Medical Laboratory Observer

Groundbreaking labor contract involves employees in decision making

The union employees of the nation’s largest HMO, Kaiser Permanente, have ratified a labor contract that gives them a voice in decisions affecting staffing, quality of care, and business planning. The company is calling this agreement the first national contract of its kind in the healthcare industry. Employees and union reps view the contract as a step forward in the era of managed care, where medical decisions are increasingly made by business people instead of healthcare practitioners. However, it remains to be seen how the newly minted, 5-year contract will affect the day-to-day lives of Kaiser employees. 

More than 90% of the union employees voted to approve the contract, according to Kaiser. Laboratory manager Marci Anderson of Kaiser’s South Sacramento Medical Center, CA, says that her union employees have given her only positive feedback about the labor agreement. She very much concurs with the underlying concept, saying, “I think the people who do the work are the best qualified to make decisions that affect their jobs. This lets them have more control over their work life.”

Anderson, a former union shop steward who was involved in the contract negotiations, adds that it is unclear how the details of the contract will be implemented. The salary provisions of the contract went into effect on October 6, and she expects to work with labor over the coming year on decision-making issues. For example, she expects a union representative to be present at this year’s budget meetings, whereas in past years the union had no say in budget making. Committees of union workers will also make decisions on rotation work schedules and how overtime hours are distributed, according to Anderson. 

The contract covers 64,000 Kaiser union employees representing 25 local unions in California, Oregon, Washington, Ohio, Texas, Missouri, Kansas, Colorado, Maryland, Virginia, and Washington, DC. 

In addition to the employee decision-making provision, the contract provides for:

• developing a state-of-the-art reporting system by both labor and management to enhance patient safety and quality of care
• maintaining fair and equitable wages and benefits
• improving performance through redesign of business systems and work processes, and
• establishing mutually agreed on performance targets.

Management and labor give some credit for the successful negotiations to a national labor/management partnership that Kaiser and a coalition of AFL-CIO unions entered into in 1997. 

Maureen Anderson, who is a spokesperson for the Kaiser coalition of AFL-CIO unions, says she believes the HMO is helping to “reinvent healthcare.” In the long run, she believes that the contract will save Kaiser money and make for better customer service because decisions made on the “front line” of the healthcare environment tend to be more practical. In addition, workers will be spared the stress that sometimes occurs with “top-down” management models. “People get very aggravated when they are told to do things that don’t make sense,” she notes.

The “bottom-up” approach represented by this contract is an idea that is gaining acceptance in the business world, she adds. Southwestern Airlines, for example, is at the forefront of empowering workers to make decisions that increase efficiency. In one case she recounts, to maintain a flight schedule, passengers of a Southwestern flight needed to board the flight in less than 5 minutes. To encourage a quick boarding process, a low-level Southwestern employee made the decision to offer every passenger a free drink if they all boarded on time. Under the traditional top-down management structure, an employee would not have been able to make such a decision without first checking with a supervisor. 

However, the healthcare industry has been less inclined to accept the bottom-up approach. Anderson also said that she hoped the Kaiser contract would be the first in a trend of many similar agreements in the medical field. “It’s really beneficial for care,” she said, “as well as customer perception. HMOs in particular have had a bad reputation, and in some cases they deserve it.” Similar contracts might persuade the public that HMOs are interested in things other than just profits, she said. 

Lab manager Anderson also believes the contract is a step in the right direction and hopes the implementation of the provisions lives up to everyone’s high hopes. “A year from now you should do a follow-up to this story,” she says. “That’s when we’ll know how it turned out.”

—Frank Celia

Jacksonville, FL-based HealthScreen America, a self-described personal health management company, has launched KidsHealth First—a community program providing free screening for children. A series of tests to determine risk factors for everything from asthma to cardiovascular disease, diabetes, and obesity is available to youngsters between the age of 10 and 17, either at the HealthScreen center or at scheduled off-site events targeting the city’s low income population. A parent or guardian must accompany each child, but no physician order is required. 

While young children generally get periodic check-ups, many of those in the 10 to 17 age group do not see a doctor regularly, asserts HealthScreen’s medical director, Eduardo Balbona, MD. Noting that the free testing is not meant to replace a physician’s care, he adds: “Our goal is to bring high-tech prevention and wellness education to families early on, regardless of their income.” 

HealthScreen America intends to build centers in some 55 communities across the country within the next 2 years. The firm also expects to expand the scope of KidsHealth First through the use of mobile clinics. Within a month of the program launch, mobile units had already brought the free testing service to youngsters in Silicon Valley, Phoenix, and parts of Connecticut. 

The Jacksonville center, which opened its doors in January of this year, offers adults more than 35 tests on demand. The children’s tests are administered by medical assistants, techs, LPNs, or RNs. These tests encompass weight, height, and body mass index (BMI); spirometry measures of lung capacity and forced expiratory volume; heart rate, pulse, and blood pressure readings; hearing and vision testing, and pulse oximetry. A fingerstick to measure fasting blood glucose levels and total cholesterol (the latter test done only if a parent had a heart attack before age 55) is included as well.

A written health risk assessment that questions each child about lifestyle, nutrition, and family health accompanies the screening, along with a written report containing test results, normal ranges, educational material, and recommendations, as needed, for follow-up with a physician. The entire package would cost about $100, Dr. Balbona reports. It takes no more than 30 minutes to complete. 

