Burnout and need for better benefits, pay, and/or family time are adversely affecting workers' plans for the future.
More than two-thirds (64%) of California's behavioral health workforce is comprised of women, most of whom have a bachelor's degree or higher and a decade or more in the field, a new analysis from the Department of Health Care Services shows.
More than 1,600 members of the workforce responded to the Fall 2021 California Behavioral Health Workforce Assessment survey, which collected information about respondents' demographics, educational and professional backgrounds, employment, communities served and use of telehealth services.
The survey also included questions related to peer support services and providers in the context of California’s current initiative to establish Peer Specialist as a provider type under DMC-ODS and SMHS programs.
The survey found that:
64% of behavioral health workers are cisgender women.
32% of respondents are Hispanic or Latino.
76% of respondents have a college or graduate degree, and 42% of respondents have been in behavioral health for more than 10 years.
35% of respondents identify as a family or caregiver of a person with behavioral health needs, and 32% have experienced a personal mental health challenge.
Burnout and need for better benefits, pay, and/or family time are adversely affecting workers' plans for the future.
The survey assessment offers seven recommendations to support, strengthen, and expand California's behavioral health workforce:
Support data-driven decision-making and policy by collecting nuanced behavioral health workforce data.
Create, expand and strengthen career pathways for racially, ethnically, linguistically and culturally diverse behavioral health providers.
Increase pay and benefits for the behavioral health workforce. Address disparities between peer and non-peer staff.
Address provider burnout and compassion fatigue. Support parents and caregivers.
Prioritize supports for unserved, underserved and inappropriately served communities. Invest in equity-driven strategies and wraparound supports
Provide additional training and technical assistance to expand telehealth.
Invest in training initiatives and programs that support integration of peers. Include and promote peer voice and leadership.
The collaboration links Tia's expertise in retail-based primary care with UCSF's specialty and inpatient facilities.
Women's primary care provider Tia is collaborating with UCSF Health to open 10 clinically integrated clinics in the Bay Area, with the flagship venue now opening at Mission & Van Ness in San Francisco.
The collaboration links Tia's expertise in retail-based primary care with UCSF's specialty and inpatient facilities, covering services that integrate physical, mental and reproductive health for women and their families via in-person and virtual care, said Carolyn Witte, co-founder and CEO of Tia.
"Women deserve comprehensive primary care that centers on our experiences — clinically, psychosocially and experientially," Witte said. "Sadly, a 'one-size-fits-most' healthcare system leaves 50% of women without a primary care provider — depriving women of essential, preventive care and forcing them instead to bounce from specialist to specialist searching for answers, which drives up costs and worsens outcomes."
"Tia wants to change that by working with UCSF to create a women-centered healthcare system that spans outpatient to inpatient with an anchoring on prevention," she said.
A Tia-commissioned survey of 500 Bay Area women found that more than 40% of them have delayed preventive health services during the pandemic, and that 80% of women in the Bay Area say that worry or stress about the pandemic has impacted their mental health.
Amy Murtha, MD, professor and chair of the UCSF Department of Obstetrics, Gynecology and Reproductive Sciences, said the collaboration will means that more women will have access to the care they need.
"UCSF Health is a leader in women's health and renowned for its integrated specialty care, but we can’t reach every woman in the Bay Area," Murtha said. "This collaboration aims to help address that fragmentation by increasing women's access to primary care services, with seamless access to UCSF's specialty care when they need it."
Tia, with a focus on early prevention, will provide UCSF Health with new outpatient access points that reach more women for its specialty care network and inpatient services, including its pregnancy, labor and delivery program.
The providers will share clinical protocols, coordinate to improve quality metrics, and link electronic health records to enable shared clinical notes, medical records, care coordination and quality data reporting. Tia's care coordination team will oversee care transfers between the two providers.
UCSF Health is the second major health system collaboration for Tia and the collaboration follows expansions in New York, Los Angeles, and Phoenix.
Researchers note the disturbing trend runs contrary to the increased emphasis of many medical schools on health equity and building a more diverse physician workforce.
