Women in the healthcare workplace: Hopeful signs and challenges ahead

Gretchen Berlin: I think as organizations are dealing with the vacancies that we’re seeing at the frontline, the turnover that we’re seeing among leaders, there’s increased focus on workplace culture, leadership support, flexibility in jobs and time in job and place of work.

Erika Grotto: Connecting the dots between motherhood, work and burnout, today on HFMA’s Voices in Healthcare Finance podcast.

Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, we’re discussing McKinsey and Company’s 2021 Women in the Workplace report with Gretchen Berlin, a senior partner in the firm’s healthcare practice. But first, let’s find out what’s happening in healthcare finance news. Here’s HFMA Senior Editor Nick Hut and HFMA Policy Director Shawn Stack.

Nick Hut: Hey, everybody. Shawn and I are here today to talk about a recent report from the HHS Office of Inspector General, which is basically the federal watchdog for government-run healthcare programs, and they issued a report about Medicare Advantage health plans. A big finding in the report was that 13% of denials of prior authorization requests in Medicare Advantage contradicted coverage criteria that rightfully would be used to approve the service if the beneficiary instead were enrolled in the Medicare fee-for-service program. Shawn, what are some of the concerns about this trend?

Shawn Stack: Yeah, Nick. This OIG audit, I think providers are very happy that these numbers are finally getting out and getting some attention, but these have been ongoing issues for years surrounding imaging services, denials of imaging services, where Medicare Advantage payers are using different criteria than Medicare are, or placing folks in post-acute care where Medicare Advantage and commercial payers have been denying or postponing the release of patients to rehab services. You know, for the most part, for lack of better words, maximizing that DRG as a hospital inpatient stay because they don’t have to pay the hospital any more for holding the patient in the bed those additional days. So it’s nice to see some light being brought on the administrative burden that this process puts on hospitals, puts on payers, puts on the patient themselves along with added stress, right, to recovery time. So it is nice to see this audit come out and these findings be put in writing as recommendations for improvement by HHS and OIG.

Hut: Yeah, without question, put in writing and quantifying the trend, I think, is an important step. OIG estimates that if you took that 13% rate of inappropriate denials and extrapolated it out, it would come out to just under 85,000 such denials per year, so if you put stock in the findings and the projections it’s a significant issue with a large number of beneficiaries being denied care that they actually need.

Stack: Yeah, Nick, and I think another important factor to pull out here is one of the recommendations for HHS and CMS to issue new guidance on the appropriate clinical care criteria that payers use. Some use two different types of clinical care criteria that are accessible by providers, and some use their own blended clinical care criteria. So being transparent and letting the providers know what the clinical criteria they are using, you know, to approve these procedures or to approve these transfers is necessary and is something that has not been able to be clarified in the past. So I know that’s one of the recommendations that the OIG made, and it will be interesting to see what happens there in that area.

Hut: Yeah, very important point, definitely something to keep an eye on. I think another noteworthy finding of the report is that 18% of payment denials were deemed to contradict coverage rules and the billing rules of the health plan in question. Now, in other words, those payments should have gone through but didn’t, and the most frequent issues with those denials seemed to just be, you know, manual and system processing errors. So again, it shows that there are certainly some kinks with Medicare Advantage, and it’s relevant just because of how quickly the program is growing. In 2021, I saw about 42% of Medicare beneficiaries were in Medicare Advantage, and that share is expected to reach 50% within the next few years. So definitely some things really, hopefully can be cleaned up.

Stack: Yeah, and I think it’s going to be interesting to see now if the OIG or CMS takes a closer look at how the Medicare Advantage clinical care policies and criteria conflict with Medicare rules and regulations, and even Medicare bundles. Take, for instance, the sepsis bundle that’s been around for years. The managed care plans adopted Sepsis 3 criteria years ago and started denying providers who were doing early intervention in sepsis, which was Sepsis 2 criteria. And Sepsis 3 criteria was established to predict mortality rates in sepsis patients. So it’s not really applicable for a clinical care pathway, so things like this that have made it very hard for providers to deploy and improve patient outcomes based on preventive care, those areas also that were not talked about in the report too much need to be looked at, and so it will be interesting to see if the OIG further probes into the data to see where improvements can be made there.

