Contributions of Medical Surveillance

Preventing occupationally derived medical disorders saves on health insurance costs, benefiting employees and employers who share the burden of costly premiums.

AMID concern for profit and production, employee health is often overlooked in the occupational setting. One method of maintaining worker health is through the implementation of work site medical surveillance, which is the endeavor to ensure continued medical fitness of a worker through periodic examination and diagnostic processes. Several recent accounts of negligence in medical surveillance are offered.

On-site services usually are driven by workforce population size and become an affordable option for businesses employing 200 or more employees.

In 2001, OSHA cited an Alabama coke plant for lack of proper surveillance for exposure to coke oven emissions and benzene (Martin, 2001). In 2000, a fuel company in Rochester, N.Y., was cited in part for neglect in administering medical evaluations to employees to assess asbestos exposure, resulting in $126,000 in fines ("Asbestos Violations," 2000). In 2000, failure to administer both audiometric testing for noise exposure and evaluations for respirator user fitness, along with other actions, resulted in penalties of $127,620 for a fabricated aluminum goods manufacturer in Hamden, Conn. ("Health Violations," 2000). After receiving prior warning, a metal reclamation company in New Jersey in 2001 continued to allow employees to be exposed to lead and other metals without implementing proper medical surveillance controls; OSHA penalized the company with $102,000 in fines (Foran, 2001). And in a substantial action in 2001, OSHA cited a carbon steel pipe manufacturer in Baytown, Texas, for failing to properly record occupationally related illnesses and injuries. The result was a proposed $536,000 fine (Sutcliffe, 2001).

Although business may suffer from OSHA's method of persuasion of "taxing" for such negligent acts, what is more devastating is the resulting occurrence of acute and chronic illnesses that the affected workers must endure. Estimates from the early 1990s reveal occupationally related deaths totaled 66,800 in one year alone, with 90.3 percent of those attributed to occupational disease (Herbert, 2000). Ironically, current industry data suggests that not only is proper occupational medical surveillance the legally and morally correct action, but the result can be big savings for today's businesses.

The application of medical monitoring and surveillance is divided roughly into two different categories: compulsory and voluntary. In the compulsory domain, OSHA has mandated that medical surveillance shall be administered for some chemical-specific and situational standards. At least 17 chemicals or categories of chemicals regulated by OSHA require surveillance in different forms that collectively include patient histories, physical examination, chest X-ray, pulmonary testing, and blood or urine analysis. Most of these standards require activation of medical surveillance upon exposure to half of the Permissible Exposure Limit (PEL) at least 30 days a year. OSHA also requires surveillance when workers are exposed to high noise, will work in compressed air environments, are engaged in hazardous waste operations and emergency response, have need to wear a respirator, or have the potential for exposure to bloodborne pathogens. Each of these standards has its own requirements for specific forms of testing and evaluation (OSHA, 2000). In addition, requirements from other regulatory agencies may come into play, such as the U.S. Department of Transportation's requirement for periodic examinations to certify hazardous material transporters.

OSHA once proposed the development of a standard for general medical surveillance in the 1988 and went as far as to survey more than 7,000 businesses across the nation in an attempt to define the scope and success of such practices ("Survey," 1993). Available literature does not explain why such an effort never materialized, but typically failures by OSHA to implement policy are the result of complaints from industry of the high cost of compliance. Regardless of lack of a specific set of rules to cite against industry when medical surveillance failures result in worker illness, OSHA always has the option to use the General Duty Clause. This can happen, for example, when an entity had knowledge of the availability of an affordable surveillance technology that could have protected a worker, yet failed to employ it because it was not specifically mandated in an OSHA regulation.

Voluntary Medical Surveillance
Voluntary medical surveillance strategies allow the practitioner to employ numerous test and evaluation methods to ensure worker protection from chemicals and other hazards and scenarios. Criteria available from occupational medicine, industrial hygiene, government, and industry resources are used to evaluate the potential for chemical exposures not otherwise regulated by OSHA, the use of regulated substances, fitness-for-duty examinations, or physical ability to operate safety-sensitive equipment, for example.
Additionally, non-occupational health disorders are many times identified through voluntary surveillance, resulting in either limited treatment from the occupational practitioner upon identification of the condition or referral of the employee to his primary care physician or a specialist for advanced treatment. As expressed by Dr. Mitchell R. Zavon, occupational health surveillance in all forms should ultimately be utilized to "avoid an adverse effect on the worker of any physical or chemical exposure in the workplace and to detect as early as possible any non-work related health problems" (Patty's, 2000).

