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The Keckley Report

Four Healthcare Workforce Issues that Require Attention

By August 3, 2020March 1st, 2023One Comment

The U.S. healthcare industry employs 16.8 million. In the pandemic, it is considered an “essential industry” among several considered necessary to managing the crisis. Its frontline workers in nursing homes and hospitals enjoy heightened appreciation and public trust. But four problems in its workforce lurk beneath the surface:


Complaints and lawsuits against employers by employees who allege unsafe working conditions as a result of the coronavirus are increasing. Prominent companies like HCA, Walmart, Tyson Foods and others face labor unrest. Note: to date, 898 frontline caregivers have died. A Lancet study published last week of 99,795 frontline health-care workers in the UK and US. found that Sars-CoV-2, the virus which causes COVID-19, was present on average in 2,747 cases per 100,000 frontline health-care workers compared with 242 cases per 100,000 people in the general community. Health care workers with adequate gloves, gowns and face masks had 3.4 times the risk of contracting the coronavirus compared to the general population and minority health care workers had an even greater risk of testing positive.

To date, Congress has not determined how it will manage the litigation tsunami that might result from the coronavirus. Some employers are taking matters into their own hands, requiring their employees sign COVID waivers, releasing them of all related liability. However, states like California have ruled on this issue, calling the waivers unenforceable because the employee essentially has no option but to comply just to keep their job. And under normal circumstances, these incidents would be covered by workers compensation. Nonetheless, it’s an incredibly complex and evolving issue- lawsuits will follow and adequate reserves by employers will be necessary.

Pay Disparity
The pandemic has brought intense scrutiny to the widespread disparity in healthcare workforce compensation. Across healthcare’s 34 licensed professions, the range is from $28,000 per year for home care aides to specialists who bill more than a million and have partial ownership in the surgery centers and diagnostic labs they use. Disparity despair will prompt scrutiny of executive compensation, physician specialties and the mechanisms used by compensation committees to assess and reward performance.

For example, not-for-profit health system C suite compensation increased 4-7% annually for the past 5 years—more than comp for their rank and file employees. And pandemic relief funds that turned red ink to profit for many health provider organizations may be factored into bonus payments for their leaders.  That’s why union organizing in nursing homes and hospitals is escalating. It explains why primary care physicians are joining private equity and insurer-backed groups to participate in their cost-reduction efforts that reduce unnecessary hospital and specialist spending. 

But specialty PPMs are not going away anytime soon. As I’ve discussed before, it’s no surprise that these highly compensated groups have taken a beating- they’ve been forced to reshuffle their cards, especially those that were heavily reliant on electives and/or were highly leveraged going into the pandemic. Some have recovered better than others- that’s clear- but impairment charges related to these roll up deals are inevitable, and valuations will no doubt be impacted. Buyers are still circling, seeing this as an opportunity to get a deal if they believe run rates will recover to pre pandemic levels. They understand the leverage they hold. And with record dry powder on the sidelines, the trend in PPM deals will continue. But you better believe physician compensation- now more than ever- will be highly scrutinized as part of the deal making process, regardless of the model (employment, ownership, etc.). While overall compensation in healthcare is higher than other industries (median $$68,190 in May 2019 vs. 39,810), it is unusually distorted by high compensation for medical specialists and low levels of compensation for around 5 million physicians in different roles.

That sets the stage for escalating pay disparity despair.

Scope of Practice Constraints

Physician-controlled scope of practice restrictions limit what nurses and pharmacists can do and vary widely state to state. They fly in the face of innovations like telehealth and guided self-care that expand the role of consumers and enable access to providers who are not local. Opposition by the American Medical Association against authorization of pharmacists to administer COVID tests is the most recent example. The frontline for scope of practice disputes are states where licensing responsibility is ascribed to professional groups. The acceleration of telehealth, recognition of whole-person care, evidence that addressing social determinants like food insecurity and others are legitimate interventions and growing discontent of consumers mean scope of practice constraints that protect the interests of each guild are no longer relevant.


