Health in the Workplace
ROLE OF EMPLOYEE HEALTH SERVICES, COMPLIANCE WITH STATE AND FEDERAL REGULATIONS
Albert A. Kowalski, M.D.
In the first years of the twenty-first century, the health of employees was a major concern for many companies due to the escalating costs of occupational (work-related) and non-occupational health care. In 2004 national health expenditures rose 7.9 percent over the previous year, more than three times the rate of inflation. In 2004 total spending on health expenditures was $1.9 trillion, or $6,280 per person in the United States. Health care expenditures in 2004 represented 16 percent of the gross domestic product (GNP).
Health care expenditures are projected to reach $4 trillion in 2015, or a 20 percent share of the GDP. This is up from only 8.8 percent in 1980. Such escalating costs reduce companies' profits and inflate the prices of goods and services.
Government regulations have also influenced health in the workplace. Since 1970 federal regulations have required companies to maintain accurate records of work-related illnesses and injuries, institute medical surveillance programs, provide safety equipment, and control the use of hazardous chemicals. As a result, the number of serious occupational injuries and illnesses has been greatly reduced. Companies must continue to monitor the health of their workers to keep insurance spending and premiums to a minimum.
This essay discusses the role of employee health services in a company, the types of programs often provided, and the federal regulations that pertain to health in the workplace. It also addresses current issues in employee health services, including AIDS in the workplace, employee assistance programs, drug testing, fitness programs, and health care trends.
ROLE OF EMPLOYEE HEALTH SERVICES
Today's occupational health care professional is not only responsible for the health of the employee but also may be involved with company medical policies and benefits, disability and workers' compensation evaluations, health promotion, wellness and fitness programs, industrial safety, and compliance with state and federal regulations. Employee health services vary widely from company to company. Employers may provide any or all of the programs outlined below to their employees.
Emergency Medical Care
Every company is responsible for establishing policies and procedures for providing first aid and emergency medical care to employees who become ill or injured at work. These services can be provided by appropriately trained personnel on-site or at local health care facilities. Many companies have organized voluntary first-aid squads from within the ranks of their employees. Some employers offer classes in first aid and cardiopulmonary resuscitation (CPR) certification.
Albert A. Kowalski, M.D., is a medical director in the Health Affairs Organization, AT&T Corporation, Basking Ridge, New Jersey.
A pre-placement or pre-employment examination is a medical assessment provided by a company. The examination serves two functions: to determine an applicant's ability to perform a specific job, and to provide a baseline medical status against which to evaluate any occupational illnesses or injuries that might arise during employment. A physician who is employed or contracted by the company usually performs this examination. It may include a physical examination, vision test, hearing test, pulmonary function test, electrocardiogram, chest X-ray, blood tests, urinalysis, and drug testing.
The physician must determine if the applicant can perform necessary job functions despite any medical condition he or she may have. A company cannot, however, legally deny an applicant a job solely on the grounds of a diagnosis such as cancer or AIDS. In addition, federal, state, and local laws prevent discrimination against people with disabilities. The company can only deny the applicant employment if, in the opinion of the physician, the applicant is unable to perform the essential functions of the job.
The pre-placement examination also establishes a baseline medical profile for the protection of the company and the employee. It may help determine whether any illness or injury that occurs later is occupational, non-occupational, or the result of previous employment.
Medical Surveillance Examinations
Medical surveillance examinations are usually required by company policy or by government health standards for employees exposed to toxic chemicals or other substances that may pose a health risk in the work environment. The purpose of the examination is early detection of work-related medical illnesses so measures can be taken to prevent serious disability or death. The physician is responsible for notifying the employee and for arranging appropriate treatment and follow-up care of all work-related illnesses. The company in turn must take appropriate action to minimize the exposure of its employees to hazardous agents. This can be done by rotating jobs, installing special engineering devices, improving ventilation, using safer chemicals, or providing workers with protective equipment.
Periodic Health Examinations
Some companies offer regular health examinations for employees and executives who do not work in hazardous environments. These assessments, which are similar to the pre-placement examination, are preventive in nature and stress the early detection of disease or predisposing factors to disease. Employers are beginning to provide these examinations free of charge because early detection and treatment of illnesses reduce absenteeism, improve work productivity, and may prevent long-term disability.
Return-to-work programs help injured or sick workers return to the workforce as early as they are able. They focus on easing the transition for employees returning to work. Companies that use return-to-work programs see benefits such as lower insurance costs, enhanced retention of skilled workers, and better employee relations.