Voluntary surveillance strategies, like their compulsory counterparts, may employ techniques such as reviewing patient work histories, general physical examinations, serum chemistry panels, urinalysis, radiological exams, and pulmonary function testing to detect occupationally related disorders. Criteria for judging the employee fit, however, may be left somewhat to the discretion of the practitioner or compared to non-compulsory references. Of great importance is the work history, which should be structured to induce the subject to reveal as much information about prior occupational exposures as possible (Patty's, 2000). The practitioner will be made aware of not only the potential for disease development stemming from previous work assignments, but also any non-occupationally related factors that could make the worker hypersusceptible to exposures in new work assignments (for example, a history of smoking coupled with asbestos abatement activities).

Stages of surveillance typically are administered at pre-placement, pre-assignment, periodic, and termination intervals (Patty's, 2000). Other opportunities for surveillance may be offered after qualifying events, such as after a spill or accident ("Survey," 1993). Surveillance events at a particular site may differ not so much in the regimen of tests or exams given, but only in the time in an employee's career at which they are administered. All of these surveillance events have the commonality of creating a reference point on which future surveillance results can be compared. The first of these becomes the baseline; any effect from occupational exposures
contributing by work occurring after this point might be identified in the baseline comparison (Polton, 1997).

Benefits Gained
Benefits gained by the worker from business investments in medical screening and surveillance are not absolutely obvious and deserve some commentary. Foremost is the identification of occupational and non-occupational disease directly affecting the individual. A modest study lead by Dr. Phillip Harber of UCLA suggests nearly half of patient respondents associated their medical disorders with their jobs (Smith, 2001). Early-stage disease identified through medical surveillance allows intervention through proper treatment to lessen the overall effect on the employee.

Should disease progress to the point that a worker is physically unable to work in normal fashion, financial impacts can be devastating. A disabled employee can expect to earn an average of only 54 percent of his normal income. Numerous hindrances can then result, such as use of family savings to compensate from missing income, loss of assets, exclusion from future health benefits, disruption of lifestyle, increased stress, and the onset of mental afflictions (Lutz, 2002). Employees have a vested interest in their own welfare and can be seriously compromised when work-related effects on their health are overlooked.

In many workplaces, employees and employers share the burden of costly health insurance premiums. Preventing occupationally derived medical disorders through medical monitoring or early detection can result in health insurance cost savings in situations that result in non-utilization of insurance benefits. Collective reduced utilization for one year, in turn, will be tracked by insurance providers and lead to contract offers with lower premiums in succeeding years. This concept was echoed in an OSHA survey where businesses reported insurance costs were one of the top three perceived positive changes realized by the establishment of medical surveillance ("Effects," 1993). Reduced cost for the employer's share of premiums also could lead to increased pay or additional employee benefit programs with redirected capital. An additional benefit is realized for locations that provide on-site services with limited treatment; again, the case arises where the employee may not have to utilize insurance for general health care services.

Two types of examinations have the characteristic of protecting employees from actions of co-workers: drug screening and fitness-for-duty examinations for safety-sensitive positions. Pre-employment and random employee drug testing are becoming the norm, especially in light of the current methamphetamine epidemic. The cost advantages for employers are numerous. For the worker, testing for substance abuse "makes the workplace a safer place" and "reduces the workload that drug abusers shift onto peers and subordinates" (Elkin, 1999). Safety-sensitive positions, including crane and forklift operations, require not only a skilled employee, but also one who has full control over his faculties while conducting the work. The impacts of allowing unfit individuals to operate equipment that positions heavy loads can be both financial and deadly to surrounding individuals, including some uninvolved in the work. For more than 20 years, OSHA has recommended that crane operators meet certain criteria for vision, hearing, and low risk for epilepsy or heart conditions. These criteria have been extended to crawler, locomotive, truck and derrick operations (OSHA, 1978).

Medical surveillance yields educational benefits and invites an employee to become actively involved in his well-being. Industrial hygienists and occupational health practitioners work in concert to protect workers, providing crucial feedback to one another that may uncover new exposure opportunities. However, if industrial hygiene assessments were the only risk management control in place, there would be an opportunity in large employer settings for one-to-one communication when employees are managed as potential exposure groups. By individually connecting with the occupational health practitioner, workers have opportunity to voice their concerns and allow the practitioner to delve deeper into employees' work practices via direct communication. According to Zavon, "every contact with the health establishment provides an opportunity for education of the worker, education can create a healthy awareness of risk without creating unnecessary fears" (Patty's, 2000). Through these vital communications, a partnership is invoked between the employee and risk management services. The worker may then feel as through he has direct responsibility for his own welfare (Magyar, 1999).

Medical surveillance can result in employees' feeling confident the employer is interested in their welfare. During the survey of businesses for medical surveillance practices, the number one perceived positive change affected employee relations. Correspondingly, during the "phase II" portion of the survey, 42 percent of respondents said medical surveillance in the workplace resulted in "healthier and happier employees" ("Effects," 1993).