A new UCLA report finds that states that have eliminated affirmative action admissions at public medical schools also saw enrollment of racial and ethnic minority students fall by 37%.
In a study published this week in Annals of Internal Medicine, researchers at the David Geffen School of Medicine said the disturbing trend runs contrary to the increased emphasis of many medical schools on health equity and building a more diverse physician workforce.
"We know that a more diverse physician workforce leads to better care for racial and ethnic minority patients," said lead author Dan Ly, MD, an assistant professor of medicine at Geffen. "But we have made such poor progress in diversifying our physician workforce. Our research shows that bans on affirmative action, like the one California passed a quarter-century ago in 1996, has had a devastating impact on the diversity of our medical student body and physician pipeline."
The study looked at enrollment data from 1985 through 2019 for 21 public medical schools in California and seven other states with bans on affirmative action and 32 public medical schools in 24 states without such bans.
The year before the eight states adopted their bans, underrepresented students in public medical schools in these states represented 14.8% of total enrollment. Five years after imposing the bans, however, enrollment of minority students at these public medical schools fell 5.5 percentage points compared to public medical schools in states without the bans. The 5.5 percentage point drop represents a 37% reduction relative to the 14.8% enrollment of underrepresented students in the year before ban implementation.
"As our country has spent the last two years weaving through the twin pandemics of racial health disparities amplified by COVID-19 and structural racism at large, our findings are critically important," said co-author Utibe Essien, MD, an assistant professor of medicine at the University of Pittsburgh.
"As we observed, affirmative action bans have resulted in a loss of underrepresented physicians, who could have been at the frontlines of caring for vulnerable populations throughout the pandemic and helping to alleviate disparities in care," Essien said. "My hope is that our findings will help provide policymakers with the tools to push back against affirmative action bans, not just for the diversity of the physician workforce, but for the equal and just health of our society."
Primary care spending, as a percentage of overall spending, varied widely among the eight health plan products examined in the report, from a low of 4.9% to a high of 11.4%.
Investing in primary care is associated with better quality medical care, fewer hospital visits, and savings of $2.4 billion annually in California, according to a new study.
The report -- Investing in Primary Care: Why It Matters for Californians with Commercial Coverage -- looked at eight health plans covering 80% of commercially insured adults in California, almost 14 million people. The report finds that primary care spending, as a percentage of overall spending, varied widely among the health plan products, from a low of 4.9% to a high of 11.4%.
The researchers speculated that if lower-spending providers matched the highest-spending providers, California could see 25,000 fewer acute hospital stays, 89,000 fewer emergency room visits, and a $2.4 billion reduction in overall healthcare spending in one year. As an added bonus, providers would see higher patient satisfaction and quality improvement scores.
"This study is the first analysis of health plan-level primary care investment in California and also the first to delve into primary care spending at the provider organization level, allowing for more granular analysis on the impact of primary care on quality and cost,” said study coauthor Dolores Yanagihara, MPH, with Integrated Healthcare Association. "Our analysis adds to the growing body of evidence that investing in primary care produces higher value and better outcomes for patients and purchasers."
The report comes as a new California Health Care Foundation / NORC Health Policy Survey reveals big differences between insured Californians who have a primary care provider and those who don't. Insured Latinos were the least likely to have a primary care provider compared to other insured Californians.
Californians who have a primary care provider have fewer language, distance, and affordability barriers to care and are less likely to delay care and are less likely to report negative provider experiences.
Kathryn E. Phillips, senior program officer at CHCF, said despite decades of research showing the cost-effectiveness of investing in primary care, "America, on average, spends only about five cents of every health care dollar on primary care."
The Primary Care Investment Coordinating Group of California, led by CHCF, Covered California, CalPERS, and other state agencies and business associations, are joining more than a dozen other states that are pushing for an increased share of healthcare dollars devoted to primary care.
"The shared, sweeping commitment of PICG members signals a major shift in priorities for healthcare in California and is intended to spur new investment in primary care throughout the state and the nation," Phillips said.