The shortages that loom most prominently are in primary and preventive health services, especially nurses trained in whole person care and organizations skillful in providing whole person care to populations. According to HRSA, 1.9 million new healthcare workers are needed by 2028. However, it remains to be seen how many are needed since these models discount the potential that technology-enabled self-care, managed Medicare and Medicaid expansion and therapeutic alternatives to unnecessary drugs, tests and procedures emerge.


These problems are manageable but more significant than what’s reported. The good will gained in the pandemic is at risk if undone by labor disruption. The historic security of employment in healthcare with better-than-average workforce benefits no longer apply: the financial services and technology industries offer comparable compensation packages with attractive professional development opportunities for career acceleration.

Like every industry, the healthcare workforce is directly impacted by school re-openings and Congress’ deliberation about unemployment benefits and the moratorium on evictions. Unlike others, it is directly exposed to the frightening physical and emotional impact of the COVID-19 virus that has rocked our world.


PS Tomorrow, voters in Missouri will decide whether their state will expand its Medicaid program becoming the 38th state to pass expansion. Primaries in 6 states (AZ, KS, MI, MS, WA, TN) will be determine candidates for the November 3 races. Presumptive Democratic nominee Joe Biden will announce his pick for VP, and school re-openings will begin. Congress will likely announce its 5th relief package.


Nguyen et al “Risk of COVID-19 among front-line health-care workers and the general community: a prospective cohort study” Lancet July 31, 2020

Kacik “As front-line workers suffer layoffs and furloughs, giving executives bonuses can stir resentment” Modern Healthcare August 1, 2020;

Gaffney et al “Illness-Related Work Absence in Mid-April Was Highest on Record” JAMA Intern Med. July 27, 2020;

Janet Adamy “Families File First Wave of COVID-19 Lawsuits Against Companies Over Worker Deaths” Wall Street Journal July 30, 2020;

“U.S. Health Workforce Chartbook” Health Resources and Services Administration

“AMA, Pharmacists at Odds Over COVID-19 Testing, Vaccine Pay” Modern Healthcare July 24, 2020;


Vital stats: CDC, World Health Organization, Johns Hopkins Center for Health Security

  • Cases: 4.5 million in U.S. (26% of 16.81 million worldwide) averaging 65,000 new cases/day for the past 2 weeks with 56,000 currently hospitalized

  • Deaths: 154,447 in U.S. averaging 1000/day since June 3 forecast to increase to 173,000 by August 22 (23% of 662,095 global total). Forecast (CDC)

  • Vaccines in development: 199 vaccines in development, 18 in phase 1 safety trials,12 in phase 2 expanded, 6 in phase 3 efficacy trials (WHO) including two begun last week by Moderna Therapeutics and Pfizer/ BioNTech. A third by Oxford University/AstraZeneca is expected phase 3 soon.

Studies: School Closure Associated with Lower Risks for Children

The Cincinnati Children’s Hospital Research team examined data from 50 states between March 9, 2020 and May 7, 2020 to isolate the association of school closure with outcomes, state-level nonpharmaceutical interventions. Results:

  • “COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100 000 population. School closure was associated with a significant decline in the incidence of COVID-19 and mortality.”

  • States with the lowest incidence of COVID-19 had a −72% relative change in incidence compared with −49% for those states with the highest cumulative incidence.

  • Closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days.

Related: The Johns Hopkins University research team examined rates of COVID-19 incidence and mortality across all 50 states after primary and secondary schools were closed in March. After adjustment for state testing rates and other nonpharmaceutical interventions, school closures were associated with a 62% decline in the incidence of COVID-19 per week (whereas the incidence had increased by 265% per week before closures). The absolute reduction in COVID-19 incidence associated with school closures was estimated at 424 cases per 100,000 people during days 17–42 after closures. Similarly, COVID-19-related mortality declined by 58% per week after school closures. The absolute reduction was estimated at 13 deaths per 100,000 during days 27–42 after closures. Reductions were greatest in states that closed their schools early, when COVID-19 incidence was lowest.