How Employers Use Surveillance Data
In a world of heightened business competition, employers must take care to protect the profits that are displaced by $170.9 billion spent in combating occupational injuries and illnesses (Lutz, 2002). Business losses take the form of lost work days, increased insurance rates, worker's compensation payouts, employee turnaround, re-training, and sick-leave use. Companies are further distracted from their profit goals with poor public perception, poor employee morale, increased efforts in attracting good workers, and workforce fears of additional injuries (Lutz, 2002).

The OSHA survey data agree with this premise. A summary of the data affirms that employers practicing workplace medical surveillance recognize the benefits of "reduced costs, early detection of medical problems, increased productivity, and reduced injury or illness rate" ("Effects," 1993). Some of the data suggest businesses may need to re-focus objectives in evaluating surveillance data. Respondents said they used the results primarily for evaluating changes in work practices, changes in administrative controls, changes in training programs, and changes in personal protective equipment. Least emphasized was the evaluation of engineering controls, at less than 25 percent ("Purposes," 1993). At best, this could indicate that businesses felt their engineering controls could not be improved upon. More likely--and to the disadvantage of the worker--was they instead chose to make adjustments through other, less effective controls because of the expense incurred with engineered solutions.

Once an establishment decides to implement medical surveillance services, different strategies can be applied to maximize savings. Traditional industrial hygiene practice allows for the findings of exposure assessments of a small section of the working population to be applied to the entire working group, assuming the population as a whole is homogenous in work type, practices, and associated risk. Medical surveillance is closely associated with industrial hygiene practice and, in fact, complements the exposure assessment picture. Hygienists assess the workplace for health risks and communicate with the medical practitioner to indicate what conditions may arise based on the worker's potential for exposure. The practitioner, in turn, will recall the employee for a surveillance event and communicate to the hygienist that either controls in the workplace must be effective because of lack of disease or that, upon finding disease, controls must be improved (Polton, 1997). The findings from voluntary surveillance on a few randomly selected subjects can be applied to a larger, representative work group without necessarily having to recall all individuals in the population for medical assessment.

A review of improved medical surveillance practices for a multi-site hazardous waste operations company indicates that the application of organized policy to a medical surveillance program can yield cost savings and refined quality. Previously, the company casually hired local physicians near field offices to conduct surveillance. Non-conformity in surveillance procedures and physician qualification was rampant throughout the program, with additional flaws noted in recordkeeping, inconsistent patient history forms, and selection of laboratories with inadequate quality assurance practices. Review of hazard assessment data from hygiene surveys also revealed overestimation of need for some personal protection controls, which also affected exam costs because respirator users require medical clearance before use. Enhancements were made through selecting a medical oversight provider to clean up deficiencies in the program. Results of those improvements meant a 7 percent reduction in average exam cost per employee and a 12 percent reduction in examinations with added data and evaluation quality (Fedoruk, "Model").

Provision of on-site medical surveillance services has the potential for contributing more savings. On-site services usually are driven by workforce population size and become an affordable option for businesses employing 200 or more employees. When contracting out these services, businesses will take on the added expenses of "lost productivity because of downtime, the cost to put another employee in place while the worker goes to a doctor's office and higher costs to provide a profit margin for private-practice medical professionals" (Nighswonger, 2001). Time was determined to be an essential key. In one study, total time including travel and waiting was compared for on-site versus off-site contracted service. On-site services averaged 15 minutes compared to almost two hours for off-site. Final tallies in this study exposed a savings between $30,000 and $50,000 when on-site services were used. Other benefits offered include more control over confidentiality and better familiarization with hazards with on-site providers (Nighswonger, 2001).

Cost Savings
OSHA and other regulatory authorities are making allowances for some technicians and professionals to provide limited medical surveillance services. Businesses may take financial advantage of this factor by staffing technicians and other medical professionals rather than hiring full-fledged physicians. The Council for Accreditation in Occupational Hearing Conservation accredits technicians who "conduct the practice of hearing conservation including pure-tone air-conduction hearing testing and associated duties" (CAOHC, 2003). Use of these audiometric technicians can provide substantial cost avoidance for collective industry because OSHA has verified through its industry-wide medical surveillance survey that the most administered type of periodic examination was audiometry. OSHA's latest respiratory protection standard allows for a physician or other licensed health care professional to administer fitness for respirator use examinations; this opened the door for professionals such as registered nurses to head up these efforts. Had the ergonomics standard been enacted, non-physician occupational health professionals may have been allowed to conduct musculoskeletal exams (Sandler, 1998).

Supervision is implied with most of these methods, but for physicians who are trying to obtain competitive advantage, the opportunity to provide these services either out of their office or on the work site through special arrangements with industry is attractive. By using technicians and other professionals, services can be competitively priced because the physician's time is limited to record review and periodic observation. The employer must take care in observing state regulations, which may be more restrictive, and ensure that cost is not the only factor considered.

