Competition and despecialization: an analytical study of occupational health services in San Diego, 1974-1984.

Occupational health care services are changing in response to rapid changes in health care organization generally; this trend is not reflected in the occupational medicine literature. San Diego is a large and rapidly developing metropolitan area with a balance of heavy, light, and service industries and is relatively isolated and self-contained in health services, making it useful for monitoring health services trends. We examined local trends in the supply of health services as reflected by facilities, manpower, and other indicators between 1974 to 1984. We also assembled findings of local market surveys and certain other sources into a profile of occupational health care resources in the metropolitan area. Corporate medical departments did not keep up with the growth of industry over the decade; freestanding "industrial medicine clinics," by contrast, began with a single facility and proliferated to 13. In the last three years, freestanding "urgent care centers" entered the health care market in force and now outnumber industrial medicine clinics. Despite an overall massive increase in the number of physicians in the area, occupational physicians with specialty credentials or eligibility remained few and primarily based in institutions, while the number of uncertified physicians and of medical groups accepting occupational medicine referrals increased considerably. Employers reported approval of acute care, traditional screening, and employee assistance services far more often than of preventive services, but if they approved of a service, they usually provided it, except in the case of employee assistance services. We conclude that the role of preventive services and of trained personnel in delivering occupational health care is declining, rather than increasing, in the face of competition and changes in the general health care system. Corporate and in-plant medical services are not keeping up with the growth of industry, and no class of health facility matched the growth of industrial medical clinics except urgent care centers, with which they are beginning to compete. The implications of this study for occupational medicine as a specialty, for the standards of patient care, and for the role of prevention is a matter of grave concern if they reflect national trends. Further studies of occupational health services are urgently needed to assess the significance of these findings.