Note: According to the National Association of School Nurses, one in four primary and secondary schools do not have a school nurse, 39% have a part-time nurse and 34% full time. There are 95,766 full-time equivalent school nurses per NASN.

Auger et al “Association Between Statewide School Closure and COVID-19 Incidence and Mortality in the US” JAMA July 29, 2020. doi:10.1001/jama.2020.14348

Sadoughi, Saitz “U.S. School Closures Tied to Decreased COVID-19 Incidence, Mortality” New England Journal of Medicine July 29, 2020;

Essential Workers in Workforce Highly Vulnerable

  • Essential workers comprise 40% of the US adult population. Of essential workers, 46% are female, 14% black, 17% Hispanic, 11% uninsured, and 8% 65 years or older. 25% of essential workers have low household income, 18% live in a household with at least 1 uninsured person, and 18% live with someone aged 65 years or older.

  • Eight of the 21 industry categories account for 73% of essential workers. Health care accounted for a larger proportion (15%) of essential workers than any other industry: 65% of health care workers held essential jobs. Black individuals were overrepresented in several essential industries, notably transportation (23%), public administration (18%), and health care (18%).

McCormack et al “Economic Vulnerability of Households With Essential Workers” JAMA. June 18,  2020;324(4):388-390;

Study: April 2020 Workforce Sickness at Record High

Using the monthly Current Population Survey (CPS), researchers examined “out sick” respondents who reported having a job but being absent the previous week due to their “own illness/injury/medical problems for the first 4 months of 2020.Findings:

  • Employment was stable at approximately 156 to 158 million from January 2019 to March 2020, but fell to 133.7 million in April 2020.

  • More workers were out sick in April 2020 than in any month since January 1976, the earliest month for which such data were available.

  • All demographic groups experienced increased rates of sickness-related work absence However, the increments, relative to 2019, were significantly larger for immigrants, workers aged 55 years or older and workers without college education.

  • “Our findings shed light on the combined health and economic effects of the COVID-19 pandemic, particularly for immigrant, older, and less-educated workers.”

Gaffney et al “Illness-Related Work Absence in Mid-April Was Highest on Record” JAMA Intern Med. July 27, 2020;

Gallup: Concern about COVID Treatment Costs Higher in Low Income, Minority Populations

According to the Gallup-West Health U.S. Healthcare Study of 1017 adults conducted June 8-30, 2020:

  • 58% of non-White adults vs. 32% of White adults report that they are either “extremely concerned” or “concerned” about being able to pay for the cost of care if they are diagnosed with COVID-19

  • Respondents from households with annual incomes under $40,000 were three times more likely to report concern over the cost of care than their counterparts from households with incomes of $100,000 or more.

Witters “In U.S., Large Racial Divide in COVID-19 Cost Concerns” Gallup July 29, 2020;

Poll: Majority Concerned about Vaccine Safety

The POLITICO/Morning Consult poll was conducted online from July 24 to 26 among a national sample of 1,997 registered voters. Results:

  • More than 60%of voters think the U.S. should fully test any coronavirus vaccine — even if that delays rolling it out and allows the virus to keep spreading in the meantime vs. 22% that think government should make a vaccine available as soon as possible, even if it had not been fully tested.

  • While 82 % of respondents overall said they would take a U.S.-made shot, 24%of Republicans and 9% of Democrats said they would refuse one.