A physician evaluating candidates for return to work programs must have a good understanding of the work employees perform and the types of restrictions an employer can accommodate. The physician must determine whether the employee can return to full-time or part-time work, to regular duty, or to modified duty. In modified-duty programs, injured workers return to jobs that are designed according to their interests and capabilities. Workers make a gradual transition back to their regular jobs while performing as many of their usual duties as possible. Modified duty should be discussed in detail with the employee and his or her supervisor. The employer should predetermine the duration of modified duty, adding responsibilities as the employee's condition improves. Collaboration between health services and management is essential for the program to be effective.
An estimated one out of five employees will use short-term disability during his or her working years. Many companies provide short-term disability programs for their employees. However, many employers neglect to control the length of absenteeism and the loss of productivity. Ideally, every disability case should be reviewed by a health care professional. The length of disability given by the personal physician should be compared with accepted standards for that disability. If the length of disability is excessive for a diagnosis, additional information should be obtained to affirm the reason. If the company's case manager or its disability insurance representative disagrees with the employee's personal physician about the length of disability, the company may request an independent medical examination (IME). A physician chosen either by the company or by its disability insurer performs the IME, which determines a return-to-work date and the length of time the employee will receive disability pay.
The type of work the employee performs also must be considered. Durations of disability are significantly shorter for clerical workers than for manual laborers.
Employee Health Management Programs
Some companies have employee health management programs that offer workers and their families convenient access to medical care. These companies have established large medical facilities off-site that offer medical care by a group of physicians and specialists, diagnostic testing, and pharmacy services.
Other companies have limited employee health management programs that offer medical care at the workplace for employees only. Employees are evaluated for non-occupational illnesses by the company physician and given the appropriate treatment. By providing workers with early diagnosis and treatment on-site, the employer benefits in reduced absence rates.
Employee Health Screening
Many employers offer special health-related screenings to their employees. These programs educate employees, detect illnesses, and increase employees' awareness of certain diseases. These screenings usually are very cost-effective, allowing early diagnosis, early treatment, and reduction of subsequent medical absences. The most common screening program is for hypertension. Blood pressure screening during lunch or before or after work is simple and often performed by a nurse. Employees with elevated blood pressure may be referred to employee health services or more often to their personal physician.
Mammography programs for early detection of breast cancer are becoming increasingly common. The most effective programs provide a mammography van or a portable unit at the workplace. Some smaller companies contract with a local mammography facility for services. Such programs usually are free to the employee or reimbursed by health insurance. Other common programs screen for cholesterol, glucose (diabetes), and skin cancer. Some companies also have screening programs for colon cancer, prostate cancer, and osteoporosis.
Many companies have introduced wellness programs or disease management programs to promote good health. Companies subsidize such programs, which can be implemented onsite or in the community, in order to reduce future health care costs and losses in productivity from workers' preventable illnesses. While these programs vary greatly from company to company, they usually include courses on smoking cessation, general nutrition, low-salt diets, cholesterol reduction, weight loss, hypertension, diabetes, asthma, prenatal care, stress management, and depression.
Smoking is the leading cause of preventable disease in the United States today. The Centers for Disease Control and Prevention estimates that cigarette smoking causes 440,000 deaths, or 20 percent of all deaths, each year. Adults who smoke will die, on average, thirteen or fourteen years earlier than nonsmokers. Cigarette smoking is a primary cause of many diseases, such as lung cancer, heart disease, emphysema, and chronic bronchitis. Because of these statistics, many companies have instituted smoking cessation programs, such as the American Cancer Society's Fresh Start program or Smokenders, to help employees stop smoking. In addition, most companies have established strict policies to create smoke-free workplaces.
Elevated cholesterol is also a significant risk factor in the development of heart disease, the leading cause of death in the United States today. Programs that educate employees about cholesterol and good nutrition are the most effective methods for long-term reduction of cholesterol.
Obesity can lead to many serious medical problems, and recent studies show it may soon match or even replace smoking as the leading cause of preventable deaths. Programs encouraging weight reduction are usually very popular with employees. The easiest and most effective weight-counseling programs are on-site, such as Weight Watchers. Such programs may be provided at the workplace on a weekly basis to educate employees and encourage weight loss. Some company cafeterias offer reduced-fat or low-calorie entrees in conjunction with these programs.
Some companies offer prenatal care courses for pregnant employees. These programs are especially valuable in companies where employees have a high incidence of complicated births. The March of Dimes offers an effective prenatal education program called Babies and You that has been adopted by many companies.