The projected savings work under the assumption that state and federal funding would be the same as under the current fragmented financing system.
A final report from California Gov. Gavin Newsom's Healthy California for All Commission claims that that the Golden State could save 40,000 lives and more than $500 billion over the next decade if it adopts single-payer.
"The commission found that, absent a shift to unified financing, California will spend $158 billion more annually on healthcare in 2031, approximately 30% more than baseline spending," the report said. "By contrast, residents, businesses, and government agencies would save money within the first year of the new system — and those benefits would increase over time."
The projected savings work under the assumption that state and federal funding would be the same as under the current fragmented financing system, and that that savings would funnel down to employers and families. The commission suggested that a portion of the projected $500 billion in savings generated by single-payer could be used to fund long-term care services for every resident of California.
Under the commission's framework a "unified financing system" would:
Provide universal entitlements for all Californians for a standard package of healthcare services that could include long-term care support and services, which would relieve the growing burdens on millions of families;
Allow no variance for entitlements based on age, employment status, disability status, income, immigration status, or other characteristics; and
Eliminate distinctions among Medicare, Medi-Cal, employer-sponsored insurance, and individual market coverage.
The report said the next big step for single-payer would be to engage the federal government to set the parameters for funding and undertake steps for legislative approval in California. However, the most-recent attempt to advance a single-payer bill in the California Assembly stalled in January after the bill's sponsor -- Assemblymember Ash Kalra (D-San Jose) -- conceded he didn’t have the votes.
As for the fate of commercial health plans, the report offers no firm recommendations, but suggests that huge savings would be generated by the reduction in administrative costs if payers are still around after the transition to single-payer, they could be relegated to administrative roles.
California hospital margins — a measure of financial performance — were 26% lower on average than before the pandemic.
The COVID-19 pandemic may be waning, but California's hospitals are still reeling from the economic fallout that has cost them $20 billion in the past two years and put more than half of hospitals in the red.
According to a Kaufman Hall study commissioned by the California Hospital Association, Golden State hospitals in 2021 lost nearly $6 billion, roughly three times the $2.2 billion that had been projected. In 2020, California hospitals lost $14 billion.
Federal CARES Act relief softened the blow somewhat, but California hospitals still took a $12 billion hit, the report says.
"The pandemic has taken a devastating financial toll on the majority of hospitals in California," CHA President and CEO Carmela Coyle said at a media event detailing the report. "In communities throughout our state, many hospitals are struggling to provide services for all who need care. It is going to take years for hospitals to recover from these losses, and the truth is some hospitals may not survive."
The report shows that 51% of the state's hospitals are operating in the red, compared to 40% before the pandemic, with higher expenses such as labor costs largely to blame. Total costs for California hospitals rose 15% in 2021, outpacing the 11% national average. These cost increases were largely driven by higher labor costs and medical supply chain shortages. Overall, California hospital margins — a measure of financial performance — were 26% lower on average than before the pandemic.
The report also shows that while hospitals took care of fewer patients in 2021 than pre-pandemic, those patients who were hospitalized were sicker and required longer hospital stays, which the report says likely is the result of hospitals caring for both extremely ill COVID-19 patients, and those patients who delayed non-COVID-19 care earlier in the pandemic.
Because hospitals are commonly paid a fixed amount per admission, fewer admissions and longer lengths of stay create additional financial pressures for hospitals.
Roger Sharma, president and CEO of Emanate Health, says his non-profit, three-hospital system serving the East San Gabriel Valley was dealt a devastating blow by the pandemic.
The system, which serves a largely Hispanic community, gets 80% of its reimbursement from Medicare or Medi-Cal, lost $30 million in FY 2020 and an additional $16.6 million in the first two months of 2022. To stay afloat, Emanate Health has had to dip into reserves to make payroll and pay utility bills, mandate 20% payment cuts for managers, and suspend pension plan contributions from mid-2020 to mid-2021, with only a 50% restoration from mid-2021 to now.
"In the last decade, we have never been in the red before," Sharma says. "The pandemic might have clinically ended, but the economic disaster is continuing — even more severely today. If the current economic burden continues, we are worried about running out of funds to keep the hospital operational and expanding much-needed services for our community."