Hut: Absolutely. Yeah, definitely something we need to continue to follow. Thanks, Shawn. Great stuff from you as always. I wanted to note that legislation has been drafted in Congress to improve prior authorization and Medicare Advantage. It’s called the Improving Seniors Timely Access to Care Act, and it recently gained enough support in the House to be considered in a vote in the full chamber. Late last year on this very podcast, I spoke with the lead sponsor of that bill, Congresswoman Suzan DelBene, so if you’re interested in hearing her insights on what the bill would do, you can find that episode in the show archives. Thanks, everybody.

Stack: Thank you, Nick.

Grotto: In January 2021, I spoke with Elizabeth Newman and Annie Kurdziel from McKinsey and Company about the firm’s 2020 Women in the Workplace report and the effect the pandemic has had on working moms. I’ll put a link in the show notes for anyone who would like to go back and listen to that conversation. As things have evolved over the last year, I’ve been eager to do an update to that episode. Recently I spoke with Gretchen Berlin, a senior partner in McKinsey’s healthcare practice, about the 2021 Women in the Workplace report as well as others the firm has released in recent months, including a December 2021 report titled “Covid-19 and burnout are straining the mental health of employed parents” and an April article titled “Women in healthcare and life sciences: The ongoing stress of COVID-19.” We discussed how burnout at work and home is affecting women in healthcare and what changes are being made and can be made with an eye toward improvement.

Berlin: Many of the trends that we’ve seen in Women in the Workplace and looking at healthcare in particular as we have over the last couple of years have held true. I would just say on the healthcare view, we continue to be optimistic about the industry and the greater representation of women throughout the pipeline, and we have seen some improvements at early promotion levels—director and senior manager, which have increased about four percentage points over the last two years and continue to outpace other industries, so that’s exciting. And we actually see lower levels of attrition among women than men in healthcare and lower in healthcare overall than other industries. I think the thing that is different this year and slightly alarming, especially just frankly, by the time we report the data, it is several months delayed from when the sentiment survey was in place and obviously, the sentiment survey is a bit of a leading indicator beyond what we look for in the pipeline data, and what we found this year is that the sentiment of those likely to leave among women has gone up. So about one in three. That has been validated in some of our additional research focused on the frontline clinical workforce, where we see consistently now over the last several iterations that we’ve done on the survey where about 30% of nurses say they’re likely to leave, and that is pretty alarming as we haven’t seen that flow through into the actual pipeline data yet, but I think we’re all on edge, waiting for the next numbers to actually see the impact of that. Of course, we have some leading indicators on parts of the industry that are tracked nationally. There was the report earlier this week in Health Affairs around the decrease for the first time ever in the nursing workforce, for example, and my sense is, we may see some of that play through into other roles throughout the leadership pipeline as well.

Grotto: That statistic you mentioned of one in three women considering downshifting or leaving the workforce, that was the thing that jumped out at me when I took a look at the report this year, because I remembered so well that last year it was one in four. And one in four to one in three is pretty shocking, I thought.

Berlin: Yeah. Some of it is increased opportunities. So our colleagues in our organization practice have been looking at this phenomenon a lot across industries and how particularly as organizations go more virtual, folks who live in a certain part of the country are now able to have a national job market at their disposal, and that may open up opportunities either across organizations or even across industries. But I think a lot of it comes down to just the increased burnout—and I know there’s sensitivity around the term burnout, but definitionally it’s having stressors and not being able to have a break—and as the pandemic wears on and particularly for, you know, you mentioned the article in parents, which, obviously it’s not everyone, but there’s a Venn diagram overlap with a lot of women in the workplace there. The increased burden and likelihood of burnout has increased as the pandemic has worn on.

Grotto: You know, thinking about healthcare specifically, the Women in the Workplace report found, and I’ll quote here, “Women in healthcare specifically are twice as likely as men to cite parenthood and increased home responsibilities as reasons for missing out on opportunities for promotion. And according to the Bureau of Labor Statistics, in 2021, women made up 77.6% of all healthcare workers in the United States. So again, talking about that Venn diagram overlap, not all women are moms, but considering worsening shortages, you know, issues with burnout in healthcare, I believe there has to be a connection here. But as you mentioned earlier, the Women in the Workplace report also showed that in 2021, women left healthcare jobs at lower rates than in other industries, and there were some sort of hopeful signs in healthcare. So what does this all mean? What do you think? Are there actions that the healthcare industry can do?

