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Cost Control, OSHA Z Tables, Compensation Study - Dec. 1992
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December 31, 1992
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Occupational Health Contacts
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Dear Colleague,
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This communication deals primarily with issues of cost control. Our customers
often are surprised when we recommend against contracting services with
physicians who have on-site rehabilitation facilities. We take a similar
stand regarding physicians who have an interest in diagnostic imaging or
radiation therapy facilities. The American Medical Association has concerns
along the same logic as we.
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Three of the articles from The New England Journal of Medicine and The
Journal of the American Medical Association show why. Whether we are talking
about workers' compensation or health benefits plan costs, unnecessary utilization
is the usual outcome. Unfortunately, these higher costs can be associated
with poorer quality, although only one of these papers deals with that issue.
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More down to earth is an article from The Wall Street Journal on control
of workers' compensation costs. It was written by a hospital administrator,
who is even more businesslike than most managers in his response to this
problem.
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| Of general interest is the article showing that cycles of weight loss
and subsequent return to obesity are risky. For success, obese employees
must commit to a substantial caloric consumption through exercise. Otherwise
we recommend that they be satisfied with the small but permanent reduction
resulting from a healthy low fat diet, i.e., if exercise is rejected, it
is healthier to stay fat. Also included is an article that every health
professional should be aware of. It shows how effective medical therapy
can be in treating early prostatism. Please pass it on to your medical staff. |
| You will recall that last July, the 11th U.S. Circuit Court overturned
OSHA's adoption of the American Council of Governmental Industrial Hygienists
(ACGIH) exposure limits for the lengthy Z table of airborne contaminants.
OSHA is continuing to enforce this standard in spite of the Court's action.
Enclosed find their instructions to field inspectors. Please advise us if
you are cited under the contested standard. |
| Finally, one of our clients participated in a survey of compensation
of occupational health professionals and shared the results with us. It
involved over 140 organizations, many in the Fortune 100. We have summarized
results of the survey. |
| Sincerely, |
| Ruth McElroy, R.N. |
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| Three articles from The New England Journal
of Medicine and The Journal of the American Medical Association |
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| TITLE: Physician Ownership of Physical Therapy Services. Effects on
Charges, Utilization, Profits, and Service Characteristics. |
| AUTHOR: Mitchell JM; Scott E |
| AUTHOR AFFILIATION: Department of Economics, Florida State University,
Tallahassee. |
| SOURCE: JAMA 1992 Oct 21;268(15):2055-9 |
| NLM CIT. ID: 93021563 |
| ABSTRACT: |
| OBJECTIVE--To evaluate the effects of physician ownership of freestanding
physical therapy and rehabilitation facilities on utilization, charges,
profits, and three measures of service characteristics for physical therapy
treatments. |
| DESIGN--Statistical comparison by physician joint ventureownership status
of freestanding physical therapy andcomprehensive rehabilitation facilities
providing physical therapy treatments in Florida. PARTICIPANTS--A total
of 118outpatient physical therapy facilities and 63 outpatientcomprehensive
rehabilitation facilities providing services in Florida during 1989. The
data from the facilities were collected under a legislative mandate. |
| MAIN OUTCOME MEASURES--Visits per patient, average revenue per patient,
percent operating income, percent markup, profits per patient, licensed
therapist time per visit, and licensed and nonlicensed medical worker time
per visit. RESULTS--Visits per patient were 39% to 45% higher in joint venture
facilities. Both gross and net revenue per patient were 30% to 40% higher
in facilities owned by referring physicians. Percent operating income and
percent markup were significantly higher in joint venture physical therapy
and rehabilitation facilities. Licensed physical therapists and licensed
therapist assistants employed in non-joint venture facilities spend about
60% more time per visit treating physical therapy patients than licensed
therapists and licensed therapist assistants working in joint venture facilities.
