Labor

Dive Brief:

• A total of 30,000 healthcare jobs were added to the U.S. labor rolls in July, representing 18% of all new jobs added during the month, according to the Department of Labor.
• Virtually all of the healthcare job growth occurred in ambulatory care — that segment accounted for 29,000 new jobs alone.
• The weak spot was in hospital job growth, which was down by 2,000 jobs from the month before.

Dive Insight:

Hospitals are often the biggest employers in many towns and medium-sized cities, but their job creation has been uneven at best in recent months. According to an analyst note from Jefferies, employment by hospitals dropped by 2,000 on a seasonally adjusted basis, although that grew to a net 1,000 new jobs on an unadjusted basis.

By comparison, hospitals added a seasonally adjusted 9,000 new jobs in June, 25,000 on an unadjusted basis. However, much of that boost was created by the minting of new residents who just graduated from medical schools.

Hospital employment is still growing at a 1.8% annual clip (compared to 1.4% as of July 2018), although that's down from the 2.1% rate reported in April.

"Overall, healthcare employment growth continues to demonstrate strong momentum, but hospital jobs growth appears to be moderating," the analysts said. Inpatient providers account for more than 5.2 million jobs nationwide.

However, Jefferies' analysts believe that healthcare will continue to be a big job engine for the foreseeable future.

"We believe the supply of clinical labor continues to struggle to keep pace with solid demand growth, resulting in tight clinician labor markets and strong demand for healthcare temp staffing services," they said.

Although healthcare job growth has been extremely robust, wages have been stagnant in recent years, a phenomenon attributed in part to continued consolidation among industry players.

The ambulatory care segment has been growing rapidly in recent years. Its addition of 29,000 new jobs was up from 17,000 in June, and significantly outpaced the year-to-date average monthly growth of 22,000.

Home healthcare services added 11,000 new jobs last month alone — the highest rate since 2017. The segment's annual growth rate is currently 5.3%, up from 3.2% in July 2018.

The nursing home segment added another 1,000 jobs.

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Dive Brief:

• The healthcare industry hired another 15,700 employees in May, bringing the total of new jobs added over the past 12 months to 391,000.
• The gains were largely thanks to the ambulatory sector, which added 12,200 jobs last month and accounted for 78% of total healthcare job growth. Physician offices alone added 7,900 jobs and other outpatient healthcare practices added 2,700. Medical and diagnostic labs added 1,100 jobs and dental offices added 800.
• Nonetheless, employment growth is tepid at best. The month of May had 42% fewer hires than in April, and almost 70% fewer than in March, according to the newest data from the U.S. Bureau of Labor Statistics.

Dive Insight:

Unemployment remains historically low, hovering at around 3.6% compared to 9.4% in May a decade ago at the height of the recession. However, though the U.S. economy is strong currently, May's job creation numbers coasted in below economists' expectations amid slowing global growth and trade tensions with Mexico, China and the European Union.

Like all other industries, healthcare is weathering the effects of a lukewarm economy, adding less than 16,000 new jobs last month — the weakest growth since September 2017, according to the U.S. Bureau of Labor Statistics.

But healthcare remains attractive to new entrants for a variety of reasons, with healthcare positions snagging 44 out of 100 slots in U.S. News & World Report's 2019 Best Jobs list in January due to high salaries and strong job security. Physician pay alone has grown 20% since 2015, although healthcare industry wages as a whole have remained largely flat due in part to rampant industry consolidation among providers.

Hospitals reported some small employment increases in May, netting 3,000 additional jobs.

The home health industry added no new hires in May and other assorted ambulatory healthcare services actually lost roughly 500 jobs. Outpatient care centers added 200 jobs last month.

Nursing and residential care facilities' job growth also was stuck in the mud last month. Nursing homes and community care facilities for the elderly added no new jobs, and residential mental health facilities actually lost 100 jobs (though that figure's far lower than the 1,400 that were lost in April).