Wellness programs also may include company-published health literature. These publications may range from one-page newsletters to complete magazines. They help increase employee awareness of the importance of a healthy lifestyle by providing information about weight reduction, smoking, exercise, and early signs and symptoms of common diseases.
Through their medical insurance or another health care company, employers also may provide disease management programs. These companies identify employees with specific chronic diseases such as depression, diabetes, asthma, or hypertension. They provide the employees with educational information to better control their conditions and encourage employees to follow physician instructions. Some of these companies have health care professionals available by telephone to answer general medical questions employees may have.
Some companies offer workers immunizations through employee health services. The most commonly given immunizations protect against influenza, tetanus, and hepatitis B. For workers who travel outside the United States, immunizations may be provided against such diseases as cholera, typhus, yellow fever, hepatitis A, and polio.
Companies whose workers travel internationally may provide necessary medications and immunizations to their workers for free. Medication for the prevention of malaria is given for travel to certain parts of the world. Company health care professionals can access Travax, a travel immunization computer program updated weekly that incorporates information from the Centers for Disease Control and Prevention, the U.S. Department of States, and the World Health Organization, to stay on top of immunization recommendations for international travelers. They may also access travel immunization information directly via the Internet at the Centers for Disease Control and Prevention (CDC) or the World Health Organization (WHO) Web sites.
COMPLIANCE WITH STATE AND FEDERAL REGULATIONS
Occupational Safety and Health Administration
The most important legislation concerning health in the workplace is the Occupational Safety and Health Act of 1970. This act established the Occupational Safety and Health Administration (OSHA) under the direction of the U.S. Department of Labor to disseminate and enforce safety and health standards to protect employees at work. Over two hundred local OSHA offices exist throughout the nation in order to enforce protective standards and implement outreach programs to employers and employees. The OSHA standards described below affect a significant number of employers and employees in the United States.
Every employer with eleven or more employees must maintain records of work-related injuries and illnesses. The employer also is required to post an annual summary of the workers' injuries and illnesses. These records must be kept for five years and must be made available to employees and OSHA representatives on request. Major financial penalties can be levied against employers who fail to accurately document employee illnesses and injuries in the workplace.
Employers are responsible for identifying chemical, physical, biological, and ergonomic hazards in the workplace. For exposure to certain materials, medical surveillance is required under the Occupational Safety and Health Act. OSHA requires medical monitoring for exposure to asbestos, benzene, noise, lead, and other chemicals and hazards. This monitoring generally begins with a medical history and physical examination. In some cases it may include specific blood tests, pulmonary function tests, chest X-rays, or hearing tests.
OSHA also requires that employees be given certain protective equipment if there is a reasonable probability of an injury at the worksite. The most common pieces of equipment supplied to employees are safety glasses and shoes, helmets, respirators, and hearing protectors.
The hazard communication standard, enacted in 1983, is one of the most important regulations formulated by OSHA. Its goal is to ensure that employers and employees know about the substances with which they work and understand how to reduce illnesses and injuries associated with chemical materials by identifying the chemicals and including hazard warnings. Employers also must provide a Material Safety Data Sheet (MSDS) for a hazardous material. This is a technical bulletin describing the chemical, its characteristics, the health and safety hazards, and precautions for safe handling and use.
State workers' compensation laws regulate work-related injuries and illnesses. These laws require that employers provide replacement incomes to employees who suffer work-related injuries or illnesses. States have different laws, but they follow similar principles under a "no-fault" system. This means the employee is entitled to receive benefits regardless of whether the employer has provided a safe workplace or the worker's own carelessness contributed to the injury or illness. Employers are required to pay a portion of the salary lost (usually about 70 percent), and many have a fee schedule for hospital and physician services. Employers pay for insurance to cover this cost, either through a state fund or through a private insurance company.
There usually is little doubt as to whether an injury or illness is work related. Basically, any injury that occurs in connection with work is covered unless it was intentionally self-inflicted or caused by substance abuse. An illness or disease is likely to be covered if it was the gradual result of working conditions. For example, lost time and health care costs caused by carpal tunnel syndrome, tendonitis, lung disease, and heart attacks often are covered by workers' compensation.
Many companies view the expense of employee health services as cost effective, since these services can have a major impact on a company's workers' compensation costs. Early onsite treatment is extremely cost-effective and reduces lost time. Appropriate referral by health services may expedite early medical treatment. In addition, health services can perform case management to aid the employee through the health care maze and avoid wasting time or undergoing unnecessary procedures.
Health services also may participate in safety programs and accident investigations. These activities prevent accidents, reduce their severity and the time lost from work, and lower medical costs.
