Jeff Bendix

Among its other consequences, the COVID-19 pandemic may be harming the mental health and career prospects of 

, especially those with children and physician spouses, a 

, looks at gender differences in work-family responsibilities and emotional well-being among 215 early-career physicians since the start of the COVID-19 pandemic. It found that about one in four of the women surveyed were primarily responsible for providing childcare or schooling compared with less than 1% of the men. Similarly, 31.4% of women said they were likely to perform the majority of day-to-day household tasks, whereas only 7.2% of men were taking those on.

The gender disparities were even greater in households with 

 where 45% of women and 5% of men performed most of the household tasks, and 28.6% of 

 were responsible for schooling and childcare versus 0% of men.

In addition, women were nearly twice as likely as men to work from home (41% versus 22%) and were more apt to voluntarily reduce work hours (19.4% versus 9.4%.) since the start of the pandemic. Here too, the differences were even more stark among two-physician households with children. Among that cohort, 65% of women and 34.6% of men. worked from home, while 25.7% of women and 2.6% of men reduced their work hours.

In terms of mental health, the survey showed mothers scoring substantially higher on surveys measuring symptoms of anxiety and 

. Among survey participants who weren’t parents, however, there was no significant difference in work/family conflicts or depressive or anxiety scores.

The authors note that even before the pandemic, parenthood often meant reduced work hours and income for women doctors, along with greater challenges 

 The arrival of COVID-19 has exacerbated these trends, however, causing more women doctors to reduce their hours and/or work from home, with possible 

“Early evidence from the pandemic suggests that women experience more negative professional consequences than men under work-from-home conditions and lower productivity,” the authors say. “Even short-term adjustments can have…. long-term repercussions as they may lead to lower earnings and negatively impact opportunities for promotion, further exacerbating gender inequalities in compensation and advancement.”

The authors say that mitigating these potential effects of the pandemic will require institutional and public policy solutions. Institutions need to focus on recruiting, retaining and advancing women and ensuring that cost-cutting measures and career advancement metrics do not disproportionately penalize them.

At the public policy level, the authors call for greater support for family care needs, such as childcare and paid family leave, along with wellness programs tailored for physician mothers. A shift in the culture around work-family balance issues is also needed, such as normalizing the use of sick days and parental leave among male physicians in order to weaken gender biases in work and family expectations.

The study, “Experiences of Work-Family Conflict and Mental Health Symptoms by Gender Among Physician Parents during the COVID-19 Pandemic” was published November 12 on 

This article was originally published by our sister publication Medical Economics.

Articles

Pandemic’s impact could worsen gender divide in income and career prospects, study finds.

Work-life conflict, mental stress due to COVID-19 pandemic more common for female clinicians

 pandemic, patients’ initial satisfaction with some forms of 

 is starting to wane, a new survey finds.

The survey by Rock Health, a health care advisory, investment and research firm, is part of an ongoing study of consumers’ use of telemedicine and attitudes towards it. It found that in 2021 43% of respondents were satisfied with the care they received via live video calls—the most widely-used form of telemedicine this year--compared to prior in-person care interactions. In 2020 53% of 2020’s respondents said they were satisfied with live video calls as a form of care.

/websites and text messaging declined, although by lesser margins than live 

 On the other hand, satisfaction with live phone calls and picture/video modalities rose, the latter from 41% to 54%. Satisfaction with email was unchanged.

The authors offer two possible explanations for declining contentment with live video calls as a form of care delivery. The first is that the sense of satisfaction patients felt for having any form of health care during much of 2020, when in-person visits weren’t possible, has faded in 2021. They note that a similar trend has occurred among physicians, 58% of whom view 

 more positively now than before the pandemic, compared to 64% of those surveyed in 2020.

A second possibility lies in the changing nature of why people used telemedicine. In 2020 the largest category of users of live video calls among survey respondents—33%--were people with a medical emergency. Among that group, 77% reported higher levels of satisfaction with virtual interactions than with in-person care.

