OCCUPATIONALMEDICINEANDTHE CZECH REPUBLIC HEALTH REFORM 2012Milan TučekCzech Society of Occupational Medicinewww.pracovni-lekarstvi.cz, e-mail: firstname.lastname@example.orgInstitute of Hygiene and Epidemiology,First Faculty of Medicine,Charles University,Prague, Czech Republic53.Jahrestagugung derDGAUM,OGA und SGARM,53.Jahrestagung der DGAUM, ÖGA und SGARM, Bregenz, March 20131
HISTORICAL DATA (1)1887 first Injury Insurance Act1929 first textbook of Occupational Hygiene1932 National Assembly of Czechoslovak Republic ratifiedILO´s Occupational Diseases Indemnity Convention(June 1, 1932 issued Act Nr. 99/1932about indemnity of occupational diseases)1932 established first Departmentof Occupational DiseasesMedical Faculty of Charles University,Prague (founder Prof. Jaroslav TEISINGER)1942 1st Congress of Occupational Diseases,Prague
HISTORICAL DATA (2)1945 12 institutes of occupational medicine established(order of Ministry of Health)1946 established Czech Society of Occupational Medicine1947 first In-Patient Department of OccupationalDiseasesMostLiberecKladnoPlzeňPardubicePrahaOlomoucHradec Králové BrnoOstravaČeské BudějoviceZlín
HISTORICAL DATA (3)1949 first issue of Journal of Occupational Medicine1952 established Institute of Occupational Hygiene andOccupational Diseases1952 regional institutes of occupational medicine abolished,specialization namedoccupational hygiene and occupational diseases1961 established Toxicology Information Center1988/1989ratification of the ILO´s Conventions No.161/ No.155Since January 1, 1992 transformation of „factorypreventive care“ into primary occupational medicalservice (no treatment possible)
HISTORICAL DATA (4)April 7,2004 occupational medicine conception withrelevant competencies accepted by Ministry of Health2004 (Act Nr.95/2004) :Occupational Medicine – basic specializationof physicians (4 years)2004 (Act Nr. 96/2004):occupational nurse specialization2005 Postgraduate education program in OM2009 Certified postgraduate course in OM (2 years)after internal medicine, paediatric medicine,general medicine and hygiene and epidemiology !!!!
INFORMATION SYSTEMSReliable information and valid data are a prerequisite forsetting priorities and allocation of resources in the fieldof occupational health. To make such information available,three major information systems were established in theCzech Republic.Those systems collect data on exposure to variousoccupational risk factors and they monitor the impact ofsuch exposures as reflected in the occurrence ofoccupational diseases.This approach makes it possible to estimate the nationalburden of occupational diseases and other work-relateddiseases.
CATEGORIZATION OF WORK OPERATIONS (1)The working population in the Czech Republic:about 5 million employees.At about 8 % of them are working at high risk of various riskfactors of work or working environment.Public Health Protection Act No. 258/2000 Dig. and theLabor Code No. 155/2000 Dig. stipulate the obligation ofemployers to perform risk assessment, i.e. to identify allhealth hazards present at the workplace, and to estimate thelevel of risk (if possible exposure assessment based onobjective measurement).According to the level of risk, all working activities areclassified into four categories (category 1 is the safest) .Based on the categorization of work operations in a particularenterprise, appropriate measures for risk management haveto be adopted including frequency and content of differenthealth examinations.
CATEGORIZATION OF WORK OPERATIONS (2)OCCUPATIONAL HEALTH RISK ASSESSMENT 2011Public Health Act (Act Nr.258/2000)13 risk factorsNumber of employees in risk categories 2R + 3 +4 (2011)Source : Annual report 2011, Ministry of Health of the Czech Republic
NATIONAL REGISTRY OF OCCUPATIONAL DISEASESAccording to Czech legislation, specialized Centers ofOccupational Diseases/Occupational Medicine arecompetent to acknowledge occupational diseases that areenumerated in the List of Occupational Diseases andmeet the prescribed medical and exposure criteria .The cases are reported to the National Registry ofOccupational Diseases, which is a component of theNational Health Information System (founded in 1991)Currently, the Registry contains data more than 40thousand cases of occupational diseases.The link between the information system Categorizationof Work Operations and the Registry of OccupationalDiseases opens up the possibility to estimate the nationalburden of work-related health problems.