Berlin: Yeah, I think in terms of what it all means, as I said, I’m not sure we’ve seen it flow through in the actual turnover data yet at all levels. I suspect that we will see changes in the pipeline data overall. What we saw in our nursing survey is the pandemic also allowed a portion of the workforce to be actually more excited about their jobs, leaning into the mission, the acuity of what was happening. And I suspect there’s a bit of that that we’re seeing in the healthcare pipeline overall for the timeline that we’re looking at, because remember, the data is a little bit lagged. So it’s more likely that what we’re looking at in this year’s report is actually the start of the pandemic in the data, where we certainly heard anecdotally from organizations across the healthcare value chain that they were not seeing turnover in their leaders at the start. They were starting to hear about burnout. Now, anecdotally, we’ve started to hear that that has changed as people have continued to have burnout. We’ve gotten through the acute peaks and we’re learning to live with Covid peaks and valleys as an industry. I suspect that that will just continue to flow through. And then I think as organizations are dealing with the vacancies that we’re seeing at the front line, the turnover that we’re seeing among leaders, there’s increased focus on workplace culture, leadership support, flexibility in jobs and time in job and place of work. And that varies depending on the part of healthcare you’re talking about, depending on the company. Certainly there’s a varied stance on it. But across the board, I think there will be more flexibility, more focus on employee support, employee mental health in the long run than there was at the start of the pandemic and that, in the end, will be a good thing for everyone. But we are hopeful that it will support women in the workplace and parents in the workplace disproportionately as well.

Grotto: I want to point out a specific area of the report. We discussed it in our episode last year, and I’m curious about your thoughts here, on the struggles of women in the workplace being worse for women of color, and that does not seem to have changed since last year. What are your thoughts about this trend?

Berlin: Yeah, I think we’ve consistently both across industries and in healthcare have seen a more challenging picture for women of color, which is consistent with what others have found in various looks at this and is very troubling that it exists, that it persists. One of the things that we looked at specifically this year in greater detail is one, the likelihood of experiencing a microaggression in the workplace is certainly higher among women of color. And so this is folks repeating a point that you made in a meeting and taking credit for it, or having to overhear a joke that is sort of demeaning to your identity in the workplace, and it’s much more likely that that happens to women and more likely that it happens to women of color. Interestingly it’s more likely that it happens to senior women, so as you think about becoming the “only” in a setting, which we’ve written about in previous years, it just becomes more and more challenging. The other focus of this year’s report has been around the disproportionate role that women and women of color play in supporting diversity, equity and inclusion agendas in the workplace and therefore having to carry a disproportionate workload on the people agenda fronts than male or white male, white women counterparts, which just adds to the level of stress. And it compounds on itself if you’re doing more of that and having more of those conversations with folks who are experiencing what we were discussing, it just continues a bit of the emotional weight that you’re carrying both as a person but then also organizationally and helping to try to address.

Grotto: What would you like to see and what do you think could be feasible if you could look ahead to next year’s Women in the Workplace report, what kinds of changes do you think we could make in a year? I’m putting you on the spot. That’s probably not a fair question.

Berlin: No, no, no, it’s fine.

Grotto: If it’s not a fair question, I will withdraw.

Berlin: No, no, no. Some, I think, is what I was saying earlier about the flexibility. I hope what we’ve found is, even if women have potentially downshifted the amount of time they’re spending in a role, they’re equally if not more satisfied in their jobs and feel supported in doing that. Or that if they haven’t downshifted, they have found some level of flexibility and support for the stressors that they have outside of the workplace, even more than they did before the pandemic. Some of that may be hard to achieve in a year, but I think healthcare organizations in particular are accelerating on the flexibility that they’re doing. From a frontline perspective, for example, a lot of systems are starting to think about virtual roles even in an inpatient setting for things like discharging patients or taking a history and physical where you don’t necessarily need to be physically present to ask those questions, and that can provide flexibility for folks who are looking for that type of role full time or even flexibility within a person’s sort of annual job, maybe spending a portion of their time doing that and providing a bit of reprieve from their day to day, which I don’t know would have happened without the pressures that we’ve seen from Covid. So that is all very exciting and I think definitely have a significant impact before next year’s report.