In 2021, however, the single biggest use for live video telemedicine (32% of survey respondents) was for minor illnesses, and only 37% of those users reported greater satisfaction compared to in-person care. In short, the authors say, “satisfaction with telemedicine as a convenient alternative may be lower than telemedicine as a necessary access point.”

The survey also found less telemedicine use among respondents identifying as white-only than other racial and ethnic groups. In 2021 70% of white-only respondents said they used telemedicine, compared to 87% of Hawaiian Native and/or Pacific Islander respondents, 79% among both Black and American Indian and/or Alaska native respondents, 78% of Asians and 73% of Hispanics.

The authors acknowledge that since the survey was conducted in English via computer, Black and Hispanic adults may be underrepresented since they are less likely than white adults to own a desktop or laptop computer or have home high-speed internet. Even so, they say, their findings are consistent with results of a 2020 Pew study showing that Black, Hispanic and other non-white adults were more likely to use telemedicine than were white adults.

The study, “Consumer adoption of telemedicine in 2021,” is available on the website of 

This article was originally published by sister publication Medical Economics.

Two possible explanations for declining contentment with live video calls as a form of care delivery.



Telemedicine preference may be waning

The study, “Experiences of Work-Family Conflict and Mental Health Symptoms by Gender Among Physician Parents during the COVID-19 Pandemic” was published November 12 on JAMA Network Open.

This article was originally posted on Medical Economics®. 

The pandemic’s impact could worsen gender divide in income and career prospects, study finds.

Female physicians seeing more work-life conflict, mental stress due to COVID-19 pandemic

The Affordable Care Act of 2010 (ACA) extended 

 to previously uninsured millions of Americans. Yet many insured adults, even those with employer-sponsored coverage, find they still can’t afford the care they need. Individuals who are “underinsured” represent a growing challenge for policy makers, insurance companies and providers.

Sara R. Collins, Ph.D., has spent nearly two decades studying insurance 

 and coverage as a vice president of The Commonwealth Fund. Collins is lead author in the latest in a series of studies by The Commonwealth Fund on the state of health insurance coverage in the United States, a project that began in 2001. She spoke recently with 

® about the study’s findings, and their implications for the future of health care. The interview has been edited for space and clarity.

 Since about 2003, we have been tracking though our biennial health insurance survey the number of adults who are insured all year but have high out-of-pocket costs or deductibles relative to their income. We defined someone as underinsured if their out-of-pocket costs are 10% or more of their income, or, if their income is under 200% of the federal poverty level, if their out-of-pocket costs are 5% or more of their income.

We have a separate measure of risk of being underinsured. Deductibles are what we use as a very rough measure of benefit design. So if someone’s deductible is 5% or more of their income, they’re also counted as underinsured.

ME: Most Americans receive their health insurance through their employer, and it seems that gives them enough coverage to meet most of their needs. But your survey shows that 25% of adults in employer-sponsored plans fall into the underinsured category. Why is that?

SC: That is a very good question. If we look at the share of people who are underinsured overall, that is largely driven by people in employer plans, because there are just so many people in employer plans. The share of people in employer-based plans who are underinsured has climbed from about 17% in 2010 to about 28% in 2020. And this growth has really been driven by the proliferation of the number of people who have deductiblesand the size of those deductibles.

In 2010 only 6% of people with employer plans had deductibles that amounted to about 5% of their income. Bu 2018 that share was 15%. So it’s really been driven by this risk of out-of-pocket exposure people experience in employer plans.

ME: The survey also shows a lot of overlap between issues of race, income and insurance status. Can you talk about that and why that relationship exists?

SC: The core coverage problem in the United States, even 10 years after passage of the Affordable Care Act, continues to be concentrated among people with low and moderate incomes, both in insurance and affordability. And this is driven by several factors that are still with us: lack of Medicaid expansion in 12 states; people working in multiple jobs and potentially churning in and out of insurance coverage. [Another factor is that] a lot of people work part time, and those jobs generally don’t come with insurance benefits. Then [there are] also complex Medicaid and ACA marketplace eligibility rules. For example, someone who works multiple jobs may have fluctuations in income that can make them eligible or ineligible depending on the time of year, such as farm workers. Their income might go way up in the summer and bump them out of eligibility for Medicaid. So much about the way people work affects whether they have insurance coverage.