OCCUPATIONAL DISEASES (1)An occupational disease (OD) is defined as a diseasecaused by the noxious effects of chemical, physical,biological, and other factors, provided that thedisease originated under conditions described in theList of Occupational Diseases.60,045,030,060,549,141,1Incidence per 100.000 of insured1994 – 2011 (18 years)37,434,330,325,629,0 29,328,728,715,00,01994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 201125,1 20,4 13,8 11,7 11,8 11,0 10,1 14,6 13,2 14,7 14,5Incidence occupational MSDsIncidence ODs
OCCUPATIONAL DISEASES (2)15 main diagnoses in 2011 men womencarpal tunnel syndrome (overloading)carpal tunnel syndrome (local vibrations)contact allergic eczemascabiescoal-miner simple pneumoconiosisbronchial asthmairritative dermatitishumeral epicondylitis rad. (overloading)simple pneumosilicosissnapping finger (overloading)vasoneurosis (local vibrations)Lyme diseaseother synovitis and tendosynovitis (overloading)humeral epicondylitis uln. (overloading)hearing impairment (noise)
176 RUTGERS LAW REVIEW [Vol. 64:1grand jury.42 She felt the amendment offered “nothing more in termsof deterring errant prosecution” because it merely created “a forumfor Members of Congress to argue that they have been unjustlytargeted for political reasons.”43 Rather, Representative Riversviewed the amendment as “harmful,” with the potential to put a“chilling effect” on federal prosecutions and to create “a form ofprosecutorial poker wherein wealthy defendants who can and dospend large amounts of money on dream team defense counsel canraise the stakes regarding their possible prosecution.”44In response to such opposition, Representative Hyde offered thispragmatic reply: “The gentlelady said the Constitution will protect usall. The Constitution protects you, but it will not pay your bills.That Constitution you carry in your pocket, the landlord will not takethat and your lawyer will not take that. They want to get paid withcash.”45 He also defended his decision to introduce the Amendmentin the context of the appropriations bill as a matter of practicality:The only reason it is here now, I saw the Murtha amendment, itwas coming to the floor, and I thought we could do it better. Thatis all. I am trying to improve someone else’s amendment to make itfairer, to make it not too broad, and to give a standard. That iswhy we are here.46Downplaying the need for further reconsideration of a proposalthat could impact the criminal justice system profoundly,Representative Hyde urged, “let us pass this law and then we willhave some experience . . . . That is not to say we will not deal with itin the Committee on the Judiciary, I am sure we will, but there maybe no need to after it passes.”47And so it was. Despite the aleatory nature of the approach thatRepresentative Hyde was exhorting, the measure passed in theHouse with enthusiastic support.48 But Representatives Skaggs andRivers had successfully planted seeds of concern during the Housedebate, for the measure did not receive immediate passage throughCongress notwithstanding the House’s bipartisan support of theAmendment.49 The Senate’s version of the appropriations bill did not42. 143 CONG. REC. H7793 (statement of Rep. Rivers).43. Id.44. Id.45. Id. (statement of Rep. Hyde).46. 143 CONG. REC. H7794 (statement of Rep. Hyde).47. 143 CONG. REC. H7793-94 (statement of Rep. Hyde).48. See supra text accompanying note 7 (indicating the measure was approved by avote of 340 to 84).49. See Joseph F. Savage Jr. & Geoffrey M. Stone, Recovering Attorneys’ Fees AfterWrongful Federal Prosecutions: New Amendment Opens the Door, 12 WHITE-COLLARCRIME REP. 1, 2 (1998).
CZECH REPUBLIC HEALTH REFORM (1)valid since April 1,2012Act No 373/2011 Dig., on specific health services§§ 53-60 Occupational medical services (OMS)preventive services, which includethe impact assessment of work, working environmentand working conditions on health,workplace inspectionsandpreventive medical fitness assessment for workaimed at protecting the health and protection againstoccupational accidents, occupational diseases and workrelateddiseases,training in first aidandregular surveillance in the workplace
CZECH REPUBLIC HEALTH REFORM (2)valid since April 1,2012Act No 373/2011 Dig., on specific health servicesProviders of occupational medical servicesa) general practitionersb) occupational health specialistsWritten contract for the provision of occupationalmedical services provider must be concluded with theemployer.In risk category 1 only (where no specific conditions areset by other legislation) may be provided preventivemedical check-ups by GP who has client in his/her generalhealth insurance register (registering GP).Other OMSs must be contracted by other OMSs provider(written statement).
