Without child care, work and family are impossible

https://theconversation.com/without-child-care-work-and-family-are-impossible-137340?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20May%2022%202020%20-%201630015658&utm_content=Latest%20from%20The%20Conversation%20for%20May%2022%202020%20-%201630015658+Version+A+CID_f23e0e73a678178a59d0287ef452fe33&utm_source=campaign_monitor_us&utm_term=Without%20child%20care%20work%20and%20family%20are%20impossible

Without child care, work and family are impossible

I have a Ph.D. from Harvard and a 20-month-old child.

Without child care, life revolves around the toddler.

I am a political science professor and researcher, but lacking child care, I count myself lucky to work a few hours each day.

I am increasingly aware there is no such thing as the so-called work/family conflict. This is not only a personal observation. Scholars have found that good jobs – full-time, with benefits – and family, without help, are simply incompatible.

The concept is also wrong. If three-quarters of American women become mothers, and also most women do paid work, then doing both is, well, life; it’s not some existential, context-free choice.

Work and family are both full-time pursuits. If the problem is framed as a choice between them, the battle is lost, since family will usually win. Telecommuting and “workplace flexibility” are important but do not make up for a lack of time and space to think and work.

Those who need care, especially little children, are needy and adorable, and mothers are evolutionarily disposed to focus on them.

(Whoops, excuse me, the toddler is trying to kill herself again … OK, child saved, with minimal screaming on both of our parts. Now what was I thinking? Did I reorder all our prescriptions? Hold on, I’ll be back.)

The national shift to home-based work and schooling has had challenging consequences for parents, especially mothers. Sometimes these effects are lovely, like giving us more time with family, but if your goal is getting work done, good luck to you.

Can you type with a toddler in your lap? Getty/Tom Werner

Not alone

Working at home these days without child care is incredibly difficult unless I can escape to another room and close a door. This inevitably triggers screaming, but oh well.

She’s worse than a cat; she climbs on me, presses things on the computer, sucks its edges and screams for attention, in addition to the normal baby bodily functions that comprise a disproportionate section of my thinking – when did she last poop? Is that a rash?

It’s not just me.

Submissions from women to academic journals have plummeted since COVID-19 hit.

One geography professor tweeted, “It’s hard enough to keep my head barely above the water with the kids at home and interruptions every 2 min … I can’t imagine writing a paper now.”

Another scholar said the data on diminished submissions from women made her cry because it wasn’t just her.

It turns out that someone has to supervise – and sometimes force – children’s learning, even if online, and this takes actual work. With parks, museums, sports, pools and movie theaters closed, and with kids mostly unable to hang out with friends, someone also has to do the physical and emotional labor of keeping children busy, engaged and upbeat. This too is work.

Then there is the simple fact that family members are eating, working and playing in houses most of the time, which means more cooking, more cleaning, more grocery shopping and, yes, more toilet paper.

(OMG the baby took a two-hour nap. I got to exercise and even shower. No time for leg-shaving but I’m still a new woman. Now what was I thinking…)

Because it is not just time, you see. Sometimes the child is playing quietly, and theoretically I could sit down and bang out a research article, but my brain is fuzzy as hell.

I used to wonder what cows thought, standing there chewing their cud in a field. Now I know. They are thinking nothing. Especially with the nursing, I have great sympathy with cows lately.

Before the baby, and before COVID-19, I had great plans for composing scholarly articles in my head during all that nursing downtime. But I forgot that hormones can change your brain and behavior.

Submissions by women to academic journals have plummeted since COVID-19 hit. Getty/ KT images

Hormones play a role

Feminist theory and research finds that much of what people think of as “biological sex” – female or male – is socially constructed, as in, strongly based on culturally contingent assumptions about women and men as groups. I firmly believe, and teach, this as evidence-based truth.

Hormones, though, have undeniable physical and mental effects. If they are turning your body into a milk-production and child-protection facility, there can be some side effects on brain function. Many of these changes (increased empathy and vigilance) are useful evolutionarily, and the physical alterations appear to be short-lived. But there can also be negative effects on memory and focus. If your brain is your job, as mine is, this can cause some serious work disruption.

Pat Schroeder had two young children when first elected to Congress as a Democrat from Colorado in the 1970s. When asked how she could do both jobs, she famously replied, “I have a brain and a uterus, and I use them both.”

I try to live up to Schroeder’s standard, but lately I’ve found I have to qualify it; I tell myself she meant sequentially, not simultaneously.