And people of color are disproportionately represented among people with lower incomes, so that’s one reason we see higher rates of uninsurance among Blacks and Hispanic patients. Those differences have fallen over time, just as they’ve fallen between people with higher incomes and lower incomes.

The other major factor is the immigrants who may be living in the country illegally who are not eligible for subsidies under the ACA or Medicaid.

SC: In commercial plans, the prices insurers pay providers are the major determinants of the cost of health care in private markets. And since premiums are primarily driven by costs, these prices also drive growth in premiums. So in order to keep premiums low, employers have tried to share more of those costs with their employees in the form of higher deductibles and other kinds of cost-sharing.

And what’s also important to keep in mind as an employee, as your health care costs grow to be a larger share of your compensation costs, employees are also making wage concessions. So their income isn’t growing. So that means the deductible becomes even a larger share of someone’s income as it grows and income growth doesn’t keep pace. And people who face high deductibles or have high out-of-pocket costs are much less likely to get needed health care.

So there’s a circular aspect to this phenomenon of rising provider prices, the impact of insurance costs and people’s demand for care from the providers whose prices seem to be one of the main culprits.

ME: Is that tradeoff between premiums and deductibles a dynamic that plays out on the ACA exchanges?

SC: It does, for sure. If you look at our report, you see that rates of underinsurance are even higher in the individual market than on employer plans. So even though a lot of the growth in underinsurance is coming from employer plans, people with individual market plans tend to have much higher deductibles. There’s just no countervailing pressure. Under the ACA, exchanges are not allowed to negotiate down price differences. Some insurers, such as California, has been very experimental in terms of getting price concessions from employers. But in general, the marketplaces haven’t had a lot of leverage to lower premiums and deductibles.

ME: How does lack of insurance or underinsurance affect individuals’ care decisions?

SC: We find that people who are uninsured, are insured part of the year but not other parts of the year or who are underinsured are much more likely to report not getting health care because of costs. In our most recent survey, more than half of adults who were uninsured for any time during the prior year reported not getting health care due to cost. This could include not filling a prescription, not getting specialist care, not going to the doctor when they’re sick, not getting a recommended follow-up test or treatment.

ME: Does that contribute to the disparities in health outcomes among racial and ethnic groups?

SC: Adequate insurance coverage is not the only determinant of access to health care, but it is the most important one. And that was the consensus of the Institute of Medicine in 2003, I believe, so this predated the Affordable Care Act.

But there is no question that insurance coverage is the most important factor. We know that there are other issues, race equity issues, in people’s ability to get high-quality health care, but people at least need to have good health insurance in order to make that first step to access.

ME: How does that also affect a family’s or individual’s overall financial situation?

SC: We find that people with inadequate coverage, particularly if they’re uninsured or have a gap in their coverage or are underinsured, are much more likely to report problems paying their medical bills. [This leads to] not being able to pay their bills, being contacted by collection agencies about unpaid bills and carrying debt over time. It’s directly related to problems paying bills.

We also find that people who report problems paying medical bills experience long-term financial issues. They’re much more likely to say they used up all their savings to pay their bills or that they had a downgrade in their credit rating because of unpaid bills. So it’s a problem that is specific to health care, but it does flow over into other aspects of people’s lives. We even find that about 25% of people report having to cut back on food, heat or electricity because of medical bills.

ME: Is it fair to say that although the ACA reduced the number of uninsured Americans, it didn’t address the problem of underinsurance or even made it worse?

SC: What’s important to remember is that the essential health benefits requirement for individual market plans and limits on out-of-pocket cost exposures, bans on preexisting condition exclusions in health plans, no annual or lifetime benefit limits, are very important provisions in terms of protecting people from catastrophic-type costs that people were regularly experiencing in individual market plans.

