Is ‘Back to Business’ ready for its close-up?

In the face of a lawsuit by state Republican legislative leaders to overturn the extension of the Department of Health Services’ (DHS) Safer at Home order, Gov. Tony Evers has more than once asked, “What is their plan?”

Indeed, neither Assembly Speaker Robin Vos (R-Rochester) nor Senate Majority Leader Scott Fitzgerald (R-Juneau) has specifically embraced an alternative to the Badger Bounce Back plan that the Evers administration rolled out.

Individual lawmakers have proffered more than one alternative. But the one that has so far drawn the most attention has been one put out by the state’s largest business lobby, Wisconsin Manufacturers & Commerce: its “Back to Business” plan.

WMC has published the broad outline of its proposal in two forms: a four-page summary and a series of digital presentation slides. The business lobbying group has circulated the plan among other trade associations and state legislators; on Thursday, April 30, the Assembly Committee on State Affairs held a hearing featuring only witnesses invited by the Republican leaders, including executives from WMC member companies as well as other trade associations. No public health experts were called to testify on the plan.

This week the Wisconsin Examiner circulated the plan for review to a collection of outside analysts for their assessment. Three responded: two public-health specialists and an economist who is part of a team that has been conducting its own analysis (not yet published or peer-reviewed) of ways policymakers might respond to the pandemic.

All three found points to commend in the WMC plan, but all three also raised questions about limitations that should be addressed before it could be safely implemented.

“Like any approach to get back to work, it’s a balance between risking transmission of the disease, and the illness and death that will follow, with the need to really get the economy going,” says Dr. Patrick Remington, a retired UW-Madison medical school professor.

Starting up the economy immediately “is not feasible at this time — that would lead to explosive outbreaks and tens of thousands, hundreds of thousands of cases and many deaths,” Remington says. “But the converse is not tenable — to simply have everybody stay at home. What we have to do is negotiate the balance. It won’t be business as usual — that’s the common ground.”

Elements of the plan

The “Back to Business” plan relies on an algorithm that would evaluate every business in the state for reopening during the continuing pandemic, assigning a risk value to the firm based on four variables: the local county’s infection rate, the county’s population density, how concentrated employees are within the workplace of the business based on its industrial classification, and the capacity and utilization of healthcare facilities in the county.

The calculation of workplace employee concentration relies on the six-digit North American Industry Classification System (NAICS), used by the federal government for statistical analysis of business operations. The healthcare capacity figures would be based on availability of intensive care unit (ICU) beds, ventilators and personal protective equipment (PPE).

The plan envisions a Department of Health Services (DHS) website where the information about a business would be entered and, based on the algorithm’s calculations, the business would be assigned a risk category of “minimal,” “moderate” or “substantial.”

All businesses, regardless of risk level, would be required to encourage sick employees to stay home, encourage employees who are able to work from home to do so, train employees on COVID-19 “awareness, personal responsibility and social distancing,” modify workplaces as needed to maintain 6-foot physical distances among employees and between employees and customers, routinely clean and disinfect the workplace, limit access to or close common areas such as break rooms where employees congregate, and develop response plans for when employees get sick at work.

Moderate-risk businesses would, in addition, be required to asses their PPE use and availability, expand routine cleaning and disinfection, limit customers or non-employees on the premises, mandate more work from home or modified work hours to reduce interaction, and regulate entrances and exits so employees and customers stand at least 6 feet apart.

Substantial-risk businesses would add to the foregoing requirements mandatory PPE guidelines for employees, screening for employees before entering the workplace if possible, a response plan for when an employee is confirmed to have COVID-19, and more stringent limits on the number of non-employees or customers on the premises.

Evaluating the plan for the Wisconsin Examiner were Remington, professor emeritus in the UW-Madison School of Medicine and Public Health’s Department of Population Health Sciences; David Larsen, an epidemiologist and professor of public health at Syracuse University; and Sarada, a professor of management and economics at UW-Madison.

The Wisconsin Examiner emailed WMC inviting the organization’s responses to a series of questions drawn from the reviewers’ comments. There was no response by publication time. This story will be updated with any response received after publication..

The rating algorithm

All three of the evaluators agreed that one of the plan’s basic premises — rating a business on the basis of conditions in its county and on the industrial classification — was essentially sound.

“I think in general it’s a good idea to try to quantify or separate the potential risks for different businesses and then respond accordingly,” says Larsen.

“The WMC plan does a good job in laying out some of the considerations and some of the decisions that businesses will have to make in coming back to work,” says Remington. The model’s inclusion of the nature of the business and what’s happening in the community are both good ideas, he adds.

The level of detail in the industrial code ensures that firms within a single group “are fairly similar in their operations and their consumer base. That’s going to be helpful,” says Sarada.

“From a business perspective there’s going to be two risks of coronavirus,” Larsen says. “The first is that the business provider transmits [the virus] to the customers, the clientele, or it transmits within the business. And the second is someone from outside enters the business and brings the virus in and it circulates within the business.”

Given those risks, “it makes sense to have different levels of risk based on how public-facing a business is, based on the number of employees, based on the spaces available and the nature of the business, the air circulation — a lot of different factors that would go into a business’ risk,” Larsen adds. “They’ve done a good job to begin to identify those.”

Remington says it will be important to differentiate within a single industrial classification what could be major differences in how a business operates — such as one restaurant that has a well-spaced group of outdoor tables and another that has standing room only inside. “There’s going to be a lot of middle ground where you just don’t know” how at-risk a particular establishment might be, he explains.

