Robert K. McLellan, MD,MPH,FACOEM

President, ACOEM

The Future of Occupational and Environmental Medicine

Overview

• Trends– in the workplace– in occupational injury and illness– in public health– in the OEM workforce, training and research

• ACOEM Initiatives

• Visioning the Future of OEM

Changes in the American Workforce:Demographics is Our Destiny

• Demographics – Workforce is more diverse in age, gender, race, and nationality – Most new jobs in businesses with less than 500 workers– Large numbers of illegal immigrant workers

• Nature of work – Increasing proportion of service, health care, computer jobs– Decreasing proportion of manufacturing, agriculture, fishing

• Organization of work– Transient employment (temporary, contracted workers)– E-commerce– Homework and the 24 x 7 workweek– Globalization

Decreasing Role of Organized Labor

0

5

10

15

20

25

'83 '02 '06

PercentUnionMembers

• Manufacturing union membership:– 1983: 4 million

– 2002: under 2.5 million

Bureau of Labor Statistics

Changes in Workplace Hazards• Traditional hazards exist, but increasingly in small

difficult to monitor settings or overseas• Adverse effects of many contemporary occupational

hazards are insidious, have long latencies, are environmentally ubiquitous and are unlikely to result in pathognomic occupational illnesses – Ergonomic– Stress– Sedentary work life– Low-level chronic exposures to environmentally pervasive

agents (pthalates, nanoparticles)

Injuries and Illnesses in Private Industry

NIOSH Worker Health Chartbook 2004

Illnesses in Private Industry

NIOSH Worker Health Chartbook 2004

Number and Rate of Fatal Occupational Injuries by Age, 2002

NIOSH Worker Health Chartbook 2004

Median Days Lost due to Occupational Injury or Illness by Age

NIOSH Worker Health Chartbook 2004

Occupational Health and Safety:37 years after the OSHAct

• 37 yrs after OSHA Act– Injury/Illness incidence has fallen from 11.0 to 4.6

per 100 full time workers– But

• A worker becomes ill or is injured on the job every 2.5 secs

• A worker dies every 8 minutes

Persistent Undercounting Occupational Injury and Disease?

• No comprehensive national surveillance system– Under the table employment or regulatory exclusion

– Bureau of Labor Statistics annual survey, Workers Comp, and physician reporting data bases not integrated

• Legal and scientific challenges in establishing causation

• Number of new injuries and illnesses underestimated by several hundred percent

Azaroff Am J Pub Hlth 2002

Regulatory Politics

• OSHA – Many exposure standards date to 1971

• Difficult to update• 1992 court decision stymied effort of global standard

update to synch with the annually revised ACGIH TLVs

– Little enforcement clout• 2000 inspectors (risk of inspection once in 88 years)• Fish and Game has 6 times the number of inspectors• 2005 Avg penalty for a serious violation: $9000• A cost of doing business?

Relaxation of Worker Protection Rules During Disasters

Workers Compensation Reform:Driven by Rising Costs

• State by state • Disability management

– Requirement for TAD– Case management– Worksite initiatives– MD education

• Optimizing medical care– Utilization review– Treatment guidelines

General Health Trends – A Public Health Crisis

• Population is aging• Obesity and sedentary lifestyle and associated

diseases are epidemic and will drive disability• Health care premiums rising at twice the inflation rate• Number of uninsured Americans continues to rise

– 46.6 million or 15.9% of population

– Health insurance coverage for working families – has declined annually for 6 years. Now at 62%

Wide Variation In Treatment and CostsRatio of Total Rates of Spine Surgery to the U.S. Average

by Hospital Referral Region (2002-03)

Source: Spine Surgery. A Report by the Dartmouth Atlas of Healthcare. CMS-FDA Collaborative.

Evidence Based Medicine and Treatment Guidelines

• Small area analysis• Critical appraisal

– Evidence review and consensus– Cochrane Collaboration

• Clinical epidemiology– Outcomes research– Randomized clinical trials

• Agency for Healthcare Quality and Research (formerly AHCPR)

• Care maps, algorithms, guidances, pay for performance

Trends in the OEM Workforce

OEM Workforce

• Total Occupational Health and Safety Professionals – 75,000 – 125,000

• AMA estimates 10,000 physicians practice some OM• 3,332 Board-certified occupational medicine

physicians since 1955 • Only 1,500 - 1,800 are actually in practice today• About 100 new diplomates per year• ACOEM

– 5100 members– Mean age 55– 93% > 40

ACOEM Members Practice Sites 1992 v 2006

46

24

8

34

17 19

2823

05

101520253035404550

Corporate PrivatePractice

Hospital Other

1992

2006

OEM Training

• Declining number of residency programs– 1994: 42 – 2007: 31

• Declining number of graduates– 1994 : 168– 2007: 101

• Educational Resource Centers – Flat, unstable funding

Grant Funding Success Rate* for NIOSH

1996-2007 (est.)