And we even see it now in plans that don’t comply with the Affordable Care Act, such as short-term policies, where people are paying premiums for very skimpy coverage that leaves them very exposed to health care costs. And if people get coverage through the marketplaces, and their incomes are below 250% of poverty, which is about $32,000 for an individual, they’re eligible for plans with reduced cost-sharing that include lower deductibles. But as you move up the income scale, people are exposed to increasingly higher out-of-pocket costs and increasingly higher deductibles.

In 2020, in the 38 states where the federal government ran their marketplaces, the average deductible for a silver level plan was about $8,100. So that’s a pretty high deductible. And it’s why we see the higher underinsured rates in individual markets still. So there has been improvement, but there is still a ways to go to lower those underinsured rates in the individual market.

ME: How is the COVID-19 pandemic affecting the problem of underinsurance?

SC: I think what we’re seeing in our biennial survey, which was in the field from January through June of [2020], is that there’s just a persistent vulnerability among working-age adults and their ability to afford health care. And this could worsen if the pandemic continues and the economic downturn continues.

And that is because, aside from many people losing their health benefits because they’ve lost a job, if people’s incomes aren’t growing, or their business revenue is taking a hit, if out-of-pocket costs don’t change, or if their deductibles don’t change or the premium contributions don’t change, that means that health care is going to take up a larger and larger share of Americans’ incomes over the next year. So it will have the effect potentially of worsening the number of people who are exposed to high costs relative to their income.

ME: Of course, that will depend on how long the pandemic lasts.

SC: That’s right. Right now the economic downturn has affected people in some industries more than others. We know that people in retail and food and beverage and accommodations have been the most likely to lose their jobs. And those tend to be industries that usually don’t offer health benefits. So a lot of people were already uninsured in those in those jobs or had coverage through Medicaid or whatnot.

But if the downturn continues, the question is whether we will see job loss in other industries that do tend to come with benefits, or just an overall drop-off in income growth or flattening in income growth that’s widespread through the economy.

This article was initially published by our sister publication Medical Economics.

A discussion about what affect under-insured patients will have on health care.

 Under-insured patients: What physicians need to know

Efforts to combat physician burnout usually focus on individual doctors through programs aimed at building resiliency and dealing with stress resulting from systemic factors such as heavy workloads and loss of individual autonomy. But a new study suggests that reducing burnout requires an organization-level response — creating medical practice cultures that value qualities such as teamwork, open communications and process improvement.

To learn more about the study and its implications for reducing burnout, 

® spoke with lead author Samuel Edwards, M.D., who is an assistant professor of medicine at Oregon Health & Science University and a practicing internist with the Veterans Affairs (VA) Portland Health Care System. The interview has been edited for length and clarity.

What led you and your colleagues to undertake this study?

 This is part of a larger study, which was an evaluation of the EvidenceNow initiative. EvidenceNow was a large quality improvement initiative funded by the Agency for Healthcare Research and Quality, focused on improving cardiovascular preventative care in small- to medium-sized primary care practices.

Our group in Oregon was part of a large nationwide team funded to do an enterprise evaluation [of EvidenceNow] called ESCALATES, [which stands] for Evaluating System Change to Advance Learning and Take Evidence to Scale.

As part of that, specifically, we did surveys of practices and people in those practices at the start of the initiative in 2015, then several times throughout, and one thing we really wanted to understand was practice climate and burnout since it’s such a common and concerning issue in primary care.

Edwards: One of the things we were interested in understanding was how much of burnout is a practice level phenomenon versus related to individuals. And we found definite evidence of a practice level effect in burnout. Specifically, we characterized practices by how much burnout they had in them.

What was interesting was we found that in 30% of our sample none of the practice members said they had any burnout. And given the dire descriptions of burnout in medicine today we thought that was an interesting finding, so we chose to focus on characterizing those zero-burnout practices versus a group of practices that were very high burnout to try and understand the differences.