Remington also would like to see added to the community metrics in the algorithm a score for the local public health department’s capacity to respond to an outbreak. “If that capacity is non-existent, that would trump the other scores,” he says.

Testing and tracing

As written, the WMC plan is silent on one important condition for making it work: It makes no reference to the presence of widespread testing for the virus and tracing the contacts of infected people to see if they have received it or spread it, while isolating people who are infected so they can’t spread it to others.

The absence of those elements drew criticism of the plan at last week’s hearing, but WMC’s chief lobbyist, Scott Manley, told lawmakers the organization assumed DHS would continue with the intensive testing and tracing project it has undertaken as part of the state’s Badger Bounce Back Plan, and that WMC would support that.

On Wednesday, DHS and Evers announced a new web-based, searchable map for residents to locate testing sites around the state operated by local public health departments. A statement from the governor’s office called the map a tool to help reach four testing goals for the state’s plan: responding to all outbreaks at places of employment, corrections facilities and congregate care facilities; testing every nursing home resident and staff member in the state; establishing testing programs for people with COVID-19-related symptoms in target communities around Wisconsin; and ensuring that everyone with those symptoms gets a test.

Remington says a robust program of testing, tracing and isolation is a necessary condition for the plan to be effective. “Until that capacity’s in place any attempt to go back to work will increase the risk of transmission,” he says. Without it, “should there be an outbreak, we won’t have the capacity to contain it.”

A related concern is that hasty implementation of the plan could lead to continued cycles of the virus popping up, being tamped down, and popping up again in other communities so that “you’re just chasing the virus,” Remington says.

Larsen says that he would want to see the results of a widespread testing and contact tracing program included in the formula in the WMC plan, not just hospital use.

“The big indicator that’s not in this conversation is the suspected cases — how many suspected cases do you have that are unable to get tested?” Larsen says. “That number gives you confidence around what the confirmed cases are — whether you’re missing a big chunk of transmissions or not.”

Enforcing compliance

Another detail that the WMC plan omits is explaining how the requirements that the plan suggests for businesses will be imposed.

“What is the incentive for a firm to conform?” asks Sarada. And if a workplace is to be reorganized to meet physical distancing requirements, “who’s going to evaluate the engineering protocols? Who’s going to be monitoring compliance?”

While voluntary compliance might not end up being an issue, one way to enforce it, she explains, is through a tax rebate that rewards the appropriate company behavior, accompanied by an inspection program that would certify that the necessary conditions have been met. Another would be a system of fines under more traditional regulatory mechanisms. Either approach would appear to require the passage of new laws in the state Legislature.

While in theory it might be argued that a company would comply in its own self-interest to rebuild consumer confidence, “the end consumer might not be aware of compliance, which might incentivize the plant itself not to comply,” Sarada says.

Sarada notes that the rating for a business can go up or down as circumstances and conditions change in the county where it’s located, or in the business itself. That flexibility could have both positive and problematic qualities.

If the risk score for a particular business rises to moderate or substantial, public safety would dictate reacting quickly to implement the more stringent measures associated with that level in order to reduce the possibility of spreading the illness, she says. But if the score falls to a less risky level, it would be prudent to delay relaxing the mitigation standards in order to be sure that the better conditions are here to stay.

“You want these risk measures at this point to be as conservative as possible,” Sarada says. “You want to give them the highest possible risk score that is both reasonable and reflects the plausible risks until they are truly ready to move down.”

Workplace testing

One idea that employers may need to consider is some form of testing in the workplace. Sarada says that would probably be reserved for more densely populated workplaces, because community testing should be able to capture a large number of people with the illness.

She and Larsen both describe approaches to testing in which representative pools of workers might be tested as a group in order to conserve testing materials but still effectively cover large numbers of workers.

Larsen says other tests, such as one based on saliva that is under investigation, may be possible. Sarada says researchers are examining whether the novel coronavirus can be detected in sewage, another way of possibly gauging how widespread it is in a particular community.

But if employers do test workers for COVID-19, they must be prepared to provide employees with appropriate protections in the form of paid time off while they recover from the illness and health insurance to cover their treatment, says Larsen.

“One of the big issues is, if people are sick, do they have the ability to keep their jobs and stay home for the required two weeks?” he asks. “And do they have the ability to feed their families during those two weeks and pay their bills?”

Workers need those protections to ensure they stay home and isolated to stop the spread of the disease, Larsen says. “Any hint of that not being the case means this thing will fail and fail dramatically.”

The limits of models

One unavoidable limitation of the WMC proposal is inherent in the nature of any mathematical model of risk that people haven’t been able to test.

“There’s really no evidence to suggest that this risk model actually translates to true risk,” says Remington. “It’s a model based on assumptions, and it’s not based on evidence.”

That’s not the fault of the plan’s designers, he emphasizes — it’s simply the nature of the COVID-19 pandemic: it’s too soon to have enough data that would provide evidence. The model’s assumptions “make sense, but they’ve never been tested.”

Whatever plan the state uses to restart its economy, there will be some viral spread.

“Going back to business will lead to more transmission — we know that,” says Remington. “The question is whether the cost of that increased transmission is lower than the benefits of going back to business.”

Everyone staying home can only work for a time. People will need to resume making a living at some point. But when they do, he says, “we should have the capacity to respond to the outbreaks and the diseases that will result once people start going back to business.”