Sequential is fine, as long as I have time and space to switch gears – I’m a first-time mom at 40 and the gears sometimes stick or stall out – and the peace of mind to focus beyond the child and the never-ending housework. We don’t call this “women’s work” anymore, and men do more than they used to, but it’s essential work and still mostly done by women.

There’s another way

With luck and science, COVID-19 will recede soon, and we can trickle back to offices, for which I have a newfound respect.

Will the U.S. take something positive from this crisis by learning an enduring lesson about the power of child care?

Americans tend to think of having children as an expensive, private choice. The alternative is to think of it as a public good.

Other countries offer far more generous parental leave and low-cost, high-quality daycare, knowing that “work versus family” is a false formulation. The U.S. is losing serious talent and promoting gender inequality by continuing to misunderstand the problem.

There are many potential options when child care is made a priority in a society.

Government subsidies for child care centers would help low-income workers have access to good care. The U.S. almost managed this in 1971, when Congress passed, on a bipartisan vote, a bill to establish child care centers across the country, funded in part by the federal government. President Richard Nixon vetoed the bill.

Universal pre-K starting at age 3, as in New York City, is another option to advance the interests of working parents and children.

And because working parents are drowning in high child-care costs, the government could offer subsidies and tax relief for curriculum-based care – which encourages child development and learning as well as safety – for those early years. I make a pretty good salary, but still, an extra US$1,000 a month or more to ensure my child is safe and well cared for while I work is painful.

It’s not a work-family conflict; it is a lack of high-quality, low-cost child care. Framing the problem otherwise damages the ability to enact good solutions.

It also makes a lot of good, hardworking parents feel enduring guilt over a problem that isn’t theirs alone to solve.

 

 

 

 

Memorial Day: Why veterans are particularly vulnerable to the coronavirus pandemic

https://theconversation.com/memorial-day-why-veterans-are-particularly-vulnerable-to-the-coronavirus-pandemic-139251?utm_medium=email&utm_campaign=Latest%20from%20The%20Conversation%20for%20May%2022%202020%20-%201630015658&utm_content=Latest%20from%20The%20Conversation%20for%20May%2022%202020%20-%201630015658+Version+A+CID_f23e0e73a678178a59d0287ef452fe33&utm_source=campaign_monitor_us&utm_term=Memorial%20Day%20Why%20veterans%20are%20particularly%20vulnerable%20to%20the%20coronavirus%20pandemic

Memorial Day: Why veterans are particularly vulnerable to the ...

As the nation takes a day to memorialize its military dead, those who are living are facing a deadly risk that has nothing to do with war or conflict: the coronavirus.

Different groups face different degrees of danger from the pandemic, from the elderly who are experiencing deadly outbreaks in nursing homes to communities of color with higher infection and death rates. Veterans are among the most hard-hit, with heightened health and economic threats from the pandemic. These veterans face homelessness, lack of health care, delays in receiving financial support and even death.

I have spent the past four years studying veterans with substance use and mental health disorders who are in the criminal justice system. This work revealed gaps in health care and financial support for veterans, even though they have the best publicly funded benefits in the country.

Here are eight ways the pandemic threatens veterans:

1. Age and other vulnerabilities

In 2017, veterans’ median age was 64, their average age was 58 and 91% were male. The largest group served in the Vietnam era, where 2.8 million veterans were exposed to Agent Orange, a chemical defoliant linked to cancer.

Younger veterans deployed to Iraq and Afghanistan were exposed to dust storms, oil fires and burn pits with numerous toxins, and perhaps as a consequence have high rates of asthma and other respiratory illnesses.

Age and respiratory illnesses are both risk factors for COVID-19 mortality. As of May 22, there have been 12,979 people under Veterans Administration care with COVID-19, of whom 1,100 have died.

2. Dangerous residential facilities

Veterans needing end-of-life care, those with cognitive disabilities or those needing substance use treatment often live in crowded VA or state-funded residential facilities.

State-funded “soldiers’ homes” are notoriously starved for money and staff. The horrific situation at the soldiers’ home in Holyoke, Massachusetts, where more than 79 veteran residents have died from a COVID-19 outbreak, illustrates the risk facing the veterans in residential homes.

3. Benefits unfairly denied

When a person transitions from active military service to become a veteran, they receive a Certificate of Discharge or Release. This certificate provides information about the circumstances of the discharge or release. It includes characterizations such as “honorable,” “other than honorable,” “bad conduct” or “dishonorable.” These are crucial distinctions, because that status determines whether the Veterans Administration will give them benefits.