Although individual health information will remain private, “results will be combined to provide valuable information about the overall health status of children in our community,” Kathy Fleming, VP of communications, says. “The aggregate data will help make a case for where services are needed,” Balbona adds. “We’re trying to focus on the underserved first.” 

First Coast News, a Jacksonville TV station, has partnered with HealthScreen to spread the word. Elizabeth Ward Cline, the station’s community affairs director, says, “Letting people know about KidsHealth First falls under the umbrella of giving parents tips on raising healthy children.” 

Also working cooperatively with HealthScreen are the American Cancer Society and the Juvenile Diabetes Foundation, Fleming reports, and Pfizer has provided some financial support for the initiative. But for the most part, HealthScreen America is underwriting KidsHealth itself. That, of course, leads to the question of how the program fits into the business goals of this for-profit company. 

The answer, it seems, is threefold. Thus far, 3 in 10 of the kids tested had a BMI of more than 25, 1 in 10 showed spirometry-based evidence of lung problems, and 1 in 10 had elevated glucose levels; so there’s an obvious need to boost children’s health, Balbona asserts. 

Then there’s the impact on family health. Youngsters who are screened are likely to pass on the message about the need to quit smoking, eat right, and take other steps to promote health. Finally, there’s the exposure. “Families will have a heightened awareness of prevention and recognize our center as one of the places that offers preventive services,” Balbona concludes. “KidsHealth First benefits everyone—the community, children, parents, and us.” 

—Helen Lippman

Boosting the ability of laboratories to help safeguard the public 

The federal government is at work developing ways to safeguard the country against the spread of infectious diseases and the threat of bioterrorist attacks. As part of this effort, it plans to improve the electronic reporting of public health data through a new program dubbed NEDSS, or the National Electronic Disease Surveillance System. The federal agency taking the lead role is the CDC, but both public and private laboratories will play an important part.

“Currently, there is no uniformity among the states relating to electronic reporting,” says Joanne Glisson, vice president of government affairs for the Washington, DC-based American Clinical Laboratory Association. “It is a nightmare for labs doing business in multiple states because they have to follow multiple requirements concerning when and how much information they are supposed to provide,” she adds.

The CDC agrees that disease control programs have not been standardized or coordinated; nor is there a mechanism in place to quickly share information when needed. In addition, this fragmented approach has meant that these systems could not take full advantage of progress in information technology. 

Implementing NEDSS. NEDSS will attempt to address some of these concerns by taking an approach significantly different from that used in the past. Traditionally, the CDC distributed to each state specific software required to participate in a program. With NEDSS, there will not be a single system or application. Instead, NEDSS will promote an integrated and coordinated public health information exchange at the local, state, and national levels. States will have the flexibility to upgrade surveillance information systems according to their particular situations, says the CDC. 

“We don’t want the private healthcare sector to have to re-enter data in any way shape or form into the public health system,” says Denise Koo in the Epidemiology Program Office at the CDC. “The idea is that labs will continue to use their own systems, but we will be able to capture data from them.”

This will be accomplished by publishing standards that all systems can use. A standards-based approach will improve the ability of public health agencies to exchange information when necessary, as is the case in multistate probes, such as the ongoing investigation of West Nile virus cases.

In addition, the CDC points out that public health information systems are unable to exchange data electronically with private providers of medical services such as labs, which by law report selected critical information to public health agencies.

As a result, the CDC says, public health agencies often receive information slowly and incompletely. The plan is for NEDSS to use information technology so that it is easier for public health agencies to electronically receive and process information about reportable diseases. Once operational, NEDSS will incorporate advanced security approaches so that the confidentiality of health data is maintained. 

As part of this effort, the program will create a standard language for the reporting of public health data. The standard for electronic lab reporting is based on HL7 (health level 7). NEDSS also will have to coordinate the lab public health reporting standards with the development of the Health Insurance Portability & Accountability Act (HIPAA) standards. 

To help get this effort up and running, the CDC recently announced awards of $9.8 million to 46 state and 3 large metropolitan health departments to begin implementing NEDSS. Fourteen states will implement NEDSS development efforts, and 35 jurisdictions will assess current state and local health departments’ information systems and plan for the implementation of NEDSS specifications and standards. Several demonstration projects with a few of the big commercial laboratories are underway.

Developing a national laboratory system. Along with NEDSS, the CDC is also pursuing the concept of initiating a National Laboratory System to help bring various laboratory and provider groups together so they recognize a common responsibility to public health. Such a system will help improve the coordination among federal, state, and local public health labs as well as independent, hospital, and physician office labs when they are required to respond to disease outbreaks caused by bioterrorist attacks, food-borne diseases, and infectious diseases.

The CDC’s concept of the National Laboratory System is to integrate public health labs and hospital and independent labs so they can better maintain the quality of the lab data exchanged. The CDC recognizes that public health labs don’t work alone on these efforts. It understands, for example, that both hospitals and independent labs use their time and resources to isolate the suspected agent from patient specimens, food, and/or other sources.

With a national laboratory system, CDC could promote the use of standard practices by using national guidelines and appropriate test methods. Ultimately, the CDC says both NEDSS and a National Laboratory System will improve the country’s ability to quickly investigate and control any public health threats that may crop up. 

—Joan Szabo