The Occupational Medicine Forum is prepared by the ACOEM Occupational and Environmental Medical Practice Committee and does not necessarily represent an official ACOEM position. The Forum is intended for health professionals and is not intended to provide medical or legal advice, including illness prevention, diagnosis or treatment, or regulatory compliance. Such advice should be obtained directly from a physician and/or attorney.
Answered by Tee L. Guidotti, MD, MPH, DABT. Dr Guidotti is an international consultant in health, safety, environment, and sustainability with medical advisory services, Rockville, MD, www.mas.md. E-mail: . Dr Guidotti is a former President of ACOEM.
These days, health care is organized into “service lines” for purposes of marketing and contracting, compensation, and quality assessment. Service lines are bundles of services that pertain to a common diagnosis or problem or management function and that are aligned with one another for optimal efficiency, cost containment, and outcome. In hospitals and managed care organizations, this might refer to diabetes care or cancer care or obesity management, starting from a patient-centered approach to what is needed for comprehensive care and aligning support from the various services (endocrinology and metabolism service, podiatry, laboratory, nutrition counseling, etc., for diabetes care).1 We'll get to occupational health in a moment, because it is different.
In a traditional health care institution, the medical and surgical services are specialty- or procedure oriented, and the support departments offer a range of individual services that are individually requested and provided. The endocrinology and metabolism department monitors the diabetic patients, the ophthalmologist sees patients on referral, the podiatrist performs foot care, the laboratory does the blood glucose and hemoglobin A1c determinations, the nutritionist does counseling, etc., all by appointment or separate encounters on their own schedules. Service lines for health care might bring all these services into one center, with the various departments providing support as needed in a coordinated manner. This is usually combined with some sort of case management, with a coordinator assisting in scheduling. One advantage of the service line approach is that it can be used for prospective payment in the form of diagnostic-related groups introduced under Medicare as the basis for compensation. Service lines are popular because they are responsive to patient needs, provide a familiar “home” for patients with chronic conditions, lend themselves to audit and quality control activities, and are statistically predictable in terms of utilization as long as the population is large enough and not skewed in the distribution of severity. The service line approach seems to result in greater patient satisfaction, as well.2 Also, a big incentive for health care providers to move to the service line approach is marketing.3
However, having said all this occupational medicine is a little different and closer to the original roots of service lines, which came out of product lines in manufacturing and sales. Hereafter, the idea more commonly refers to bundles of similar or related services or services with a similar function or objective.
Occupational health services can be provided for individuals or populations (as in health monitoring or epidemiological studies), for current health status or for future risk (which is by definition a population-level intervention, because risk is controlled on a group basis), and for work-related health problems or personal health problems (the latter affecting fitness to work, disability from other than occupational injury and illness, and future health and disability).
Services relevant to occupational medicine can be consolidated into four main consolidated service lines, with common features. Table 1 outlines the four essential, consolidated service lines in providing occupational medicine services, with an indication of whether they are oriented to the present or future and deal with individuals or groups:
1. Case management. These services are based on the evaluation and management of individual health care needs in the present. They include clinical services, such as the acute management of injuries and rehabilitation. They may involve clinical preventive services to limit disability or to support wellness in an employee who has a chronic condition. This service line involves the occupational physician in individual patient care. These services require common data elements in personal health information.
2. Occupational health protection. These services are preventive in nature, oriented toward future risk, and although they may be given to individuals and serve as screening tests, they are provided for the purpose of protecting the workforce as a whole. Periodic health surveillance is considered here to be a strategy for secondary prevention for workers at risk on a population basis, not an individualized medical service for individual workers, although it also serves a screening purpose for the individual worker. These services require common data elements including detailed exposure assessment and workplace descriptions but not detailed personal health information.
3. Work capacity. These services are based on the evaluation and management of individual work capacity in the present. Work capacity is not projected into the future, unless there is a permanent impairment. Work capacity evaluation may involve judgments of short-term fitness to return to work, fitness for duty for a particular job assignment or may involve chronic and permanent medical conditions and evaluation for separation (with or without disability benefits). However, these services all involve matching the employee's capacity to do the job with job requirements (in the case of long-term disability evaluation, usually any job). These services require common data elements including detailed job descriptions and requirements but not detailed personal health information.
4. Health risk management. These services are based on the evaluation and management of an individual's capacity in the future. Impairment evaluations are intended to determine the employee's work capacity in the future: that is why they are only done at permanency. These services may involve clinical preventive services at all three levels and support for programs in health promotion, in an effort to intervene to modify future health risk. These services require common data elements, including personal health information.
Table 2 lists the major services provided by the occupational physician or an occupational health service, and whether they are provided in a clinical setting or are nonclinical in nature.4
There are many practical advantages to presenting occupational medicine services to a manager or client as four simple service lines instead of itemizing them individually. It is much easier to tell managers that the occupational health service provides many specific services in four general areas than it is to describe 50 or 60 specific services and then explain how they fit together. Because all or most services in a given service line have the same data requirements, it is easy to identify minimum data sets that should be called up or retrieved from the electronic record to have on hand when a worker is seen for a particular service. These frameworks can be used to drive IT requirements and standardized data fields in the electronic medical record, which is already better established in occupational medicine practice than in general medicine. Contracts are easier to write and billing made simpler when four service lines are used as general categories for the many individuals services provided.
One objective of redefining these service lines is to shift the mission of the occupational physician or occupational health service toward a different balance, emphasizing occupational health, the workforce as a whole, and future risk.
1. Jain AK, Thompson JM, Kelly SM, Schwartz RW. Fundamentals of service lines and the necessity of physician leaders. Surg Innov. 2006;12:136–144.
2. Turnipseed WD, Lund DP, Sollenberger D. Product line development: a strategy for clinical success in academic centers. Ann Surg. 2007;246:585–590.
3. Berenson RA, Bodenheimer T, Pham HH. Specialty-service lines: salvos in the new medical arms race. Health Aff (Millwood). 2006;25:337–343.
4. Guidotti TL. The Praeger Handbook of Occupational and Environmental Medicine. Santa Barbara, CA: Praeger; 2010.