We had this measure of practice culture which we called adaptive reserve. It consists of six domains: facilitative leadership, work environment, teamwork, sense-making, culture of learning and relationship infrastructure. All that stuff is superstrong. These practices used more quality improvement strategies, and they tended to be physician-owned solo practices and didn’t participate in large transformation initiatives like accountable care organizations or the Transforming Clinical Practice Initiative or a number of others. In general, we saw this signal that smaller practices with greater agency and a strong culture tended to have less burnout than other practices.

ME : Do you have any thoughts as to why practice culture is such an important factor in the presence and level of burnout?

Edwards: I think it’s intuitive to some extent. A place where you have strong leadership and good relationships among practice members have been shown to be associated with low burnout. One thing that stood out to us was that leadership is so important. Specifically, facilitative leadership, which is not traditional command and control, hierarchical leadership, but more fostering relationships, enhancing communication, attending to power imbalances, focusing on psychological safety and cultivating teamwork.

I think we can all identify with environments where we’ve felt that everyone’s on the same team, working towards a common mission that’s meaningful and important, where people like and care about each other, versus places where you don’t feel listened to, and you don’t feel like the work is important.

ME: I want to explore that term “psychological safety” a bit more. What do you mean by that?

Edwards: Psychological safety is basically the idea that you feel safe bringing things up. Like if there’s a problem, you’re willing to bring it up because you don’t feel like you’ll be criticized or punished for pointing it out. If you’re in an organization that’s trying to improve its performance and everyone’s too scared to say something’s wrong, you’re not going to get anywhere. You have to have that trust, that rich communication, that feeling you’re safe in bringing things up to really make progress. It has a superstrong relationship with burnout.

ME: Another interesting finding was that zero-burnout practices tended to be ones that didn’t participate in accountable care organizations. I’m wondering if you think that might discourage practices from joining accountable care organizations (ACOs), and if so, what affect that might have on the drive to move practices towards value-based care?

Edwards: That’s a great question. On the one hand it’s important to remember that all these practices were willing to participate in EvidenceNow, so they were already practices ready to engage with a large quality improvement effort. But the signal around ACOs was pretty strong. We’ve cut these data several different ways and this is a pretty strong relationship.

Since this is a cross-sectional analysis the “why” and “how” is difficult to say. But some ideas we had is that maybe it’s kind of an overload for practices, like if you’re involved in too many quality improvement initiatives pulling you in too many different directions that might contribute to burnout. We know that different health plans use different measures and ACOs have different measures and that might lead to burnout.

ACOs vary a lot, too. On the one hand when you put ACO funding together with the independently owned practices and the solo practices you might imagine that ACOs represent a loss of agency for the practices. So practices that have more independent control of what they’re working on and why might have less burnout compared [with] those who are responding to more external demands.

But ACOs are not all monolithic, hospital-driven quality measure machines. A lot of them engage practices in constructive ways. So I don’t think there’s a single lesson here, but I think there’s reason for concern that some of the policy-level levers for improvement could be related to more burnout and we should understand why.

ME: Have you gotten any pushback to your study from CMS or organizations representing ACOs?

Edwards: No. But I think we all appreciate that fee-for-service primary care medicine is suboptimal and moving towards a system where practices are paid for meaningful work is reasonable. But there’s some evidence that some of these approaches that may be a little more top-down have the secondary impact of increasing burnout. But again, this is a cross-sectional study so we’re just theorizing based on the associations we see.

ME : You mentioned that a lot of the zero-burnout practices were small and/or clinician-owned. That’s not the kind of environment most primary care doctors practice in today. Can any of the features of zero-burnout practices be replicated in large health care institutions?

Edwards: Well, on the one hand there are a surprising number of smaller practices still in existence. But I operate in a large-practice environment and many doctors do nowadays. But it’s certainly possible to maintain a strong practice culture within a large organization. Making larger organizations feel small by having smaller practice groups with more autonomy about how they run their day-to-day operation and have more control can really make a big difference.

I think about our practice in the VA, which is a big federal system, we really take time on our team to build relationships so that we trust each other and work together to get the work done. We all share that common mission about providing primary care to our patients is important and meaningful, and we care about it.