Research shows that some veterans with discharges that limit their benefits have PTSD symptoms, military sexual trauma or other behaviors related to military stress. Veterans from Iraq and Afghanistan have disproportionately more of these negative discharges than veterans from other eras, for reasons still unclear.

VA hospitals across the country are short-staffed and don’t have the resources they need to protect their workers. AP/Kathy Willens

The Veterans Administration frequently and perhaps unlawfully denies benefits to veterans with “other than honorable” discharges.

Many veterans have requested upgrades to their discharge status. There is a significant backlog of these upgrade requests, and the pandemic will add to it, further delaying access to health care and other benefits.

4. Diminished access to health care

Dental surgery, routine visits and elective surgeries at Veterans Administration medical centers have been postponed since mid-March. VA hospitals are understaffed – just before the pandemic, the VA reported 43,000 staff vacancies out of more than 400,000 health care staff positions. Access to health care will be even more difficult when those medical centers finally reopen because they may have far fewer workers than they need.

As of May 4, 2020, 2,250 VA health care workers have tested positive for COVID-19, and thousands of health care workers are under quarantine. The VA is asking doctors and nurses to come out of retirement to help already understaffed hospitals.

5. Mental health may get worse

An average of 20 veterans die by suicide every day. A national task force is currently addressing this scourge.

But many outpatient mental health programs are on hold or being held virtually. Some residential mental health facilities have closed.

Under these conditions, the suicide rate for veterans may grow. Suicide hotline calls by veterans were up by 12% on March 22, just a few weeks into the crisis.

6. Complications for homeless veterans and those in the justice system

An estimated 45,000 veterans are homeless on any given night, and 181,500 veterans are in prison or jail. Thousands more are under court-supervised substance use and mental health treatment in veterans treatment courtsMore than half of veterans involved with the justice system have either mental health problems or substance use disorders.

As residential facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go. They may stay incarcerated or become homeless.

Courts have moved online or ceased formal operations altogether, meaning no veteran charged with a crime can be referred to a treatment court. It is unclear whether those who were already participating in a treatment program will face delays graduating from court-supervised treatments.

Further, some veterans treatment courts still require participants to take drug tests. With COVID-19 circulating, those participants must put their health at risk to travel to licensed testing facilities.

As veterans’ facilities close to new participants, many veterans eligible to leave prison or jail have nowhere to go and may become homeless, like this Navy veteran in Los Angeles. Getty/Mario Tama

7. Disability benefits delayed

In the pandemic’s epicenter in New York, tens of thousands of veterans should have access to VA benefits because of their low income – but don’t, so far.

The pandemic has exacerbated existing delays in finding veterans in need, filing their paperwork and waiting for decisions. Ryan Foley, an attorney in New York’s Legal Assistance Group, a nonprofit legal services organization, noted in a personal communication that these benefits are worth “tens of millions of dollars to veterans and their families” in the midst of a health and economic disaster.

All 56 regional Veterans Administration offices are closed to encourage social distancing. Compensation and disability evaluations, which determine how much money veterans can get, are usually done in person. Now, they must be done electronically, via telehealth services in which the veteran communicates with a health care provider via computer.

But getting telehealth up and running is taking time, adding to the longstanding VA backlog. Currently, more than 100,000 veterans wait more than 125 days for a decision. (That is what the VA defines as a backlog – anything less than 125 days is not considered a delay on benefit claims.)

8. Economic catastrophe

There are 1.2 million veteran employees in the five industries most severely affected by the economic fallout of the coronavirus.

A disproportionately high number of post-9/11 veterans live in some of the hardest-hit communities that depend on these industries. Veterans returning from overseas will face a dire economic landscape, with far fewer opportunities to integrate into civilian life with financial security.

In addition, severely disabled veterans living off of VA benefits were initially required to file a tax return to get stimulus checks. This initial filing requirement delayed benefits for severely disabled veterans by at least a month. The IRS finally changed the requirements after public outcry, given that many older and severely disabled veterans do not have access to computers or the technological skills to file electronically.

There are many social groups to pay attention to, all with their own problems to face during the pandemic. With veterans, many of the problems they face now existed long before the coronavirus arrived on U.S. shores.

But with the challenges posed by the situation today, veterans who were already lacking adequate benefits and resources are now in deeper trouble, and it will be harder to answer their needs.