CURRENT ISSUES IN EMPLOYEE HEALTH SERVICES
AIDS in the Workplace
AIDS is a viral disease that gradually destroys the body's immune system. As a result, unusual or opportunistic infections and certain cancers, such as Kaposi's sarcoma, may occur. It can be transmitted by sexual intercourse, the use of infected needles, the transfusion of infected blood, or the transfer of the virus from a mother to her infant before birth or while breast-feeding. There also have been reports of AIDS transmission to health care workers via accidental sticks from contaminated needles or contact with infected blood. This disease is not transmitted by casual contact or social association in the workplace. Unfortunately, much fear and misinformation still surrounds AIDS.
In 1986 zidovudine, the first antiviral drug used in preventing HIV replication, was approved by the U.S. Food and Drug Administration. Many more antiviral drugs, which attacked the HIV virus in different ways, were approved for use in the subsequent decade. Since 1997 these drugs have been used in combination—referred to as "highly active antiretroviral therapy," or HAART—to great effect. The development of these drugs and drug combinations does not represent a cure for AIDS, but they do significantly reduce the amount of virus present and significantly increase the life expectancy of AIDS patients.
In terms of company policy, AIDS should be treated like any other disease or disability and should not be the basis of discriminatory practices. If an employee with AIDS is able to perform the duties of the job, he or she should be allowed to work. If the employee is not able to work, he or she should be placed on short-term or long-term disability.
Employee Assistance Programs
Some employers offer employee assistance programs (EAPs) to help workers and their families with personal problems that may affect the employees' wellbeing and job performance. Alcoholism, drug abuse, and emotional, medical, legal, financial, work-related, or family problems are commonly treated. Early intervention, counseling, and appropriate referrals are the primary objectives of EAPs. The employee is given between three and eight EAP counseling sessions, usually at no cost. If further intervention is necessary, the costs usually are covered by the employee's medical benefits.
EAPs generally are not located at the workplace. An employee often uses a toll-free telephone number to make the initial contact. Employees can seek help on their own by calling the EAP directly—which is usually the case—or they can be referred by supervisors. Once the employee makes contact with the program, he or she is evaluated by either a social worker or a psychologist, depending on the problem. After the evaluation, the employee may continue with the social worker or psychologist or may be referred to an appropriate specialist or center. The information gathered about a particular employee and his or her problem is confidential, and the employer is not notified.
A referral to an EAP by a supervisor is usually made because of an employee's poor job performance or behavior at work that may reflect personal problems. In this case the employee is required to contact the EAP and to comply with the EAP's treatment or recommendations. Failure to do so may result in disciplinary action by the company.
In 2001 a survey found that about 60 percent of employees surveyed had access to an EAP. The overwhelming majority (86.3 percent) of employees working in large firms with more than five hundred employees had a company EAP. All federal agencies have EAPs. These programs are successful and cost-effective. They help increase productivity by reducing employee turnover, absenteeism, and accidents. The federal government estimates that for every $1 a company invests in an EAP, $1.50 to $15 is saved in lower absenteeism, turnover, and medical claims.
Many companies have instituted substance abuse programs to deal with the problem of drug and alcohol abuse in the workplace. These programs take a firm stand against the use of substances that may affect safety or the performance of employees in the workplace.
During the administration of President Ronald Reagan (1981–89), the federal government began to aggressively pursue drug testing in the workplace. By the late 1980s new Department of Transportation regulations mandated extensive drug-testing programs in numerous fields including the aviation, maritime, mass transit, motor carrier, pipeline, and railroad industries. Despite periodic challenges to these regulations and specific company policies, the U.S. Supreme Court has upheld the federal government's right to impose drug-testing requirements on both private employees and government workers when their duties affect either law enforcement or general public safety. Various laws regulate drug-testing policies at the state level, as well. Legal challenges to drug-testing policies continue to be brought before the justice system at all levels.
An employee may be tested on several occasions. The first is during an applicant's pre-placement physical. Medical personnel may request that applicants provide urine and blood samples for testing purposes. It is important that the company follow a proper procedure called "chain of custody," which requires an applicant's signature and witness of the specimen's sealing with a special tape. This procedure guarantees it is the applicant's urine and prevents tampering. The specimen is sent to a laboratory for detection of illegal and prescription drugs. Some drugs, such as marijuana, may be positive in the urine for up to twenty-eight days, whereas other drugs may be detected for only three to four days. If the initial results are positive, a more sensitive testing method is used to confirm them. If an applicant tests positive for illegal substances, he or she usually will be denied employment. Even marijuana found in urine weeks after use can be a legal cause for denying employment. When the drug test is positive for a prescription medication such as Valium, the applicant may be asked to produce a letter from the prescribing physician stating the reason for the medication. This information is important and might prevent the applicant from being hired (for example, if the job includes operating heavy machinery).