Remaining types of residential care facilities added 500 jobs.

However, healthcare hiring was stronger than almost all other industries, including construction, which added only 4,000 jobs in May. Mining, manufacturing, wholesale trade, retail trade, hospitality and transportation saw little change over the past month, although professional and business services was the outlier with 33,000 new hires.

Article top image credit: Getty Images

Dive Brief:

• Hospital profitability declined for the first time this year during the month of June. Operating margins were down 1.88%, according to a new flash report from Kaufman Hall.
• Analysts blamed the decline on the inability of many hospitals to rapidly cut expenses to match a decrease in patient volumes. Bad debt and charity care expenses were also up.
• Meanwhile, non-labor expenses per adjusted discharge rose 5.3% compared to June 2018, while labor expenses per adjusted discharge increased 4.9%.

Dive Insight:

Hospital and healthcare system operations are often so large and complex that at times they can't act quickly to address declines in profitability. Based on the most recent Kaufman Hall flash hospital report, June 2019 appears to be one of those times.

The report concluded hospitals lacked the flexibility to cut costs as patient volumes decreased. In June, adjusted discharges, patient days and emergency department visits dropped more than 5% compared to May 2019. Operating room minutes declined by 7% compared to May and are down 1.8% year over year, a trend the report said was "most concerning." At the same time, expenses rose significantly compared to June 2018.

There were some exceptions. Hospitals with 500 beds or more saw an increase in pre-tax profit margins for the third consecutive month, which the report attributed to increased revenues. Smaller hospitals ( fewer than 25 beds and 200-299 beds) also had improved margins, which was connected to increased inpatient volumes. However, mid-sized hospitals (300-499 beds) saw the biggest decline in profitability, while those in the 100-199 bed range also struggled.

Hospitals in the South also fared better than average, which the report attributed to "strong expense management during a period of stagnant volume growth." By comparison, hospitals in the Midwest, where revenues were flat while bad debt and labor costs were on the rise, had pre-tax margins that were nearly 3.7% lower.

But the report also suggested that most hospital operators are not seeing the big picture. "Nationwide, hospitals continue to be overly optimistic about inpatient volumes, while underestimating the increase in ambulatory care," it said.

Hospitals also face other potential headwinds: The upcoming Physician Payment Fee Schedule from CMS may not be favorable to providers; federal legislation to end surprise medical bills could wind up being enacted in law; and the courts could wind up striking down the Affordable Care Act, leaving some 20 million Americans without health insurance.

The report concluded "a lack of flexibility is a fundamental risk to hospitals and health systems and something that industry disruptors are likely to use to their advantage in the coming months and years."

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Healthcare employment is growing at a record pace, but wages remain stagnant, which some experts say likely results in part from the trend of consolidating health systems.

The latest Bureau of Labor Statistics numbers show the industry gained 49,000 jobs in March and 398,000 over the past 12 months. Analysts at Jefferies say the month-to-month growth is the second largest increase on record for the sector. Healthcare job growth has surpassed non-healthcare job growth and nudging the share of total jobs to an all time high, according to consulting firm Altarum.

Hospital employment grew by 14,000 jobs in March, adding up to a total of 120,000 for the combined first quarter of 2019. BLS tallied ambulatory jobs at 27,000 and home health and skilled nursing jobs at 9,000.

At the same time, real average weekly earnings for production and non-supervisory employees across sectors grew 0.1% over the month according to BLS. That growth in earnings is due to an increase in average weekly hours.

For nurses and pharmacists working in hospitals in heavily concentrated markets, annual wage growth has been lagging behind national rates by as much as 1.7 times. That's according to researchers Elana Prager and Matt Schmitt, of Kellogg and UCLA, respectively, whose working paper compares wage growth rates in markets where mergers have occurred.

The paper drew the ire of the American Hospital Association.