 

 

 

 

Employers seeking a “source of truth” for coronavirus guidance

https://mailchi.mp/f2774a4ad1ea/the-weekly-gist-may-22-2020?e=d1e747d2d8

What Is Truth? | Psychology Today

As states begin to reopen, employers need guidance to ensure safe, COVID-free operations, and are beginning to call local health systems for advice on how to manage this daunting task. Providing this support is uncharted territory for most systems, and they’re learning on the fly as they bring back shuttered outpatient services and surgery centers themselves. This week we convened leaders from across our Gist Healthcare membership to share ideas on how to assist employers in bringing businesses safely back online—and to discuss whether the pandemic might create broader opportunities for working with the employer community.

It’s no surprise some companies are hoping that providers can step in to test their full workforce, but as several systems shared, “Even if we thought that was the right plan, testing supplies and PPE are still too limited for us to deliver on it now.” Better to support businesses in creating comprehensive screening strategies (with some offering their own app-based solutions), coupled with a testing plan for symptomatic employees.

Health systems have been surprised by the hunger for information on COVID-19 among the business community. Hundreds of companies have registered for informational webinars, hosted by systems through their local chambers of commerce. They’re excited to receive distilled information on local COVID-19 impact and response. As one leader said, the system isn’t really creating new educational content, but rather summarizing and synthesizing CDC, state and local guidance.

Business leaders are looking for “a source of truth” from their local health system amid conflicting guidelines and media reports. Case in point: employers are asking about the need for antibody testing, having been approached by testing vendors and feeling pressure from employees. Guidance from system doctors provides a plain-spoken interpretation on testing utility (great for looking at a population, meaningless right now for an individual), and helps them make smarter decisions and educate their workforce.

Health systems are hopeful that helping employers through the coronavirus crisis will lay the foundation for longer-term partnerships with employers, allowing them to continue to provide benefits through lower cost, coordinated care and network options. 

Timing is critical, and it may be smaller businesses that have the ability to change more quickly. Large companies have mostly locked in their benefits for 2021, whereas many mid-market businesses are looking for alternative options now.

Worksite health, telemedicine, and direct primary care arrangements are all on the table. One system surveyed local brokers and employers and found that 20 percent of mid-market employers are open to narrow-network partnerships. “The number seems low,” they reported, “but it’s up from five percent last year, a huge jump.” For systems seeking direct partnerships with employers, there’s a window of opportunity right now to find those businesses committed to continuing to offer benefits, who are looking for a creative, local alternative—and to get that first Zoom meeting on the calendar.

 

 

 

Congress headed toward unemployment showdown

https://thehill.com/homenews/senate/499074-congress-headed-toward-unemployment-showdown?utm_source=&utm_medium=email&utm_campaign=30143

Alabama Starts Giving $600 Federal Stimulus Payments to the ...

A debate over whether to extend enhanced unemployment benefits is emerging as a significant obstacle to getting a deal on another round of coronavirus relief legislation.

With the national unemployment rate expected to creep toward 20 percent in the months ahead, the fight over whether to boost benefits for Americans who lose their jobs or to keep benefits lean to motivate laid-off employees to rejoin the workforce is set to become a defining issue ahead of the election.

Senate Majority Leader Mitch McConnell (R-Ky.) says that Senate Republicans don’t have any interest in extending the $600 federal increase to state unemployment benefits that was a core component of the $2.2 trillion CARES Act.

The enhanced benefits are due to expire at the end of July, making them a principal topic of the upcoming negotiations.

McConnell told House GOP lawmakers in a conference call Wednesday that the Senate will not extend the beefed-up federal unemployment benefits, which GOP senators say has become a disincentive for middle- and lower-wage workers to return to the job.

But not all Republicans are on board with McConnell.

Sen. Pat Roberts (R-Kan.) said “my inclination would say that that’s going to have to continue for a while.”

“I get it, I talk to a lot of business people in Kansas — and South Carolina — about that and the disincentive if you continue to pay it to work. So I say it’s a tough a choice. But I think under the circumstances it should be continued in some form,” he added.

The employment picture grew darker on Thursday after the Labor Department announced that another 2.4 million Americans filed unemployment claims last week, bringing the total for the past nine weeks to 38 million new claims.

Sen. Thom Tillis (R), who faces a tough reelection race in North Carolina, said he wants to wait and see how the unemployment numbers play out.