Joint ventures also generate more of their revenues from patients with well-paying
insurance. |
| CONCLUSION--Our results indicate that utilization, charges per patient,
and profits are higher when physical therapy and rehabilitation facilities
are owned by referring physicians. With respect to service characteristics,
joint venture firms employ proportionately fewer licensed therapists and
licensed therapist assistants to perform physical therapy, so that licensed
professionals employed in joint venture businesses spend significantly less
time per visit treating patients. These results should be of interest to
the medical profession, third-party payers, and policymakers, all of whom
are concerned about the consequences of physician self-referral arrangements. |
| |
| TITLE: Consequences of Physicians' Ownership of Health Care Facilities--Joint
Ventures in Radiation Therapy (see comments) |
| Mitchell JM; Sunshine JH |
| Graduate Public Policy Program, Georgetown University, |
| Washington, DC 20007 |
| N Engl J Med 1992 Nov 19;327(21):1497 |
| N Engl J Med 1992 Nov 19;327(21):1522-4 |
| Physicians are increasingly the owners of health care facilities to which
they refer patients for services but at which they do not practice. We studied
such ownership arrangements, known as "joint ventures," in the
field of radiation therapy, examining their effects on access, use of services,
costs, and quality. |
| METHODS. Because 44 percent of free-standing facilities providing radiation
therapy in Florida in 1989 were joint ventures, as compared with 7 percent
elsewhere (95 percent confidence interval, 3 to 10 percent), we compared
data for Florida with comparable data for the remainder of the United States.
We also compared radiation-therapy facilities in Florida that were established
as joint ventures with those that were not. Since most data were derived
from entire populations rather than from samples, any differences found
were of necessity statistically significant. RESULTS. No joint-venture facilities
providing radiation therapy were located in inner-city neighborhoods or
rural areas, but 11 percent of other free-standing facilities and hospital-based
facilities were located in such areas. Among free-standing facilities, joint
ventures received 39 percent of their revenues from patients with well-paying
insurance coverage, as compared with 31 percent for facilities that were
not joint ventures (P < 0.01). The frequency and costs of radiation-therapy
treatments at free-standing centers were 40 to 60 percent higher in Florida
than in the rest of the United States; there was no below-average use of
radiation therapy at hospitals or higher cancer rates that explained the
higher rates of use or higher costs in Florida. Radiation physicists at
joint-venture facilities (the principal personnel involved in quality control
other than physicians) spent 18 percent less time with each patient over
the course of treatment than did their counterparts at free-standing facilities
that were not joint ventures (P < 0.05). Mortality among patients with
cancer in Florida was not lower than the U.S. average, even though joint
ventures are much more common in that state. |
| CONCLUSIONS. Joint ventures in radiation therapy appear to have adverse
effects on patients' access to care. They also appear to increase the use
of services and costs substantially. Some indicators show that joint ventures
cause either no improvement in quality or a decline. Our results add to
the evidence indicating that physicians' self-referral generally has negative
consequences. We recommend legislation to ban ownership of joint ventures
by referring physicians. Such legislation needs to be carefully designed
in order to achieve its objectives and forestall new, financially abusive
arrangements. |
| |
| TITLE: Physicians' Utilization and Charges for Outpatient Diagnostic
Imaging in a Medicare Population [see comments] |
| AUTHOR: Hillman BJ; Olson GT; Griffith PE; Sunshine JH; Joseph CA; Kennedy
SD; Nelson WR; Bernhardt LB |
| AUTHOR AFFILIATION: Department of Radiology, University of Virginia School
of Medicine, Charlottesville. |
| SOURCE: JAMA 1992 Oct 21;268(15):2050-4 |
| NLM CIT. ID: 93021562 |
| COMMENT: JAMA 1993 Apr 7;269(13):1633; discussion 1634~ JAMA 1993 Apr
7;269(13):1633-4 |
| ABSTRACT: |
| OBJECTIVES AND RATIONALE--For 10 common clinical presentations, we assessed
differences in physicians' utilization of and charges for diagnostic imaging,
depending on whether they performed imaging examinations in their offices