0

5

10

15

20

25

30

35

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Su

cces

s R

ate

(%)

NIOSH Success Rate

* Success rates are for the combined R01, R03, and R21 mechanisms only

ACOEM’s Strategic Response

1. Excellence in health care

2. Health and productivity

3. Workforce protection through emergency preparedness

Excellence in Healthcare

• ACOEM OM Practice Guidelines, 2nd ed– Providing the best care, at the right time, every

time…– Better outcomes at less cost– Updated Methodology, roll out of updated chapters

• The Value of OEM … ACOEM (OEM) gains credibility, prominence, and influence

• Valuing excellence in occupational health care with upgraded fee schedules

Excellence in Health Care

• Promote the Future of OEM– Enhance training opportunities – White Paper

• Funding

• Training Models

– CME in core competencies of OEM – Preventive Medicine and Public Health Training

Act of 2007– IOM 2007: Training Physicians for Public Health

Careers

Redefining Core OEM Competencies

• Clinical Occupational and Environmental Medicine

• OEM Related Law and Regulations

• Environmental Health

• Work Fitness and Disability Integration

• Toxicology

• Hazard Recognition, Evaluation, and Control

• Disaster Preparedness and Emergency Management

• Health and Productivity

• Public Health, Surveillance, and Disease Prevention

• OEM Related Management and Administration

Excellence in Health CareEnvironmental Medicine

• Hippocrates– On Airs, Waters,

and Places (c 400 BC)

• Enormous public concern and daily dose of issues

• 1998 Keynote National Leadership Forum for Health Care Professionals– “How to persuade physicians

to consider environmental issues in assessing and treating their patients?”

Environmental Medicine

• 1992: ACOM becomes ACOEM – A core competency– Environmental Medicine Core Curriculum– Increasing presence in courses, OEM journals

• 2007– What are the career opportunities?– What about in practice?– AOHC 2008

Social Justice

• Maldistribution of risk and burden of poor health

• Protection of vulnerable groups

• Updating ACOEM code of ethics

• Section for Underserved Populations

#2 Health and Productivity:ACOEM as Thought Leader

Promoting Employee Health: Cost or Investment?

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• Impact of health on human and business performance shifting from cost to be justified to an investment to be leveraged

• Will HPM decrease the burden on SSDI and Medicare

Health and Productivity Initiatives

• NIOSH WorkLife Workshop• Health and Productivity Center • HPM tools

– Revised tool Kit– HPM Webinar Curriculum– HPM clinic

• Cornerstone collaboration with payers, employers and labor to prevent and manage disability

• Implications of HPM for Social Security Disability and Medicare

#3 Workforce Protection:Mandate of Homeland Security

Disasters Threaten Workers and the Workforce as a Critical Infrastructure for

Business Continuity

Terrorism Natural DisastersIndustrial Accidents

“Occupational health services can make your company more profitable.”

“Occupational health services could save your butt in a real emergency.”

Traditional New Message

A New Message for Employers

Equipping OH Professionals With The Right Tools

• Education– SOTAC 2006 was a surprising disaster! (drill)– Just in time webinars

• OHDEN – Occupational Disaster Expert Network– … a web-based tool kit for OH professionals– Currently

• Under construction at www.acoem.org • See the full featured prototype

Implications of the Trends In US

• Workforce and global economic changes complicate implementation of workplace health and safety programs and the monitoring of occupational injuries and illnesses

• Looming public health crisis/opportunity

• Fate of OEM parallels societal protection of workers (and the environment?)

We Need

• Improved systems of occupational injury and illness reporting

• New research needed to explore risk and control of new hazards

• New training, funding systems and regulatory reform• New health care financing/delivery systems• New approaches to meeting the OH needs of the

underserved populations at home and abroad

Making Progress in Protecting Workers?

• Align worker protection with themes of health and human rights

• Create a zero injury and illness culture• Achieve 100% “coverage” of all workers by

competent OEM and OHS programs• Form coalitions around issues of importance to

business, labor, environmental groups, community groups, public health professionals

Silverstein 2007 & Rantenan 2007

Where the Future?

• OM physicians are public health professionals for the employed population

• OH constitutes a parallel healthcare system, with different capabilities and drivers

• OH services support productivity but also – protect the future of the enterprise and the critical

human resource needed for all economic sectors– May protect social welfare systems from

bankruptcy

• OH can play a key role in public health– Disaster management– Population health promotion– Environmental medicine

• A new– Business case for OEM!– National security case for OEM!– Public health case for OEM!

Where the Future?

ACOEM’s Vision and Mission

• We champion the health and safety of workers, workplaces, and environments

• We are the specialty that is “devoted to prevention and management of occupational and environmental injury, illness and disability, and promotion of health and productivity of workers, their families, and communities.”