, and with that those thorny return to work issues and questions of symptom magnification and/or even outright malingering. But it has to be a simpler system if the providers have built-in incentives to optimize quality and efficiency, and know that if they don't perform well they won't get paid, or at least not for long. Moreover, to borrow and paraphrase another popular management cliché, we shouldn't let the pursuit of perfection get in the way of recognizing and going with something that's already very good. So let's encourage all our friends in the regular healthcare world to have a look at what we do in Occ Med, maybe even ask us advice about how we do it. There's bound to be some value in that conversation.