(self-referral) or referred their patients to radiologists (radiologist-referral). |
| METHODS--Using previously developed methodologies, we generated episodes
of medical care from an insurance claims database. Within each episode,
we determined whether diagnostic imaging had been performed, and if so,
whether by a self-referring physician or a radiologist. For each of the
10 clinical presentations, we compared the mean imaging frequency, mean
imaging charges per episode of care, and mean imaging charges for diagnostic
imaging attributable to self- and radiologist-referral. |
| RESULTS--Depending on the clinical presentation, self-referral resulted
in 1.7 to 7.7 times more frequent performance of imaging examinations than
radiologist-referral (P < .01, all presentations). Within all physician
specialties, self-referral uniformly led to significantly greater utilization
of diagnostic imaging than radiologist-referral. Mean imaging charges per
episode of medical care (calculated as the product of the frequency of utilization
and mean imaging charges) were 1.6 to 6.2 times greater for self-referral
than for radiologist-referral (P < .01, all presentations). When imaging
examinations were performed--including those performed in both physicians'
offices and hospital outpatient departments--mean imaging charges were significantly
greater for radiologists than for self-referring physicians in seven of
the clinical presentations (P < .01). This result is related to the high
technical charges of hospital outpatient departments; in office practice,
radiologists' mean charges for imaging examinations were significantly less
than those of self-referring physicians for seven clinical presentations
(P < .01). |
| CONCLUSIONS--Nonradiologist physicians who operate diagnostic imaging
equipment in their offices perform imaging examinations more frequently,
resulting in higher imaging charges per episode of medical care. These results
extend our previous research on this subject by their focus on a broader
range of clinical presentations; a mostly elderly, retired population; and
the inclusion of higher-technology imaging examinations. |
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| General Interest |
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| TITLE: Change in Body Weight and Longevity [see comments] |
| AUTHOR: Lee IM; Paffenbarger RS Jr |
| AUTHOR AFFILIATION: Department of Epidemiology, Harvard University School
of Public Health, Boston, Mass 02115. |
| SOURCE: JAMA 1992 Oct 21;268(15):2045-9 |
| NLM CIT. ID: 93021561 |
| COMMENT: JAMA 1993 Mar 3;269(9):1116 |
| ABSTRACT: |
| OBJECTIVE--To investigate the effect of body weight change on longevity.
DESIGN--Cohort analytic study, following men from 1977 through 1988. |
| SETTING--The study was conducted among Harvard University alumni with
mean age of 58 years. |
| PATIENTS--Alumni, free of cardiovascular disease and cancer, completed
questionnaires on weight, height, cigarette habit, and physical activities
in 1962 or 1966 and in 1977 (n = 11,703). We assessed weight change between
questionnaires, based on self-reported weights. MAIN |
| OUTCOME MEASURE--Mortality from all causes (n = 1441), coronary heart
disease (n = 345), and cancer (n = 459), determined from death certificates. |
| RESULTS--Lowest all-cause mortality was among alumni maintaining stable
weight (+/- 1 kg).With this category as referent (relative risk = 1.00),
relative risks of death associated with losing more than 5 kg, losing between
1 and 5 kg, (more than 1 kg and up to 5 kg) gaining between 1 and 5 kg (more
than 1 kg and up to 5 kg), and gaining more than 5 kg were 1.57 (95% confidence
interval, 1.34 to 1.84), 1.26 (1.10 to 1.46), 1.06 (0.90 to 1.24), and 1.36
(1.11 to 1.66), respectively. For coronary heart disease mortality, relative
risks were 1.75 (1.26 to 2.43), 1.43 (1.05 to 1.93), 1.28 (0.91 to 1.80),
and 2.01 (1.36 to 2.97), respectively. Weight change did not predict cancer
mortality. Findings were not explained by cigarette habit, physical activity,
or body mass index. We observed similar trends for follow-up between 1977
and 1982 and between 1983 and 1988. Those losing or gaining more weight
also reported greater total lifetime weight loss, which may indicate weight
cycling. |
| CONCLUSIONS--Both body weight loss and weight gain are associated with
significantly increased mortality from all causes and from coronary heart
disease but not from cancer. |
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| JOURNAL ARTICLE |
| LANGUAGE: Eng |
| TITLE: The Effect of Finasteride in Men with Benign Prostatichyperplasia.