"Among the many serious concerns about the study are its lack of rigor in the definitions and assumptions it used, and absence of data on total compensation and the recognition of other obvious factors that could affect wage growth," an AHA spokesperson said in a statement criticizing media coverage of the research.

Academics researching the impacts of consolidation have asked the Federal Trade Commission to look at the impact horizontal mergers have on labor and consumers before they become difficult to challenge. FTC green-lit hundreds of horizontal hospital mergers over the past decade, maxing out at 115 in 2017, according to the National Institute for Health Care Management. In 2009, there were 50 such deals.

A Penn Law paper on mergers and labor markets published last year found employer consolidation has had a direct impact on wages and productivity in concentrated labor markets in the past. Wages, the authors write, tend to dilute when competition is scarce and labor concentration is "very high, as high or higher overall than product market concentration."

Jason Plagman, a healthcare analyst at Jefferies, agreed, telling Healthcare Dive it becomes an "oligopsony situation where there are only a handful of buyers of a product" — in this case, labor — "you tend to see [employers] exert more control."

As AHA noted, hospital and health systems tend to offer non-wage benefits, "such as employer-sponsored insurance, time off and education benefits" rather than increase wages. That's an important caveat, said Dennis Shea, a health policy professor at Penn State.

 

Labor push

The debate comes as nurses unions have been pushing hard for additional staff and higher wages for hospital workers in consolidated states like California, New York, Massachusetts and Pennsylvania. Hospital consolidation has raised prices as much as 20% to 40% when they occur in the same market, according to National Institute for Health Care Management, with some prices reaching as much as 55%.

Unions argue hospitals can afford to pay extra to hire more nurses. Jefferies analyst Plagman said it's not that easy. About 50% of hospital revenue goes to salary, wages and benefits, he said, and half of that chunk of revenue goes to nurses. "If they give a 3% raise to all nurses, that's a big impact on their overall expense line," Plagman said.

The lack of competition bars labor from seeking work elsewhere. A nurse in a concentrated labor market can't quit their job to work for the hospital down the street, because it's probably owned by the same health system, Shea said.

Shea and Plagman agreed that movement of labor away from concentrated markets is one way to break the wage slump. But lack of mobility was one of the consequences of concentration found in a National Bureau of Economic Research published in February 2018. The paper suggests a negative relationship between consolidated markets and wages that becomes more pronounced with higher levels of concentration and only increases over time.

Pay raises have historically been pushed by labor unions, and though some hospitals have already raised wages, few have been inclined to raise staffing levels as well.

"Strikes are picking up," Shea said. "That's always an indicator that wage and salary growth will pick up a little bit."

While labor disruption has been on the rise over the past year, Plagman ​said he expects employment and wage growth to continue at the current pace. At some point, he said the market will have to resolve itself.

"What we're seeing is hospitals and healthcare providers are hiring, but they've been very disciplined over the past few years giving raises to nurses and therapists," Plagman said.

In testimony to the FTC in October, economist Alan Kreuger alleged employers in concentrated markets "collude to hold wages to a fixed, below-market rate," even when the economy is booming. Union membership has plummeted 25% since 1980, and without a counterweight to balance the power of a monopsony, he argued, employers are free to set wages at will — even if they lag behind inflation rates.

Pressures to contain costs and move from volume to value is forcing health system executives to be extra delicate with their labor expenses. When nurses strike, hospitals have temps at the ready. That's a boon for staffing agencies like AMN Healthcare Services and Cross Country Healthcare.

Cost control in healthcare is a bit like "pushing on a balloon," Shea said.

Slow growth or declines in one sector means business is booming for another. In this case, ambulatory added 27,000 jobs month-to-month in March, up from 22,000 in February, and Jefferies analysts are looking favorably at temporary staffing agencies.

While "all indicators" say healthcare wages should be pushed up, Shea said, he wouldn't be surprised if the growth rate continued to limp along for a little while longer.