“I think a lot of it really depends on how well the business openings go. I for one think that anything we do has to be tailored to where we’re not in the situation where the benefit’s greater than the salary it was replacing,” he said.

Other Republicans, however, say there is strong support for shutting off the federal boost to unemployment insurance after July.

“They think it is a huge disincentive to get the economy back and growing again. They’re not happy it was done in the first place,” said Sen. Rob Portman (R-Ohio), who helped craft the unemployment benefits section of the CARES Act, referring to complaints he has heard from GOP colleagues about the beefed-up benefits.

Sen. Rand Paul (R-Ky.) on Thursday warned: “When the government wage exceeds the market wage you’ll get institutionalized unemployment.”

“It was a mistake to make it so high to begin with. It would be a mistake to extend it,” he added. “If you favor extending it, basically you’re favoring institutionalized unemployment.”

Other Republicans are raising concerns that adding $600 in federal assistance to weekly state unemployment compensation creates a benefit that exceeds the hourly wage for many jobs in their states.

“I think it needs to end,” said Sen. John Boozman (R-Ark.). “Hopefully the economy will start to be getting back on track and we’ll be able to get rid of it.”

Portman has proposed a bill that he hopes will give laid-off workers incentive to give up their enhanced benefits and look for new jobs before the July 31 expiration of the $600 federal add-on.

His legislation would let these workers continue collecting $450 of the $600 weekly benefit if they find work in the next nine weeks.

This sets up a major fight with Democrats, who see expanded unemployment benefits as the most effective way to help Americans hit hardest economically by the pandemic.

Speaker Nancy Pelosi (D-Calif.) and House Democrats have passed a $3 trillion coronavirus relief bill that would extend the $600 federal add-on to state unemployment benefits through July.

Sen. Sherrod Brown (D-Ohio) said Democrats “absolutely” will insist on extending the federal increase to state unemployment benefits.

“It’s been a longtime Republican plan to reduce the amount of UI to workers, to shrink the number of weeks and to make fewer people eligible. In Ohio, only a quarter of unemployed workers are eligible for Ohio unemployment,” he said.

He said Democrats will make extending the program a top priority.

“Democrats are the party of workers, clearly, and they aren’t,” he said of his GOP colleagues.

The debate is just beginning, but it will grow heated in the weeks ahead as both sides begin to negotiate in earnest the size and scope of the next relief bill.

Senate Democratic Whip Dick Durbin (Ill.) predicted: “Republicans will catch … hell back home when they try to explain cutting off unemployment.”

He also predicted fallout for not reforming the Small Business Administration’s Paycheck Protection Program or providing more aid to state and local governments.

Durbin warned that failing to extend enhanced unemployment benefits would be a “disastrous mistake.”

“The economists tell us it is probably the single best stimulus that we can put into this economy,” he said

Durbin said if McConnell blocks extending beefed-up unemployment benefits past July 31, there will be hardship across America and in the commonwealth of Kentucky that “he doesn’t even begin to contemplate at this moment.”

Sen. Bernie Sanders (I-Vt.), who was a competitive candidate in the Democratic presidential primary and whose support is seen as crucial to turning out voters in the fall, also weighed in Thursday.

“Republicans are going nuts about the $600 per week expanded unemployment benefits that workers now receive. Imagine that! Americans not forced to live on starvation wages. What a frightening precedent. What will they want next? Health care as a human right?” Sanders tweeted Thursday afternoon.

Some Democratic moderates, however, have signaled in private talks that they’re open to negotiating with Republicans to scaling down the $600 in additional weekly assistance after July.

A Republican source familiar with the preliminary talks said that moderate Sens. Christopher Coons (D-Del.), Bob Menendez (D-N.J.) and Joe Manchin (D-W.Va.) have expressed interest in finding a compromise.

Sen. Michael Bennet (D-Colo.) has also signaled a willingness in reviewing the impact of the generous federal payment on people rejoining the workforce.

 

 

 

 

Advocate Aurora reports Q1 operating loss, gets $328M bailout

https://www.beckershospitalreview.com/finance/advocate-aurora-reports-q1-operating-loss-gets-328m-bailout.html?utm_medium=email

MyAdvocateAurora | Health Record | Advocate Aurora Health

Advocate Aurora Health saw revenue increase year over year in the first quarter of this year, but it ended the period with an operating loss, according to recently released unaudited financial documents

Advocate Aurora Health, which was formed in 2018 and has dual headquarters in Downers Grove, Ill., and Milwaukee, reported revenue of $3.1 billion in the first quarter of 2020, up from $3 billion in the same period a year earlier. Patient service revenue climbed 3.5 percent year over year, while capitation revenue dropped 13.2 percent.

