Private healthcare companies are developing consultancy services to ensure cost-effective solutions to workplace health issues. Through these consultancies, experts can support employers in deciding how to get the best value for money out of their investment in occupational health. Nic Paton reports.
The creation of a robust evidence base to support the effectiveness of occupational health interventions has been at the heart of much of the debate about the reform and improvement of workplace health provision for many years now, and certainly since the Dame Carol Black reforms of 2008.
A corollary to this, in the continuing tough economic climate, is the understandable demand from employers to make sure their healthcare spend is appropriate, that interventions or treatments are actually necessary and that they are getting both value for money and a return on investment from their provider.
Indeed, the transparency of the private healthcare market when it comes to pricing, quality of care and the evidence base of its interventions is one issue at the heart of the Competition Commission's investigation into said market (see box 2), which was announced back in April and is expected to report in April 2014.
One of the long-term issues around private healthcare is that it is structured on the basis of a "fee for service" model, meaning that, in essence, the more you do as, say, a private surgeon, the more you get paid for, explains Dr Natalie-Jane Macdonald, managing director of Bupa Health & Wellbeing. This, in turn, can lead to a tendency - or at the very least the temptation - for there to be higher rates of intervention than may be necessary or "over-treatment", something also cited recently in the BMJ as a growing issue (see box 1 below).
Box 1: Problems with overdiagnosis
An Australian doctor has argued that unnecessary overdiagnosis poses "a significant threat" to human health.
Ray Moynihan, senior research fellow at Bond University in Queensland argued in the BMJ recently that overdiagnosis posed a significant threat to human health "by labelling healthy people as sick and wasting resources on unnecessary care".
An international conference on the issue is due to be held in the US in September next year.
The BMJ highlighted the example of a large Canadian study that found that almost one-third of people diagnosed with asthma may not in fact have the condition, while a systematic review of breast screening had suggested one in three detected breast cancers may be overdiagnosed. It also stated: "Some researchers argue osteoporosis treatments may do more harm than good for women at very low risk of future fracture." Resources wasted on unnecessary care can be much better spent treating and preventing genuine illness rather than "pseudo-disease".
"Increasingly we've come to regard simply being 'at risk' of future disease as being a disease in its own right," said Moynihan.
Moynihan R et al, Preventing overdiagnosis, BMJ, 2012.
To this end, Bupa and other private healthcare providers have been working to respond to this growing demand from employers for a more proactive and questioning approach to intervention and treatment.
In May last year, for example, Bupa announced that it was reviewing the way it dealt with knee arthroscopies, as "some surgeons are three times more likely to perform a knee arthroscopy on Bupa customers than others", including introducing a new medical review process to confirm eligibility for funding.
In January of this year, Bupa introduced a new "open referral" system, whereby GPs no longer need to specify a named consultant, with clients offered a choice from a Bupa-approved network.
Similarly, three years ago, Aviva launched a concept called "back-up", a rehabilitation service centred on managing back and neck pain but without the need to refer to a GP first.
Another key strand of activity is the development of in-house health and well-being "consultancy" services, essentially brokering services designed to work and have proper dialogue with employers to ensure they are purchasing the best, most appropriate, services for their workforce and that health and wellbeing is being delivered in a "joined-up" fashion.
In 2011, Bupa Consultancy was launched, which is designed to bring together the provider's experience and knowledge around healthcare, insurance and risk, explains Macdonald. "What the consultancy can do is work with an employer to understand what it is they are trying to achieve, what is really important to them as a business, what part it wants to play in employee health and wellbeing, and what part it wants its employees to play," she says.
Bupa is by no means the only private healthcare provider going down this route. AXA PPP, Aviva and Capita all now have consultancy models in place.
So how can such consultancies change how employers purchase and perceive health and wellbeing? And, just as importantly, what sort of role can occupational health professionals play in this evolving process?
"Organisations are, of course, all very different and will have different pressures, strategies and employee value propositions, one of which is health and wellbeing. But often in an organisation that is not linked together," says Macdonald.
"Sometimes organisations waste money by providing services in a way that is not connected. So it is about creating better integration of health and wellbeing.
"Often firms, of course, want to do the right thing but do not know how to do it. Organisations can do a lot of good things but still see the improvements in productivity they could be achieving not being reached. There can also be issues around often relatively undetected health risks, such as diabetes or mental health, cardiac disease or back pain. Cardiac disease, for example, has high morbidity but is difficult to detect.
"At a practical level, therefore, the consultancy is about reviewing the services an employer has or does not have and developing a clear, informed picture of their healthcare needs. Then, the consultancy can also work to take the data an organisation has gathered and link that to what services it provides and interrogate it to provide the right combination of services.
"It is about helping organisations spend more wisely, develop a more sustainable health and wellbeing strategy and get a proper return on their investment."
Consultancy at Aviva
Aviva's Health and Risk Consultancy was launched 18 months ago.
"Occupational health is a specialist area but the reasons why employers choose it range from compliance and health and safety issues through to executive and medical screening, lifestyle, wellbeing and coaching. So there is a huge variation," says Dr Doug Wright, medical director, UK Health at Aviva.
At a practical level, therefore, the consultancy is about reviewing the services an employer has or does not have and developing a clear, informed picture of their healthcare needs."
Dr Natalie-Jane Macdonald,
Bupa Health & Wellbeing
"So if an employer is going to talk about occupational health, what it needs to be doing first is asking: 'what do I need it for?' Is it compliance and health and safety, which will probably be a more transactional service, or is the priority more the general health and wellbeing of the workforce and getting the best out of the business, which may be an area where more guidance and more of a consultancy approach can work well?" he adds.
The consultancy, says Wright, is "about managing health, but it also about managing the risk to the employee in terms of future cover or future absence".