Grotto: Yeah, I’ve been in some conversations lately that have talked about that as well of, you know, maybe now if ever is going to be the time when actual change comes. We talk about things like maternity leave, which we don’t have in this country, you know, and you’re lucky if you get it at your workplace. And it seems like there is a big societal push for some change that we won’t be relying on—there’s a podcast I listen to that one of the hosts is always talking about the individual solution to the systemic problem. Not gonna work. But it seems like we are maybe working our way toward the systemic solution, and I hope that is the case.

Berlin: Yeah, absolutely. I actually think that there’s been some universal pressure on the parental leave front for example. I mean, this push for the hashtag #showusyourleave, and the push for greater leave, not only for birthing parents but for non-birthing parents. I mean, we’ve been talking a lot about women, but obviously many of the stressors, and in particular the working parent pressures are just as present for men, and the more I personally believe the more that it is normalized across men and women to share that, it will lift all boats in the workplace. So I think some of the pushes that have been happening organically in our national dialogue are going to help change that pretty quickly, even if it’s not nationwide policy.

Grotto: Yeah, yeah, I would agree with that. Alright, well, thank you so much. This topic always feels sort of depressing, but I think there are some glimmers of hope here.

Berlin: I agree.

Grotto: So Gretchen Berlin, thank you so much for joining me today.

Berlin: Thank you.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is our director of content strategy. Our president and CEO is Joe Fifer. If you plan to attend HFMA’s Annual Conference in Denver, I hope you’ll come say hi between sessions. We’ll be easy to find. Or if you want to talk with us via email, you can do that too. Reach out at [email protected].

More women considered leaving the workforce in 2021 compared to the previous year, but many are seeing greater success in their careers by way of promotion, according to McKinsey & Company’s Women in the Workplace survey for 2021. On a recent episode of HFMA’s “Voices in Healthcare Finance” podcast, Gretchen Berlin, a senior partner in McKinsey’s healthcare practice, discussed the report and other recent research from the firm.

Berlin pointed out some hopeful signs in the report, which was conducted for the seventh year in 2021, particularly in healthcare.

“We continue to be optimistic about the [healthcare] industry and the greater representation of women throughout the pipeline, and we have seem some improvements at early promotion levels—director and senior manager—which have increased about four percentage points over the lats two years and continue to outpace other industries,” she said. “And we see lower levels of attrition among women than men in healthcare and lower in healthcare overall than other industries.”

But the number of women considering leaving the workplace is alarming when compared to the year before, Berlin said. The 2020 report showed that one in four women were considering downshifting their careers or leaving the workforce. In 2021, that number increased to one in three. In healthcare, about 30% of nurses said they were likely to leave. That has not yet come to fruition, but Berlin said the firm is watching to see what will happen.

Combating burnout

A 2021 “Voices in Healthcare Finance” podcast episode looking at the 2020 Women in the Workplace report focused on the effect of the pandemic on working mothers, and the burden on parents continues to be a challenge, Berlin said. Women represent 77.6% of all healthcare workers in the United States, and although not all women are mothers, parenthood can play a role in burnout, she said.

Organizations that present flexibility can help alleviate some of the stressors experienced by workers, Berlin said.

“Even if women have potentially downshifted the amount of time they’re spending in a role, they’re equally if not more, satisfied in their jobs and feel supported,” she said. “Or if they haven’t downshifted, they have found some level of flexibility and support for the stressors that they have outside of the workplace.”

Remote work can be one way of alleviating some of the pressure, even in clinical settings, Berlin said.

“A lot of systems are starting to think about virtual roles even in an inpatient setting for things like discharging patients or taking a history and physical where you don’t necessarily need to be physically present to ask those questions,” she said.

Providing parental leave also can help alleviate pressure, especially when it is equally applied to birthing parents and non-birthing parents, she said.

“The more it is normalized across men and women to share [parental responsibility], it will lift all boats in the workplace,” she said.