One observer says the best way to address sketchy labor practices is through civil litigation, not criminal prosecutions.
The April 15 acquittal of conspiracy in restraint of trade charges against DaVita Inc. and its former CEO Kent Thiry should raise red flags for the U.S. Department of Justice that its unprecedented criminal prosecution of no-poaching agreements, wage-fixing, and other sketchy labor practices could be a hard sell for juries, one observer notes.
"Many of us in the defense bar have questioned the wisdom of the Antitrust Division's fixation on so called 'labor market cases' and resource expenditures to try to find and bring criminal no-poach cases," says Ann O'Brien, a former assistant chief of DOJ's Competition Policy & Advocacy Section, and now an attorney with BakerHostetler.
"What we are seeing in these trial defeats for the Antitrust Division is the culmination of a years-long effort to find 'labor market' cases and push the boundaries of Section 1 of the Sherman Act to criminalize conduct that has never before been treated as per se criminal conduct," said O'Brien. "Juries have spoken, as have judges in their jury instructions, and they do not agree."
"Defense counsel often put 'labor market' in quotes because people are not widgets and labor is not a proper antitrust market," O'Brien says.
"I question the wisdom of the Antitrust Division bringing no poach cases as criminal per se cases because for decades non-compete and non-solicit agreements have been analyzed as civil offenses under the rule of reason standard because there are often procompetitive benefits attendant to such agreements, which means they are not per se harmful. Context matters."
In U.S. vs. DaVita et al., the Denver-based kidney dialysis specialists and Thiry were charged in three separate conspiracies with rival healthcare companies to suppress competition for some employees from 2012 through June 2019.
O'Brien, who observed the trial, says prosecutors failed to show "beyond a reasonable doubt that the defendants entered into these alleged no poach agreements with the purpose of allocating the market."
"The defense conceded the agreement but hinged the defense on providing context, including strategic business reasons and friendships," O'Brien says. "The defense brought these issues out on cross and also were allowed to present an economist as an expert witness to provide opinions that the movement of employees and wage data was inconsistent with a market allocation agreement and did not result in the widespread harm the government theoretically alleged.
O'Brien says the jury appeared to focus on the context of the agreements and the expert testimony "and could not find that the purpose of the conceded agreements was to allocate the market as defined."
Since the DaVita case was brought forward in 2021, DOJ has filed another five no-poach cases, including one against Surgical Care Affiliates LLC, an alleged co-conspirator with DaVita. O'Brien doesn't believe that DOJ will have much success in those cases, either.
"Since 2016 the Antitrust Division has said prosecuting wage-fixing and no-poach cases is a top priority. They do not seem ready to concede defeat or back down," O'Brien says. "But in the DaVita case the defendants conceded the agreement – typically the heart of an antitrust crime – and they did not win."
"There were defense victories in the DaVita case beyond the acquittals," she said. "The court's findings on the motion to dismiss and jury findings will be helpful to defendants in pending no poach cases."
Instead of criminal prosecution, O'Brien says DOJ should pursue civil charges, or press for legislative changes.
"The Antitrust Division should be thinking long and hard about its ability to win these cases and whether they should be brought under the principles of federal prosecution," she says.
The payer's 2021 data show a massive increase in telehealth use when compared with pre-pandemic levels.
UnitedHealthcare Inc. members logged more than 28 million virtual care visits in 2021, a 2,500% increase over pre-pandemic usage, the payer says.
"While the COVID-19 pandemic triggered an unprecedented spike in the number of virtual care visits, we are seeing that telehealth has staying power even as many people have returned to in-person appointments," UnitedHealthcare CMO Donna O'Shea, MD, tells HealthLeaders.
"Virtual care visits in 2021 by UnitedHealthcare members approximately matched the total for 2020, with continued significant use of telehealth so far in 2022."
UHC data show that:
Members used virtual care 28 million times in 2021, a 2,500% increase from the pre-pandemic baseline and steady from 2020.