The health system said it began postponing or canceling elective procedures on March 17 due to the COVID-19 pandemic, and the public curtailed visits to physicians, clinics and emergency rooms for fear of contracting the virus.

“These actions have served to decrease revenues from non-COVID-19 patients while driving up costs to prepare for and care for COVID-19 patients with minimal additional revenues from these patients,” Advocate Aurora said.

To help offset financial damage caused by the COVID-19 pandemic, the health system implemented cost-reduction measures. Since April 1, it has also received $328 million in grants made available through the Coronavirus Aid, Relief and Economic Security Act and about $730 million in advance Medicare payments, which must be paid back.

Advocate Aurora’s expenses were up 9 percent in the first quarter of this year compared to the same period of 2019. The increase was due in part to it acquiring the remaining 51 percent interest in Bay Area Medical Center in Marinette, Wis., in April 2019.

Advocate Aurora posted an operating loss of $85.6 million in the first quarter of this year. That’s compared to operating income of $112.8 million in the same period a year earlier. Excluding nonrecurring expenses, the health system posted an operating loss of $49.3 million in the first quarter of this year and operating income of $131.2 million a year earlier.

The 26-hospital system reported a nonoperating loss of $1.23 billion in the first quarter of this year, which was largely attributable to investment losses. Advocate Aurora ended the first quarter with a net loss of $1.3 billion, compared to net income of $596.8 million a year earlier. 

As of March 31, the health system had 229 days cash on hand, down from 274 days in December 2019. 

 

 

 

 

Congress Should Redirect The Medicare Shared Savings Program To Address The COVID-19 Emergency

https://www.healthaffairs.org/do/10.1377/hblog20200518.386084/full/?utm_source=Newsletter&utm_medium=email&utm_content=COVID-19%3A+Redirecting+The+Medicare+Shared+Savings+Program%2C+The+Hidden+Homeless%2C+Senior+Housing+Communities+Need+Support%3B+Reimagining+Involuntary+Commitment%3B+Book+Reviews&utm_campaign=HAT+5-22-20

Congress Should Redirect The Medicare Shared Savings Program To ...

The COVID-19 virus has unleashed a rolling series of crises among fee-for-service providers. First, and most directly affected, providers in areas with major outbreaks have suffered extreme personal hardship and risked infection themselves with inadequate equipment and protective gear when treating patients. Second, everywhere in the country, physician practices and hospitals have seen revenue drops from 20 percent to 60 percent due to the need to follow social distancing practices to minimize infection. This revenue collapse has perversely resulted in staffing reductions that are likely to accelerate unless Congress provides further assistance to the industry. Third, and only partially observed so far, there is a pending “second wave” of health crises discernible in the “missing heart attacks” and reports from nephrologists and oncologists of patients making difficult decisions about whether to continue necessary care. In some cases, emergency care has shifted out of the hospital, and some triage is conducted on the street to avoid risk of COVID-19 infection.

The COVID-19 public health emergency has generated a massive set of emergency changes in Medicare payment policy, loosening regulation of acute hospital care, dramatically expanding use cases for telehealth and other types of virtual care, and, through the Coronavirus Aid, Relief, and Economic Security (CARES) Act and subsequent relief legislation, releasing a $175 billion pool of money that attempts to prop up Medicare providers dependent on in-person, fee-for-service revenue. Now, with that first batch of changes handled, a debate has started among proponents of value-based purchasing as to the appropriate direction for the Medicare Shared Savings Program (MSSP) and other value-based initiatives during the emergency.

In this context, a number of stakeholders have begun to call on the Centers for Medicare and Medicaid Services (CMS) to modify existing MSSP parameters to maintain the program through the emergency. CMS has responded by eliminating downside risk for accountable care organizations (ACOs) for the duration of the public health emergency and taking COVID-19 costs out of ACO financial calculations. These are welcome changes but don’t completely address the serious problems ACO participants face. We urge a different focus—the federal government should charge these existing networks with addressing the “second wave” of health care needs going largely unaddressed, as patients with serious, non-COVID-19-related chronic conditions see procedures and visits postponed indefinitely. Commensurately, Congress should suspend all financial impacts from the MSSP for the duration of the public health emergency—and consider excluding any data from 2020 for performance years 2021 and beyond. We describe key elements of these changes in this post.