He adds: "It is about developing an understanding of your business, what your workforce is like, what you currently have in place and what you know about your customers. It is about connecting it to the business objectives."
Within this there is, inevitably, a lot of use of analytics and data mining to ensure organisations begin to put better reporting mechanisms in place.
Consultancy at AXA PPP
AXA PPP healthcare launched a health consulting team in April last year, again in response to growing demand from employers, says director Elliott Hurst.
"It is about partnering, aggregating data and putting in more analytics and algorithms. There is more of a demand for extracting things of value from data and taking a much broader perspective than simply a single product or line," he adds.
"So it is about looking to support the employer to engage with the employee in the health equation, draw together data and emerge from siloed delivery lines to put in place better tactics to develop an overall strategy to help employers move to a better place.
"Rather than a siloed transactional approach to reporting, it is much more joined-up and coordinated. Employers are also then able to look at what they are doing and see much better the value they are getting from their investment in their programmes."
Meeting employer needs
Of course, one of the issues with this may be that the employer simply does not want to listen to the "medicine" it needs or what will be best for the organisation. As Dr Mike O'Donnell, chief medical officer at Atos, explains, the first challenge is often to get beyond seeing the tendering process as simply being an "offer us what we're asking for" conversation.
He cites the example of a contract that the company had with one big employer, where, when it came around to being re-tendered, Atos lost out because its bid became "non-compliant" after arguing that various changes and improvements could be made.
"But a few months later they came back saying 'sorry, can we talk about that non-compliant bid?' Now the particular organisation has a sickness absence rate to die for," he says.
A consultancy element is also a key part of Capita's wider occupational health, medical screening and related services.
OH has an important role to play, especially when it comes to ensuring managers take more 'ownership' of health and wellbeing within their organisation."
"The strategy will inform what employers want to achieve," says Jason Powell, managing director for Capita's health and wellbeing business.
"Is it risk mitigation, improved productivity, reduced turnover, employee engagement, or is it more than one or all of these? Once we know what the objectives are, then we can work with employers to provide a bespoke service that allows employees access to relevant services in a number of ways - from home visits and clinic settings to the use of web-based interventions."
The role of occupational health
So, where can, or should, occupational health sit within this whole debate? Certainly, it is clear OH has an important role to play, especially when it comes to ensuring managers take more "ownership" of health and wellbeing within their organisation. "It is important that OH does not simply take over the role," explains O'Donnell.
Bupa's Macdonald agrees that occupational health practitioners have a vital facilitating position and opportunity: "Occupational health is very important to this process. OH sits in the heart of it; it is where the rubber hits the road."
"OH is a sophisticated area of health. The OH nurse and physician are always trying to match the needs of the individual to those of the organisation and, moreover, will have a close working relationship with line managers, HR and health professionals, so they can play a critical role when it comes to interpreting how things can best come together," she adds.
"OH practitioners have a key role to play in this," adds Aviva's Wright.
"They are one of the few players who can blend together the view of the employer and the health and wellbeing side, so they can play a central, coordinating role. It is those organisations that have strong connections with their occupational health provider that tend to be making the inroads in this."
Capita's Powell says: "We see a core role for occupational health nurses in the future, both in terms of specific interventions and in terms of a broader brokering and educational role, developing and promulgating healthy workplace initiatives."
Powell's view is far from the more traditional reactive OH role, and one that is shared by AXA PPP's Hurst: "Occupational health, in many instances, has been used by employers in a fairly reactive manner. But that is often not necessarily the best way to be using occupational health."
"OH nurses, in my experience, have on occasion been frustrated by the fact that the service they can provide is often rather reactive. So it is about trying to get to a point where things are linked together to provide far more focused, work-centric and timely solutions.
"Employers are becoming more demanding in terms of product and service provider, whether that is the OH provider or the medical insurer. So it is about taking it to the next level and being able to demonstrate added value.
"You need to be auditing and understanding where the gaps exist and how to close those gaps, and then get underneath that. It is about putting a picture around it and benchmarking against other employers," he adds.
Box 2: investigation into the private healthcare market
The Competition Commission's investigation into the private healthcare market will be focused on "any features of this market which prevent, restrict or distort competition", the commission has said.
The submissions were made to the investigation in May and the commission says it is required to report by 3 April 2014, "although it will aim to complete the investigation in a shorter period".
The investigation was prompted by a referral to the commission by the Office of Fair Trading (OFT) following its own investigation into the market last year.
The OFT has argued there "are reasonable grounds for suspecting that there are features of the market that prevent, restrict or distort competition".
- A lack of easily comparable information available to patients and their GPs on the quality and costs of private healthcare services. "This may mean that competition between private healthcare providers and between consultants is not as effective as it could be. In addition, the full costs of treatment may not always be transparent for private patients," said the OFT.
- The fact that there are only a limited number of significant private healthcare providers and larger health insurance providers at a national level. "There are pockets of particularly high concentration in some local areas where private patients have a limited choice of hospital. Given the desire for patients to be treated locally, this may mean that insurance providers will generally rely on these larger healthcare providers to provide this access to treatment for their policyholders," the OFT argued.
- A number of the features of the private healthcare market combine to create significant barriers to new competitors entering the market and being able to offer private patients greater choice. "For example, some larger private healthcare providers can impose price rises or set other conditions if an insurer proposes to recognise a new entrant on its network. There also appear to be certain incentives given by private healthcare providers to consultants, such as loyalty payments for treating private patients at a particular facility, which could raise those barriers further," the OFT concluded.
As OFT chief executive John Fingleton put it: "Private patients and their GPs face difficulties selecting private healthcare providers on the basis of quality or value for money, and this may ultimately result in patients paying higher prices, or receiving lower quality care."