Maritime Medical Evaluation Process: Ensuring Safety and Consistency

1. Medical Evaluations DivisionNMC-6Laura G. Gillis, MD, MPH, FACOEMChief, Medical Evaluations Division

2. NMCMariner Medical Evaluation Process Medical Evaluations Division: • Our focus: • Consistency, • Fairness, • Use current standards of care, • Do what’s right for public safety • When fully staffed, 35 people total • Three physicians, 14 physician assistants • Staff of clerks and Certified Medical Assistants • One Administrator, 1 Program Analyst, 2 Health System Specialists

4. The Evaluation Process Team Member Responsibility Level of Review

5. NMC-6 Personnel Government Staff Contract Support Medical Screening Initial Medical Reviews Data Entry and File Accountability Inventory Management Contribute to improvement of Division processes • Responsible for process and quality of mariner fitness for duty determinations • Denials/ Reconsiderations

6. NMCMariner Medical Evaluation Process Additional Medical Information (AI) • Rate-limiting step of the process • 70-80% of reviewed 719Ks lack supporting objective documentation of medical conditions • Recent process changes have significantly improved consistency and reliability of information requested • NVIC 04-08 provides guidance for requesting AI, but is outdated in some areas and inconsistent with current clinical guidelines in others • Patient advocacy statements vs objective data

7. Quality Assurance Review Program Process Improvement Section Team Leaders Monitors Screening and Medical Processes Updates MMS Quarterly Q/A of work by screening and evaluations branches. • Gov’t PA Quarterly Review of CTR performance. • Physician Quarterly Review of Gov Reviewers • Quarterly assessment of division performance

8. Quality Assurance Q/ A Focus Group MMS Review Schedule Quarterly review of MMS Documents Ensures performance mirrors documented processes • Monitors quality of division work and deliverables • Comprised of Evaluation, Screening, Clerical, Gov’t, & Contract Staff • Responsible for Semi-Annual assessment of Division performance • Can recommend process changes, new initiatives and training

9. Quality Assurance Performance Measurement Training Program New Employee Orientation Bi-Weekly Training (Annual Calendar) Teachable Moments • Daily Inventory Tracking • Daily Throughput Measurement • Performance Database • Performance Templates

10. NMC Medical Performance Update Weekly Calls to Customer Service Handled by a Medical Team Member Periodic Inventory Status Update of Files Flowing Through the Medical Team

11. Medical Evaluation

12. Medical Denials • Top Denial Diagnoses: • Coronary Artery Disease • Uncontrolled Diabetes Mellitus • Chronic use of Narcotics, Benzodiazepines, Sedative-hypnotics Medications • Uncontrolled Sleep Disorders • Unstable Mental Health Conditions • Seizures

13. Hot Topics • Merchant Mariner Medical Advisory Committee (MMMAC) • Inaugural meeting occurred September 19-21, 2011 • Composed of 10 medical professionals and 4 mariners • Committee accepted three tasks: • Top 10 Medical Conditions • Development of the Designated Medical Examiner Program • Comments to the STCW proposed rulemaking

14. On the Horizon • Electronic submissions/IT overhaul • Designated Medical Examiner Program • Revisions of guidance documents (NVIC) • In conjunction with recommendations from the MMMAC • Evidenced-based approach in conjunction with current standards of care • Revision of Physical Exam Forms (719K and K/E)

15. Questions?