CZECH REPUBLIC HEALTH REFORM (4)valid since April 1,2012Act No 373/2011 Dig., on specific health servicesThe employerhas the right to send employees to extraordinary medicaloccupational examinationThe employeeis obliged to undergo all preventive medical occupationalexaminations indicated by health services provider for theevaluation of health status
CZECH REPUBLIC HEALTH REFORM (5)valid since April 1,2012Act No 373/2011 Dig., on specific health servicesThe employer pays the occupational medical services provided underthis Act, except the assessment of occupational diseases andpreventive medical examinations at the end of the work.Initial/entry medical examination shall be paid by the person applyingfor the job.The employer pays the initial/entry examination in case of futureemployment relationship.
through employer to ensure the measurement/expertise and analysis of theworking conditions, working environment including the results ofcategorization of health risksCZECH REPUBLIC HEALTH REFORM (6)valid since April 1,2012Act No 373/2011 Dig., on specific health servicesThe provider of occupational medical services is requiredto inform employees about the possible influence of factors of workingconditions on his health, and with knowledge of the development of his stateof health,to inform employers about the possible influence of factors of workingconditions on the health of employees,to perform periodic monitoring of the workplace conditions,to cooperate with the employer, employee, safety and health at workspecialist, govenrmental inspection authorities and trade unionsto notify promptly the employer of serious or repeated facts adverselyaffecting health and safety at work
CZECH REPUBLIC HEALTH REFORM (7)valid since April 1,2012Act No 373/2011 Dig., on specific health servicesAn implementing regulation will be aboutprocedures for providing medical examinations, types, frequency andcontent of preventive medical examinationsorganization, content and scope of occupational medical servicesRecognition of occupational diseases is allowed to the providers ofoccupational medicine who have obtained authorization from theMinistry of Health.
STAFFING (1)Institutes of public healthAmong the OMSs providers are:Private general practitioners specialized in general medicine(about 1/3 of of 6.000 general practitioners)Physicians specialized in occupational medicine(industrial hygiene and occupational diseases)Public health care centers (policlinics)Health care centers established by large companiesDepartments of hospitals and teaching hospitals,specialized in occupational medicine
STAFFING (2)The need for primary level specialists in OMSs isestimated to be about 1.500 – 2.000 physicians.The general practitioners provide the largest proportionof OMSs, 422 of them attended a one-year voluntarycourse organized by the Department of OccupationalMedicine at the Institute for Postgraduate MedicalEducation in Prague (1995-2011).Currently 121 physicians are certified in occupationalmedicine. They have completed a three/four-yearcourse in occupational medicine. Those specialists areworking mostly at the secondary level of OMSs.
783614máme 18%1533637/121= 19%778/422 ?
COVERAGEIt is very difficult to estimate the coverage of OMSs in theCzech Republic (no precise statistics are at hand):10.298 controls in enterprises were performed (2011),checking existence of a signed contract between an employer and an OMSprovider, and provision of OMS in the full scope as prescribed by the legislature.At about 2% of employers did not provide OMSs at all.32 % of employers did not provide OMS in the scopeprescribed by the legislature.Especially the workers in SMEs are rarely covered by OMSsbecause of the costs of services , the lack of providers ofthese services or an unfavorable geographic location of theenterprise.
QUALITY ASSURANCE/CONTROLConcerning the quality assurance system, thedevelopment of guidelines and standards in occupationalmedicine is of primary importance. The standards forpreventive examinations define the minimum range andfrequency of medical examinations performed byauthorized occupational physicians and the kind ofconsultations which have to be performed in workers at aparticular workplace. Instructions or Guidelines arepublished by the Society of Occupational Medicine.Currently, there is no specific system for qualityassurance for OHS. The Czech Society of OccupationalMedicine has submitted a project aimed at preparation ofsuch a system in the field of OMS.
FINAL REMARKS (1)Big part of physicians provide only health examinations ofworkers without any other important activities, such asworkplace visits, risk assessment, consultations foremployers and employees etc.Only exceptionally these physicians consult themultidisciplinary problems with other specialists.This simplified approach may have serious consequences,particularly in incorrect assessment of ability to work.Unfortunately, those physicians, although being untrainedin occupational medicine, have been permitted toundertake the role of occupational physicians in orderto make it possible for employers to fulfill their legalobligation to provide OMSs for their employees.Main officially declared reason for this „liberalization“ wasthe lack of occupational medicine specialists.
FINAL REMARKS (2)Quality control of OMSs providers is urgent.Sometimes looks OMSs like „good business“ only.A keystone of quality performance by an occupationalphysician is the familiarity with specific workingconditions and demands of the respective job andthe knowledge of the state of health of individualworkers.Modification of the system of social/injury insurancefocusing on health prevention and health promotiontogether is needed.Reintroduction of the basic specializationin occupational medicine is urgent.We can characterize present situation like „liberalizationof occupational medical service for enterprises/atenterprise level without relevant quality control“.