A point I mentioned in the paper is the concept of facilitative leadership. We think it’s important for people with formal leadership positions to act that way, but we can also build that culture as a team and have everyone participate in a work environment where there’s open communication and trust.

ME: I suppose if you’re a hospital system the sweet spot is maintaining the efficiencies of a large organization while still giving practices and individual physicians enough autonomy to operate on their own and feel they’re an important part of the larger organization?

Edwards: Yeah, and there are so many pressures for these organizations — the financial pressures and quality reporting pressures. Everyone’s getting pushed to do a lot with less. If you give people complete autonomy it probably wouldn’t work. But we’re certainly seeing in primary care things have kind of reached a head, where there’s a lot of turnover, it’s hard to retain and recruit people to environments where they don’t have any control and aren’t inspired by the work. And obviously retention and recruitment is super-expensive, so it’s in their interest to make people happier, want to stay longer and hopefully do a better job.

But we saw examples in our study of larger practices that were able to achieve zero burnout and strong adaptive reserve.

ME: Are you planning any sort of follow-up to this study?

Edwards: We have three waves of this survey, so one thing we hope to do is look at the longitudinal data to see if burnout declined over the time of the intervention and maybe look at some of the associations there. Hard to say whether the intervention did it or maybe just the changing context and challenges that continue in primary care. But that’s what we’d like to do.

ME: What are the key takeaways from this study?

Edwards: I think burnout is definitely a practice- or organization-level phenomenon and it affects all employees, and that practice-level culture is really important and potentially a place for intervention. So fostering leadership development could be really powerful.

The fact that smaller practices with clinician ownership who don’t participate in ACOs have less burnout really illustrates the importance of agency. So improving agency at the practice level also will help reduce burnout.

ME: You say in the study that too many of the remedies for burnout have been aimed at the individual rather than the practice level and aiming at the individual will only take you so far.

Edwards: Absolutely true. And if you look at the burnout literature, it’s been recognized forever that work environments contribute to burnout. But we continue to offer individual-level solutions, even though we know that the organization and the core of the work environment is more of the cause. So I think our study just adds to the literature that organization-wide approaches are essential.

This article was originally published on Medical Economics®. 

A new study suggests that reducing burnout requires an organization-level response — creating medical practice cultures that value qualities such as teamwork, open communications and process improvement.

Reducing burnout requires an organization-wide response

The wide availability and high degree of efficacy of COVID-19 vaccines means that the vast majority of COVID-related hospitalizations in the U.S. now are preventable. And those hospitalizations have cost the nation’s health system more than $2 billion this summer, according to a new 

Using data from the CDC, CMS the Department of Health and Human Services, the authors found 185,000 adults with confirmed cases of COVID-19 were hospitalized in June and July. Of those, 182,000, or 98.3%, had not been vaccinated for the disease. From that they subtracted those who may have been hospitalized for reasons other than COVID-19—a number derived from CDC data on vaccinated patients—leaving an estimated 134,000 who were hospitalized primarily due to COVID-19.

The authors then used CDC data on vaccines’ effectiveness in preventing hospitalizations to estimate that 84% of hospitalizations due primarily to COVID-19 are preventable, leaving 113,000 preventable hospitalizations due to COVID-19.

Finally, the researchers estimated that each COVID-19 hospitalization cost around $20,000, a figure derived from CMS and FAIR Health statistics along with Kaiser’s own pre-pandemic data for commercial insurance claims related to pneumonia with complications. Multiplying the cost by the number of preventable hospitalizations, they arrived at a total of $2.3 billion.

That figure, they add, probably understates the true cost burden to-date of preventable COVID cases, since it does not include infections and hospitalizations that have occurred in August, or any costs of outpatient treatment for the disease.

Since hospitalized patients usually pay only a fraction of the total cost of their care, most of the cost of treating the unvaccinated is borne by the nation as a whole, in the form of taxes for public programs and higher premiums for commercial plans.

185,000 adults with confirmed cases of COVID-19 were hospitalized in June and July. Of those, 182,000, or 98.3%, had not been vaccinated for the disease.