An employee may be tested for drug use during an annual physical examination, randomly during the year, "for cause," or after an accident. Drug testing during the annual physical or done randomly may deter substance abuse, but such testing has legal implications. It is important for the company to have a clear drug policy covering this type of testing. Employees who test positive are subject to disciplinary action or termination. They also may be referred to an EAP or for professional evaluation and recommended for individual or group counseling, outpatient care, or hospitalization. Those testing positive for illegal drugs after an accident may be denied unemployment, workers' compensation, or disability benefits.
When an employee acts in an unusual manner, the supervisor may request drug and alcohol testing commonly referred to as "for cause" testing. It is important that the employee be examined by a medical doctor before testing to document the problem and to be sure the symptoms are not the result of a medical condition.
Many companies have instituted fitness or exercise programs to improve the health of their employees. When employees take advantage of these programs they can increase productivity, decrease absenteeism and turnover, reduce stress, and improve morale, in addition to reducing health care costs.
Surveys show that most large employers are active in promoting health. Employers may offer subsidized gym memberships or onsite fitness facilities. The simplest type of program reimburses the employee for participation in an exercise course at a local YMCA or health facility. Such a program is easy to initiate and manage. Disadvantages include low employee attendance and scheduling problems.
Some large corporations have taken this idea further. They have constructed complete onsite fitness centers that include exercise bicycles, elliptical trainers, treadmills, rowing machines, muscle-strengthening equipment, specially equipped aerobics rooms, running tracks, basketball courts, and full-size swimming pools. An exercise specialist evaluates the employees and designs individualized exercise regimens. This type of program is very popular because it provides a convenient facility and a customized exercise program.
Evidence suggests most companies experience a direct reduction of medical costs as a result of these programs. Companies also benefit from decreased absenteeism and increased productivity.
Health Care Trends in the United States
A serious health care crisis exists in the United States today. It is an economic crisis as well as a medical one. According to the National Coalition on Health Care, insurance premiums increased by 10 percent in 2005. This increase was nearly three times the rate of inflation. The annual family health plan premium averaged $10,800 in 2005, which is more than the earnings of a full-time, minimum wage worker.
National health expenditures are expected to continue to outpace inflation. Inflation, the aging of the population, and major technological innovations have contributed to the increase in the cost of health care. To make matters even worse, according to an April 2005 article in the Hamden Journal, the U.S. health care industry is losing $100 billion a year due to payment errors. This means even higher premiums for employers and employees.
In the past, many employees and their families had health benefits paid entirely by their companies. Employees were enrolled in indemnity programs, which provided the freedom to see any physician and go to any hospital. Rising health care costs have caused many companies to switch to managed care plans, which include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point-of-service (POS) plans. Under managed care, employees are limited to network physicians and hospitals and are required to get referrals to see specialists. In addition, employees may be asked to pay a larger percentage of their health insurance premiums while receiving less coverage and having higher deductibles. Coverage for new employees may not start for one to six months from the date of employment. This trend of rising costs and declining coverage is projected to continue.
Some companies have even tried to eliminate or reduce the medical benefits of retirees. With escalating costs for their medical benefits and longer life expectancies, many medical plans for retirees were underfunded. As a result, many companies are reducing and eliminating medical benefits for future retirees.
In 2004 45.5 million Americans under age sixty-five were uninsured. More than 80 percent of these uninsured people come from families with workers, and 70 percent of them from families with at least one full-time worker. Two-thirds of uninsured people come from low-income families. Uninsured people rarely receive primary care, generally waiting until their condition reaches the emergency stage before seeking medical attention. The results are higher costs and poorer prognoses (predictions of the probable course of a disease and the chances of recovery).
Companies have looked to insurers to better manage their health care costs. As a result, insurance companies developed physician networks, such as managed care systems and HMOs, to reduce health care costs. These networks of hospitals and doctors provide medical services at discounted fees. Companies did not, however, realize the savings they anticipated because they incurred increased administrative costs from the programs. Instead, companies have reduced costs primarily by shifting premium increases to employees for the same or less coverage than they had before. Unfortunately, this trend will continue as companies try to remain competitive in an increasingly changing business environment.
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