Strategies for infection control and employee health program survival in a changing health care environment.

The following quiz will help you decide if these strategies apply to you.

• Has anyone in your health system lately questioned your costs for various parts of your program?
• Has your pharmacist questioned you on the rationale for 3 antiviral drugs as prophylaxis for HIV needlesticks?
• Have you had any downsizing? Has your hospital merged with or acquired some other health care provider to form a system and you read about it in the newspaper after it happened?
• Have there been meetings to talk about consolidating employee health and infection control for the system and you did not have a seat at the table to explain what it is that your program does?
• Is the office space that you had your eye on for your program now occupied by an outside vendor, agency or staff member who was not even a part of your hospital a year ago?

If any of these things have happened to you, then you have come to the right place.

Part 1: The language of managed care.

Managed Care definition: a sytem of health care delivery that influences utilization (access) and cost of services, and measures performance (quality).

Methods of payment under the old system Fee-for-service:

Methods of payment in managed care: there are many DRGs:

Discounted fee-for-service:

Capitation:

Partial capitation:

Organizations that deliver managed care

Hospitals, physician's offices, HMOs, ambulatory care facilities, clinics, community health centers, community agencies. Many of these organizations are combining into health systems.

What is driving the shift toward managed care?

Employers, the major purchasers of health care in the US, are striving to cut their premium costs for health care benefits. HMOs are attractive to employers as a way of containing premium costs.

Several major shifts are taking place:

• away from expensive inpatient care ¥ toward ambulatory care
• toward other forms of reimbursement as just described.
• lower occupancy in hospitals
• consolidation of hospitals and physician practices into health care delivery systems ¥ alliances, mergers, acquisitions, and closures of some facilities.
• shift of the financial risk from the payor to the provider, in this case, the physician, hospital, laboratory, etc.
• other groups of payors joining the move to managed care are medicaid and Workers' Compensation.

Part 2: Strategies for survival

Access to service

Example: The CDC says the preventive therapy for HIV positive needle sticks needs to be given within hours of the exposure. How will the employees you serve be able to access this preventive therapy after hours? We also need to ensure that follow-up takes place. Access can also affect compliance: staff are working off-site

Quality Issues

In infection control and employee health, quality means prevention. This is where employee health and managed care speak the same language. A big part of prevention involves vaccination of employees in advance of exposure. Some vaccination programs are straightforward, and include hepatitis B, a required program under OSHA, and yearly flu vaccine.

Not as easy are incorporating new vaccines into employee health programs. I believe that varicella vaccine has a role for health care workers who are susceptible to varicella, and hepatitis A vaccine has a more limited application, especially for food service workers.

We need to monitor what we do for quality assurance purposes. Given all the constraints on time and money, we need to FOCUS.

Start with volume indicators that look at numbers of employees who use your service and the reasons they use the service. Which employees are they? Where are they served? In the employee health office? The office of a private physician? The emergency department?

Practice indicators also include rates of compliance with PPD readings, flu vaccine utilization, completion of 3 doses of hepatitis B vaccine.

In the case of our HIV needlestick program, we want to know how many needlesticks were reported, how many were known HIV-positive, how many courses of prophylactic antiviral drugs were given, and how many employees actually coompleted the program of testing, follow up and compliance with medication.

Cost Effectiveness

Know your costs for personnel, drugs, and labs. And, if you have any contractual relationships of any kind, how much do they cost?

There are 2 important questions to ask when assessing cost effectiveness in a managed care environment.

1. Are you paying the best price for pharmacy, laboratory, and contracted services? Nobody pays retail in health care anymore. These components of care are usually discounted, so don't fall into the trap of paying the so-called "list price."
2. How are you being reimbursed for the services that you provide? Remember the various types of reimbursement we talked about earlier.

Then, once you know your costs, you can compare it to your reimbursement to avoid losing money.

Using our example of the needlestick prevention program, the most cost effective way of managing employee needlesticks is to try to prevent them.

However, some employees will have needlestick accidents from a known HIV-positive source, and this needs to be addressed as a part of the program.

Cost areas in such a program:

• Labor
• Laboratory
• Pharmacy
• Overhead

These costs are highly variable, depending on your program, how it is put together, and how the policy is set up.

For example, if you incorporated the new recommendations from CDC for prophlylaxis with 3 drugs rather than AZT alone, has your reimbursement increased accordingly? Also if you buy drugs and dispense them, are you getting the best price for those drugs? Are you buying wholesale or retail? What are your costs for HIV testing? The range of prices for laboratory work can be considerable. Look for other opportunities to market your services to home care organizations, infusion therapy companies, and community agencies for both preventive services and for workers' compensation.

Part 3: Putting the pieces together.

The world of health care delivery and finance is changing. This new world of managed care presents opportunities for employee health programs. In order to survive, we need to change our strategies.

Remember the key words contained in the definition of managed care: access, quality, and cost. They all need to be addressed as a part of the survival plan and as we put the pieces together.