A study issued in the Journal of Occupational and Environmental Medicine identified a link between proactive communication between patients and physicians and the speed of recovery from disabling injuries. The study reported that "patients who received such advice early on were about 60 percent more likely to return to work within the first month after an injury and less likely to go on disability for a prolonged period" ("Communication," 2001). Although this revelation is not directed specifically toward typical occupational surveillance as discussed here, it does re-affirm the notion that having professionals who consider and respect psychosocial aspects of occupational medicine adds value to this risk management approach.

Medical surveillance practices in industry present a rare win-win situation where both employees and employers reap the rewards. Workers are afforded a fundamental level of protection in their work, while employers stand to save money when surveillance is properly implemented. Although conventionally thought of as only a necessary evil meant to satisfy federal mandates or insurance directives, data continually surfaces to define medical surveillance as vital key for worker protection that can be exploited for added business incentives.

References
1. Author unknown. August 2001. "Doctor-Patient Communication Reduces Leave Time." Occupational Hazards.
2. CAOHC. 1 December 2003. "CAOHC Certified Occupational Hearing Conservationist Scope of Practice and Limitations." Available at: http://www.caohc.org/scopeofpractice.html. Accessed 14 May 2004.
3. Conway, Hugh, Jennifer Simmons, and Terry Talbert. July 1993. "Effects of Occupational Surveillance Programs as Perceived by Respondents to the Occupational Safety and Health Administration’s 1990-1991 Survey." Journal of Occupational Medicine.
4. Conway, Hugh, Jennifer Simmons, and Terry Talbert. July 1993. "The Occupational Safety and Health Administration’s 1990-1991 Survey of Occupational Medicine Surveillance Prevalence and Type of Current Practices." Journal of Occupational Medicine.
5. Conway, Hugh, Jennifer Simmons, and Terry Talbert. July 1993. "The Purposes of Occupational Surveillance in US Industry and Related Health Findings." Journal of Occupational Medicine.
6. Elkin, Samuel. March 1999. "How to Establish a Drug-free Workplace Program." Occupational Hazards.
7. Fedoruk, Marion J., Peter P. Greaney, and Phil L. Jones. "A Model Medical Surveillance Program for Persons in Hazardous Waste Operations." Briefed at the NORA Surveillance Research Methods Team/DSHEFS Workshop on November 7-9, 2001, entitled "Best Practices in Workplace Surveillance." Available at: www.cdc.gov/niosh/sbw/management/pdfs/jones.pdf. Accessed 15 April 2004.
8. Foran, Virginia. 27 August 2001. "Company Fails to Protect Employees from Lead Exposure." Occupational Hazards.
9. Herbert, Robin and Philip Landrigan. April 2000. "Work-Related Death: A Continuing Epidemic." American Journal of Public Health. Vol. 90, No. 4. Pp. 541-545.
10. Lutz, Monte. Fall 2002. "Safety and Health Add Value to Your Business, to Your Workplace, to Your Life." Job Safety and Health Quarterly.
11. Magyar, Jr. Stephen V. September 1999. "Occupational Health Management: Does Your Program Measure Up?" Professional Safety.
12. Martin, Melissa. 5 June 2001. "OSHA Cites Coke Oven Plant for Serious Health and Safety Violations." Occupational Hazards.
13. Nighswonger, Todd. April 2001. "Do Onsite Health Services Pay Off?" Occupational Hazards.
14. Occupational Safety and Health Administration. 31 August 1978. Physical Qualification Requirements for Crane Operators. Standard interpretation letter.
15. Occupational Safety and Health Administration. 2000. Screening and Surveillance: A Guide to the OSHA Standards.
16. Polton, Thomas D. 1997. Chapter 46: Collaborating with the Occupational Physician. "The Occupational Environment--Its Evaluation and Control." AIHA Press. Fairfax, Va.
17. Sandler, Howard M. April 1998. "Move Over, Physician: OSHA's New Approach to Evaluations." Occupational Hazards.
18. Smith, Sandy. 3 December 2001. "Study: Patients Blame Work for the Majority of Their Ills." Occupational Hazards.
19. Sutcliffe, Virginia. 3 May 2000. "OSHA Turns Up Heat on Contractor for Asbestos Violations." Occupational Hazards.
20. Sutcliffe, Virginia. 10 November 2000. "Conn. Employer Cited for Numerous Safety, Health Violations." Occupational Hazards.
21. Sutcliffe, Virginia. 23 January 2001. "Texas Pipe Manufacturer Cited for Recordkeeping Violations." Occupational Hazards.
22. Zavon, Mitchell R. 2000. "Patty's Industrial Hygiene, Fifth Edition." Chapter 47: Health Surveillance Programs in Industry.

This article originally appeared in the May 2007 issue of Occupational Health & Safety.

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