Local providers delivered 95% of those virtual care visits.
Half (50%) of virtual visits -- 14 million -- were for behavioral health, and 63% of all behavioral health visits were done virtually, up from 1.5% pre-pandemic.
The share of virtual care users aged 25 to 44 grew from 36% in 2020 to 38%.
The share of virtual care users among women grew from 62% in 2020 to 64%.
In an email exchange with HealthLeaders, O'Shea talked about the new data on telehealth usage, and what it reveals about the burgeoning sector.
HL: What do your numbers say about the status of telehealth today in the USA?
O'Shea: While the COVID-19 pandemic triggered an unprecedented spike in the number of virtual care visits (a 2,500% increase compared to pre-pandemic levels), we are seeing that telehealth has staying power even as many people have returned to in-person appointments. Virtual care visits in 2021 by UnitedHealthcare members approximately matched the total for 2020, with continued significant use of telehealth so far in 2022.
Virtual care has expanded from delivering care to people who are sick to also focusing on preventing and detecting disease and helping people manage chronic conditions. Through better insights and digital tools, we are seeing virtual care enable the ability to flag gaps in care, prevent complications and avoid unnecessary hospitalizations – all of which can help improve health outcomes and curb costs. As more consumers and care professionals move to a digital mindset, we will continue to expand the use of virtual care, including to help people access primary, behavioral and specialty services such as dental, hearing and physical therapy support.
Importantly, virtual care for behavioral health issues has come in to its own since the start of the pandemic. Many people recognize virtual services for mental health can be as good or better than in-person services, bringing added privacy and convenience. In fact, 66% of our behavioral health claims were virtual in 2021, up from 1.5% in 2019.
HL: What are these numbers telling payers?
O'Shea: The on-going, widespread use of virtual care is an indication that consumers and care providers have embraced this technology. We know that virtual care can help make care more affordable and accessible, especially during nights or weekends and for the 20% of Americans in rural areas. In fact, industry estimates show savings of between $19 and $120 per virtual visit compared to an in-person appointment.
Importantly, many minor ailments can be addressed via a virtual urgent care visit, rather than in the emergency room. A UnitedHealthcare analysis found that about 25% of emergency room visits involve conditions that could appropriately be addressed with a virtual urgent care visit. UnitedHealthcare members using 24/7 Virtual Visits generally pay less than $49 per appointment compared to an average of $740 for an emergency room visit for a similar low-severity condition. These virtual visits are designed to help provide an alternative way to access care when clinics and urgent care facilities may be closed or inconvenient to visit.
Based on the trends we are seeing, we expect telehealth to continue to play an important role in helping people access urgent, preventive, routine and chronic condition care.
HL: We have seen some indications that telehealth use has been tapering off. Should payers do something, i.e. offer incentives to enrollees, etc., to maintain telehealth use?
O'Shea: To support the on-going use of virtual care, it will be important continue certain practices even after the COVID-19 pandemic end. For instance, UnitedHealthcare has supported our network physicians in this regard by modernizing our reimbursement policies to compensate care professionals for virtual visits, while assisting some network health care providers to adopt the information technology infrastructure to virtually connect with patients.
More specifically, a UnitedHealthcare reimbursement policy enables certain primary care, specialist care, and therapy services to be administered virtually as an alternative to in-person visits. Due in part to this policy that will continue even after the COVID-19 public health emergency ends, over 95% of virtual care visits among our members are being conducted with local care providers.
To drive further adoption, we are working with employers to offer employees incentives, such as a financial reward, to jump-start their interest in using virtual care. For example, some employers may consider offering $5 prepaid gift cards to employees for completing a virtual visit registration*. According to one study, that small incentive helped generate a 40% increase in sign-ups compared to a control group.[1]
HL: How does UHC see telehealth growing, both in use and in specialty areas, in the next five years?
O'Shea: We believe the future of virtual care will feature a hybrid model, seamlessly connecting members to care via telehealth and in-person services, when needed. This is already coming to fruition through new virtual-first health plans, which offer an integrated approach to provide care virtually and in-person to make care more simple, convenient, and reduce costs.