  • 23% percent said they would not take a China-made vaccine vs. 17% who would turn down an American shot. The largest group declining a China-made vaccine were those who viewed Trump “very favorably,” with 40% saying they would not take a vaccine made in China

“Most voters say they’d rather wait for an effective coronavirus vaccine” Politico July 29, 2020;

Poll: Trust in Trump Impacts Views about Pandemic

This ABC News/Washington Post poll was conducted July 12-15in English and Spanish, among a random national sample of 1,006 adults:

  • 64% of Americans distrust what President Trump says about the COVID-19 pandemic—including 46% who say they don’t trust him “at all”—while only 34% trust what he says.

  • Americans in counties with the most cases of COVID-19 per capita have the least trust in the President with only 24% in those counties trusting.

  • Americans broadly disapprove of Trump’s response to the coronavirus pandemic; 60% disapprove and only 38% approve, as compared with 53% disapproval and 46% approval in May.

  • Mask-wearing is correlated with how much a respondent trusted the president: Only 41% of those who trust Trump regularly wear a mask, as compared with 66% of those who distrust him.

  • Only 33% of respondents prioritize the economy over controlling COVID-19—as Trump has pushed—while 63% want to “control the spread, even if it hurts [the] economy.”

“ABC NEWS/WASHINGTON POST POLL: The Coronavirus Pandemic” July 17, 2020;


Axios/Harris Poll: Healthcare Gains Public Trust but Lags in Overall Reputation Relative to Tech

Notable changes in how the public views these industries/sectors since the beginning of the coronavirus:

  • Big gains: doctors, hospitals, nurses (+47%), grocers (+35%), technology (+28%), pharmaceutical (+17%)

  • Big losses: airlines (-7%), media (-5%)

  • Notable findings in Axios/Harris Reputation Scores for companies:

  • Healthcare Providers in Top 100: None

  • Healthcare Insurers in Top 100: United #59

  • Healthcare Retailers in Top 100: CVS #37, Walgreens #38, Walmart #85,

  • Pharmaceutical/Medical Device Manufacturers in Top 100: Pfizer #61, Johnson & Johnson #68

  • Tech Companies with Health Industry Verticals in Top 100: Amazon #3, Microsoft #19, Google #24, Apple #27, Facebook #97

Methodology: The Harris Poll conducted four rounds of nominations totaling 8,392 respondents to determine the companies included in the ranking: Nov. 4-6, 2019; Nov. 12-14, 2019; Dec. 5-9, 2019; and June 11-15, 2020.This year’s company ratings phase was conducted June 24-July 6, 2020 among 34,026 U.S. adults who are very or somewhat familiar with the company. Each company received an average of approximately 305 ratings per company

“The 2020 Axios Harris Poll 100 reputation rankings” Axios July 30, 2020;

Oscar, Humana, CVS Adds Care Management Partnerships

The New York-based health insurance startup Oscar Health said Thursday that it will offer individual and family plan members in certain states a new option to receive all primary care services virtually, starting in 2021. Each primary care visit, as well as generic and low-cost brand name prescription drugs, labs, and diagnostic imaging orders and the first specialist visits will cost the member nothing out of pocket. Separately, Oscar also announced expansion that will bring its health plans to 19 states and 47 markets, including four new states (AR, IA, OK, NC) and 19 new markets next year.

Also last week, Humana announced its latest foray investing $100 million in primary care house call company, Heal to provide “house calls and one-touch medicine” to its 3.8 million Medicare Advantage members.  It’s consistent with its previous investment in Strive Health that offers in-home renal care services.

And CVS announced addition of five companies focused on weight loss and mental health including Daylight, an app to help users manage worry and anxiety, Vida, a startup that offers personalized health coaching and therapy, Naturally Slim, an online weight loss program and Weight Watchers, which has built out its own digital plans. And Kurbo, a program designed by Weight Watchers to help children and teens make healthy lifestyle choices

Note: In recent weeks, primary care acquisitions among insurers (United, Humana, Oscar, Blue Cross of NC et al have increased as have investments by Walmart, Walgreens, and CVS.

“Humana Buys $100 Million Stake In Doctor House Call Company, Heal” Forbes July 29, 2020;

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