The Finasteride Study Group [see comments] |
| AUTHOR: Gormley GJ; Stoner E; Bruskewitz RC; Imperato-McGinley J; Walsh
PC; McConnell JD; Andriole GL; Geller J; Bracken BR; Tenover JS; et al |
| AUTHOR AFFILIATION: Merck Research Laboratories, Rahway, NJ 07065. |
| SOURCE: N Engl J Med 1992 Oct 22;327(17):1185-91 NLM CIT. ID: 93024703 |
| COMMENT: N Engl J Med 1992 Oct 22;327(17):1234-6~ N Engl J Med 1993 Feb11;328(6):442-3~
N Engl J Med 1993 Feb 11;328(6):443 |
| ABSTRACT: |
| BACKGROUND. Benign prostatic hyperplasia is a progressive, androgen-dependent
disease resulting in enlargement of the prostate gland and urinary obstruction.
Preventing the conversion of testosterone to its tissue-active form, dihydrotestosterone,
by inhibiting the enzyme 5 alpha-reductase could decrease the action of
androgens in their target tissues; in the prostate the result might be a
decrease in prostatic hyperplasia and therefore in symptoms of urinary obstruction. |
| METHODS. In a double-blind study, we evaluated the effect of two doses
of finasteride (1 mg and 5 mg) and placebo, each given once daily for 12
months, in 895 men with prostatic hyperplasia. Urinary symptoms, urinary
flow, prostatic volume, and serum concentrations of dihydrotestosterone
and prostate-specific antigen were determined periodically during the treatment
period. RESULTS. As compared with the men in the placebo group, the men
treated with 5 mg of finasteride per day had a significant decrease in total
urinary-symptom scores (P less than 0.001), an increase of 1.6 ml per second
(22 percent, P less than 0.001) in the maximal urinary-flow rate, and a
19 percent decrease in prostatic volume (P less than 0.001). The men treated
with 1 mg of finasteride per day did not have a significant decrease in
total urinary-symptom scores, but had an increase of 1.4 ml per second (23
percent) in the maximal urinary-flow rate, and an 18 percent decrease in
prostatic volume. The men given placebo had no changes in total urinary-symptom
scores, an increase of 0.2 ml per second (8 percent) in the maximal urinary-flow
rate, and a 3 percent decrease in prostatic volume. The frequency of adverse
effects in the three groups was similar, except for a higher incidence of
decreased libido, impotence, and ejaculatory disorders in the finasteride-treated
groups. |
| CONCLUSIONS. The treatment of benign prostatic hyperplasia with 5 mg
of finasteride per day results in a significant decrease in symptoms of
obstruction, an increase in urinary flow, and a decrease in prostatic volume,
but at a slightly increased risk of sexual dysfunction. |
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| October 29,1992 |
| MEMORANDUM FOR: REGIONAL ADMINISTRATORS |
| FROM: ROGER A. CLARK, DIRECTOR |
| DIRECTORATE OF COMPLIANCE PROGRAMS |
| SUBJECT: Recent Court Decision and Enforcement of1910.000 |
| The Eleventh Circuit Court of Appeals denied the Department of Labor's
request for a rehearing concerning the court's decision that OSHA's standards
for 428 toxic substances, 29 CFR 1910.000 were invalid. |
| The Solicitor of Labor will file a motion for a 30-day delay in issuing
the mandat of the court's July 7, 1992 decision. This delay will enable
the Department to review its options and respond accordingly. |
| In the interim, and until a mandate is issued, the standard remains in
effect, and OSHA enforcement of the standard is to continue. |
| We request the state designees be notified accordingly. |
| cc: Directorate Heads |
| Ann Rosenthal |
| State Designees |
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| Median Total Compensation of Occupational Health
Professionals |
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Median Total Compensation of Occupational Health Professionals
(All figures in dollars)
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| CATEGORY |
LOWEST |
MEDIAN |
HIGH |
| Entry Nurse |
26,000 |
32,800 |
42,300 |
| Experienced Nurse |
28,600 |
37,200 |
52,000 |
| Supervisory Nurse |
28,000 |
40,500 |
60,700 |
| Plant Physician |
81,000 |
101,700 |
114,300 |
| Corporate Medical Director (Physician) |
100,000 |
144,900 |
262,000 |
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| * Compensation for nurses reports base salary. If included in profit
sharing or bonus eligible, figures were higher. Physicians' compensation
include bonus. Department of Labor Occupational Safety and Health Administration
Washington, D.C. 20210
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