[MCOH-EH] [EXTERNAL] immunizations/ TB testing who pays?

[Swift, Melanie D., M.D.]

So! Many! Things!

Where to start?



First, it probably is *legal* to put the expense of preemployment vaccinations on the employee except for hepatitis B which clearly they must provide at no cost. But legal doesn't equate to optimal, fair, or correct. Here is my in-no-particular-order list of concerns to address:

*         This policy will have a disproportionate adverse impact on low-income employees such as housekeeping, who are much less likely to have extant/available vaccination records than health professional. This exerts both a recruitment suppressive effect and a financial hardship for the employees who can least afford it.

*         Turfing the preemployment assessment to outside providers who are not part of your MCOH program will yield inconsistencies, such as:

o   They will be told their TST of 12 mm is negative (15 mm is the cutoff for the general public)

o   They will not understand a 2-step TST

o   They will do weird things with serologies - ordering them after documentation of vaccination with MMR or VZ for instance

o   They will issue their own version of policy exemptions, like not doing TST in pregnant women, or accepting a verbal history of chickenpox in lieu of serology or vaccine.

*         There are very specific policy requirements that are not reasonable for an outside provider to know, e.g.:

o   What is your Tdap requirement, if any - all employees, only pediatrics?

o   What is your approach to women in early pregnancy before Tdap is optimal?

o   Do you require influenza vaccination, and if so do you accept LAIV - and in whom?

o   What's the hire date range for which new employees need to get flu vaccine, vs just starting work and waiting for the employee campaign?

o   What evaluation is done for positive TST/IGRA - do you retest low level positive IGRAs? How do you handle CXR in pregnancy? How do you connect people with LTBI to evaluation for symptoms, lymphadenopathy, and offer of treatment?

*         There are some elements you cannot outsource, HBV notably. Then you have a situation where your OH team still interacts with them AND they have to see another provider on their own.

*         This will definitely delay onboarding due to access to care issues and people paying for evaluations that end up not meeting your requirements.



At a previous institution we piloted a program to have one of our own outpatient clinics do the preemployment evaluations, using our protocols and sending all documentation to us, and we paid for it. This was done just to increase access after hours/weekends. It did not go well. All of the errors listed above, plus many more, happened. OH ended up still needing to interact with almost every new employee.



I cannot express how strongly I recommend not going down this road. Best of luck my friend, and keep us posted! If by chance they insist on doing this, you should insist on a time-limited trial with a quality monitoring program including screening errors, unnecessary services, compliance problems, and employee complaints. YOU monitor the data and present the outcomes of the trial, and set a date in stone for reviewing the outcomes and continually remind folks it is a trial you will end if quality and compliance suffer.



Melanie



Melanie Swift, MD

Senior Associate Consultant

Assistant Professor of Medicine

Division of Preventive, Occupational, and Aerospace Medicine

Phone 507.284.2560

_______________________________

Mayo Clinic

200 First Street SW

Rochester, MN 55905

www.mayoclinic.org



-----Original Message-----
From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Philip Adamo
Sent: Wednesday, November 07, 2018 10:12 AM
To: MCOH/EH
Subject: [EXTERNAL] [MCOH-EH] immunizations/ TB testing who pays?



Hello colleagues,

I have been in EHS for various hospital for over 20 years. The hospitals/medical centers have always provided the required immunizations and TB testing and assume the costs of delivering this service.



I have been approached by one of our leaders that the hospital should only consider employing someone if they meet our immunization requirements and that they pay to go to their PCP for immunizations and TB testing. I know OSHA specifically addresses that the Hospital pays for the Hep B vaccination and titters in the BBP regulation. I cannot find other documents to supporting that hospitals are not responsible fro MMR V and Tdap as well as TB testing.



There was also a suggestion that we contract out the pre-placement to an urgent care center. The candidate would then come to EHS for the mask fit, and clearance.



I am currently at a large academic medical center. My opinion is that there is so much wrong on many levels with tis approach. I would like to get opinions from many of you especially of this process works.



Best regards,



Philip Adamo, M.D., MPH, CPE

Baystate Health

Springfield, MA

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