For instance, our new NavigateNOW plan represents a transformational step that helps people seamlessly move between virtual and in-person care. People enrolled in this plan are supported by a personalized care team that not only delivers virtual primary, urgent, and behavioral health services at the touch of a button, but also offers a concierge service to make it as easy as possible to schedule follow-up appointments with Optum providers and other health care professionals.
The result: simple, convenient, and more affordable health care, including lowering plan premiums by approximately 15%. Members enjoy $0 for virtual and in-person primary care and behavioral health visits, virtual urgent care and most generic medications, with unlimited chat, online scheduling and on-demand, same-day appointments
[1] UnitedHealthcare internal analysis of more than 90,000 small employers spanning small businesses, key accounts, national accounts and public sector employers, 2020
Those lucky enough to continue to afford health insurance likely will see "significant" premium hikes.
More than 3 million people will join the ranks of the uninsured across the nation in 2023 if Congress allows premium tax credits in the American Rescue Plan to expire, according to the Urban Institute.
Jessica Banthin, a senior fellow at the Urban Institute, said the study shows "that 4.9 million fewer people will be enrolled in subsidized Marketplace coverage in 2023 if the enhanced PTCs aren't extended."
"This comes at a pivotal time when millions of people will be losing Medicaid as the public health emergency expires," Banthin said.
The tax credits have been available for some consumers based on financial need when they buy health insurance through marketplaces created through the Affordable Care Act. The Urban Institute notes that ending the credit would disproportionately disenroll non-Hispanic Blacks, young adults, and low-income people.
Congress would need to act by midsummer to extend PTCs to give Marketplaces, insurers, and outreach programs time to prepare for the 2023 open enrollment, which starts in November.
Those who can afford to keep their insurance can expect to pay hundreds if not thousands of dollars more in per-person premiums.
"The combined effect of ending both the premium tax credits and the public health emergency could lead to a tsunami of coverage loss," said Kathy Hempstead, senior policy adviser at the Robert Wood Johnson Foundation, which commissioned the report.
"A reversal of progress in boosting the coverage rate to record levels seems inevitable if Congress does not act," Hempstead said.
The Fairfield-based nonprofit is trying to determine if the secured access to the personal records of any of its more than 850,000 members in 14 counties has been compromised.
Medi-Cal managed services provider Partnership HealthPlan of California announced on its website that it had been hacked.
Now, the Fairfield-based nonprofit is trying to determine if the secured access to the personal records of any of its more than 850,000 members in 14 counties has been compromised.
Local media are reporting that a ransomware group known as Hive is claiming to have stolen private data, and PHC published a statement on its website acknowledging that it has "recently became aware of anomalous activity on certain computer systems within its network."
The (Santa Rosa) Press Democrat published a screenshot purportedly from Hive claiming that the "stolen data includes...850,000 unique records of name, SSN, date of birth, address, contact, etc." along with 400 gigabytes of data stolen from PHC's file server.
"We are working diligently with third-party forensic specialists to investigate this disruption, safely restore full functionality to affected systems, and determine whether any information may have been potentially accessible as a result of the situation," the statement said.
"Should our investigation determine that any information was potentially accessible, we will notify affected parties according to regulatory guidelines."
Because of the hack, PHC said it can't receive or process Treatment Authorization Requests. As a result, the company said that procedures scheduled within the next two weeks for inpatient admission or for urgent services can proceed as scheduled and the TARs can be submitted retroactively.
The FBI last August issued a Flash Report on Hive ransomware, which surfaced in June 2021 and "likely operates as an affiliate-based ransomware, employs a wide variety of tactics, techniques, and procedures (TTPs), creating significant challenges for defense and mitigation."
"After compromising a victim network, Hive ransomware actors exfiltrate data and encrypt files on the network. The actors leave a ransom note in each affected directory within a victim’s system, which provides instructions on how to purchase the decryption software. The ransom note also threatens to leak exfiltrated victim data on the Tor site, "HiveLeaks."