A Growing Call For MSSP Modifications

The Medicare Payment Advisory Commission (MedPAC) issued a comment letter urging CMS to allow ACO providers to focus on COVID-19, rather than shared savings. MedPAC, acknowledging the dramatic shifts in care delivery necessitated by the COVID-19 crisis, made several recommendations about treatment of savings and losses in the MSSP for 2020. MedPAC asked CMS not to use 2020 data for purposes of ACO quality, bonuses, and penalties. MedPAC would also have CMS disregard 2020 claims when assigning beneficiaries to ACOs, since a shift to telehealth, with physicians and patients potentially located far apart, could distort the ACO assignment with unintended effects. Finally, MedPAC recommended extending all ACO agreement periods, keeping everyone in the current risk arrangement for one year, a recommendation CMS adopted.

William Bleser and colleagues recently suggested immediate and short-term actions that could help preserve ACOs through this crisis. Their blog post identifies the decision point, coming on June 30, 2020, for ACOs to stay in the program and be accountable for losses in 2020. The impact of the emergency on ACOs will still be unclear at that time, and the authors recommend that CMS allow ACOs to completely opt out of downside risk for 2020 while accepting a capped amount of potential shared savings. Eliminating the downside and offering a limited upside might just convince ACOs not to leave the program entirely. CMS has taken these concerns seriously and removed all COVID-19–related costs from ACO financial calculations and eliminated shared losses during the public health emergency.  

Another recent blog post by Travis Broome and Farzad Mostashari makes the case that the population health focus and financial incentives for ACOs position them uniquely, not just to survive, but to lead the way for primary care during the COVID-19 crisis. ACO participation may protect these practices because of the program’s unique financial metrics. Unlike Medicare managed care, MSSP ACOs are measured against a benchmark that trends forward at actual regional and national spending growth rates. During an unusual spending year, as 2020 is sure to be, those factors are included in the trend, and the ACO is not heavily penalized for the spending pattern. Broome and Mostashari recommend that CMS focus on shielding primary care practices from certain quality reporting and information collection requirements to pave the way for high-quality care and solid financial performance.

A More Focused Re-Envisioning Of The MSSP

Foundational to the MSSP is an agreement between groups of providers and the federal government to align their financial relationship with patient and taxpayer goals: to improve the quality of care for their patients and reduce the growth of health care spending. Both of those elements must take a back seat during a massive public health emergency.

Reducing overall health care costs is not an appropriate consideration for providers today. Even though national and regional growth factors will track actual changes in expenditures and may allow for identification of more efficient providers, this objective is second order to directly responding to the threat of the emergency. Given the overwhelming need to respond to the COVID-19 crisis in their communities, the ability of any health system or ACO to influence costs this year is likely to be dwarfed by factors outside its control. This type of highly infectious, novel pandemic is a risk that can only be properly assumed by the federal government. Neither physician practices, nor hospitals, nor any other ACO participants can realistically budget and prepare for such an event on their own. Congress and CMS should adopt MedPAC’s suggestion to suspend charging penalties or paying bonuses for all of 2020, no matter how long the public health emergency is in effect.

Similarly, while the prevention and care management metrics embedded in the MSSP remain appropriate indicators directionally, difficulties in seeing patients for well visits and new standards for documentation during telehealth visits will make any precise differentiation of quality in primary care practices near impossible. MedPAC is correct that using 2020 data for performance evaluation would undercut the legitimacy of the program, and the commissioners are right to support the call to suspend the use of such data in establishing bonuses, penalties, and benchmarks in 2020 and beyond.

However, many practices have made significant investments in population health technology, staff, and training that remain as valuable as ever during this emergency. And the public has an interest in maintaining those staff and those skills, as the basis for a better health system in the future. All told, like much of the rest of the economy, putting the MSSP and other ACO arrangements “on ice” to allow providers to focus on near-term priorities would best serve the public interest. That includes delaying or freezing requirements to step up to higher-risk tracks in the Pathways to Success program, as well as delaying or canceling quality submission requirements. These delays, however, should be paired with public funding to reflect the work that ACOs have already undertaken, as well as work that they can do to help manage through the crisis, discussed further below.

Taking steps to preserve ACOs through 2020 is a good start, but we believe Congress and CMS should think bigger and empower ACOs to focus directly on the current crisis for the next two years.

Adapting ACOs To Serve The Current Emergency

ACOs are a valuable asset for the Medicare program, reflecting nearly 10 years of work across hundreds of thousands of providers serving tens of millions of beneficiaries. Disbanding them by indifference would be a mistake. The current collapse in fee-for-service volume is a problem of fee-for-service medicine primarily, and ACOs represent an infrastructure for a further step away from volume-focused medicine once the danger from this emergency passes.

Suspending financial considerations and consequences for the duration of the emergency is insufficient. Without the responsibility for managing risk and sharing in any savings, the ACO contract with CMS loses its organizing force, and the program becomes “a solution in search of a problem.”

We see two opportunities for ACOs to redirect their energies productively this year and next. First, ACOs should be directed to follow best practices in testing and public health data collection, in collaboration with local and state officials. Managing the spread of the virus in their communities is already a daily task for these providers; additional surveillance and data collection could be adopted and updated continuously as recommendations evolve. By providing resources to ACOs to support this work directly, CMS would help ensure providers can keep up.

Second, and perhaps more important in most of the country to date, ACOs should be charged with meeting explicit virtual care management requirements to identify, contact, and serve patients in their panel with multiple high-risk chronic diseases. These patients are underserved today, and efforts to address their needs are piecemeal. In place of the current financial incentives, we propose that CMS require ACOs to perform a variety of care management and COVID-19 surveillance functions in exchange for a care management fee. Congress could enable and CMS could specify that ACOs place 10 percent to 15 percent of their patients under virtual care management programs, for example, and require that ACOs maintain regular contact with these patients as well as others at higher risk. The 10 percent to 10 percent figure is a fairly low bar, considering that more than 60 percent of Medicare patients have multiple chronic conditions, according to CMS. Additionally, COVID-19 patients could be offered principal care management, a new service for Medicare beneficiaries with one serious health condition, for a month or more after their diagnosis. New flexibilities for remote patient monitoring and virtual care make this far easier to implement than it had been before the pandemic.

CMS could quickly adapt existing financial models to support this work, drawing from analysis and design of the Primary Care FirstComprehensive Primary Care Plus, and other care management programs. ACOs are by design collaborative and can rapidly learn and share best practices for establishing virtual care management services. Behavioral health services and outreach, as well as other valuable preventive care, could also be directly funded through this structure. As an alternative to the fee for care management and surveillance, Congress could allow ACOs to receive their 2019 shared savings amounts again for 2020, for ACOs continuously operating in each year.

Looking Ahead

The steps we have outlined here will accomplish several worthwhile ends in this crisis:

  • directly funding primary care capacity at a time when volumes are nosediving;
  • keeping the nearly 500,000 physician and other clinicians already in ACOs working together, maintaining the infrastructure that has already been built; and
  • providing upfront resources to manage patients whose conditions could deteriorate in the coming months, potentially catching them before they do.

These modifications should be executed first by Congress, not CMS, to ensure that such changes to the program do not become commonplace. This would invigorate the ACO programs by focusing them on the unique set of problems of this crisis, unencumbered by requirements better suited to peacetime than wartime. And when the war is over, these organizations can resume their longer-term mission to manage total costs and quality with all of the new tools and capabilities they have acquired during the crisis.

 

 

 

 

Essentia Health lays off 900 employees

https://www.beckershospitalreview.com/finance/essentia-health-lays-off-900-employees.html?utm_medium=email

Essentia Health to lay off 900 employees, including 178 workers in ...

Essentia Health is laying off 900 employees, about 6 percent of its workforce, to help offset severe financial damage caused by the COVID-19 pandemic.

The Duluth, Minn.-based health system is facing $100M in losses due to declines in patient volumes since the beginning of March. Essentia has taken several steps to help offset those losses, including placing 850 employees on administrative leave, reducing physician and executive compensation, eliminating certain leadership roles and limiting capital spending. The health system said it is now forced to permanently reduce its workforce.

“Despite our best efforts, the many cost-reduction measures we’ve taken over the last several weeks are not sufficient to preserve our mission and the health of the organization,” Essentia Health CEO David C. Herman, MD, said in a news release. “This has prompted our leadership team to carefully consider the most difficult decision we’ve faced since I joined Essentia five years ago and move forward with permanent layoffs.”

Essentia said it will continue to provide health insurance for noncontract employees affected by layoffs for the next three months. The health system said the 850 employees on administrative leave will be called back as needed.