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Labor disputes made healthcare headlines in 2018, with nurses demanding better staffing ratios from chains Tenet and Community Health Systems, nonprofit systems University of California Health and Kaiser Permanente and a handful of smaller independent hospitals.

Fights over the ratio of nurses to patients fueled strikes, rallies and even a midterm ballot initiative in Massachusetts, but it wasn't the sector's sole labor battle in 2018. The year saw heated collective bargaining negotiations, hospitals busting union activity and big struggles over benefits and wages for service workers.

Staff shortages and medical benefits are two primary pain points for mental health professionals at Kaiser's San Francisco Medical Center, and 4,000 of them kicked off a five-day strike this week after six months of contract negotiations. Members of the National Union of Healthcare Workers plan on demonstrating at Kaiser facilities up and down the state.

The skirmish is far from the first strike at Kaiser this year. The nonprofit health system has been the target of several union-organized demonstrations. 

Union membership across all industries has been trending downward for the past four decades, and healthcare is no exception. The Union Stats database reports that the percent of unionized hospital workers has dropped from 22% in 1983 to 15.2% in 2017.

Organized labor in the the healthcare industry — within hospitals specifically — is markedly different from other sectors, considering hospital unionization wasn't federally legal until the '70s. The majority of private sector hospital workers were excluded from collective bargaining rights for nearly three decades until the National Labor Relations Act was amended in 1974. Once those workers were brought into the fold, the percentage of hospitals with collective bargaining agreements increased from 3% in 1961 to 23% in 1976. 

Strikes followed. The Federal Mediation and Conciliation Service, a government agency that mediates negotiations when a contract is within 30 days of expiring, routinely publishes data on work stoppages it was unable to prevent dating back to 1984. According to the agency's data, healthcare and social assistance have had the fourth-most work stoppages (mostly strikes and lockouts) of all industry categories, trailing manufacturing, construction and retail.

Hospitals have seen some of the largest strikes in the past decade, including a one-day, 23,000-workers strong hospital strike in California in September of 2011 that resulted in a four-day lockout for 6,000 Sutter nurses. 

Here's a month-by-month breakdown of the hospital strikes and pickets that made headlines in 2018. 

January

California protests dominated early 2018. The year kicked off with UC nurses picketing at eight of the system's locations on Jan. 25. The nurses, represented by National Nurses United founding member California Nurses Association (CNA), demanded "safe staffing, patient protections and retirement security," Maureen Berry, a UC nurse, said in a statement.

The informational picket followed over eight months of bargaining negotiations. California was notably the first state to mandate nurse-to-patient staffing ratios in 2004, but nurses across the state haven't been satisfied with wages and benefits.

Days later, about 100 CNA nurses picketed at Dignity Health's St. Mary's Medical Center in San Francisco, citing concerns about staffing strains at the height of flu season.

February

UC picketing picked back up again in early February, this time held by roughly 70 cafeteria, custodial and a mix of patient care workers at UC San Diego's Thornton Pavilion in La Jolla. Organized by UC's largest employee union, the American Federation of State, County and Municipal Employees (AFSCME) Local 3299, workers demanded a new union contract offering market-competitive wages. One union official told the San Diego Union-Tribune that some employees can "barely afford to feed their families."

On Valentine's Day, more than 1,000 healthcare workers represented by Service Employees International Union-United Healthcare Workers West (SEIU-UHW) began picketing at hospitals owned by Kaiser Permanente over what the union purported to be plans to cut wages, outsource warehouse jobs and relocate others.

A Kaiser Permanente spokesperson told Becker's Hospital Review that the claims were "loud, false criticism and wage misleading attacks." The protest continued into March.

March

Nurses at Ascension-owned Borgess Medical Center in Kalamazoo, Michigan, held what would be the first healthcare union action to occur outside of California in 2018. On March 5, more than 150 Michigan Nurses Association members rallied in protest of the St. Louis-based hospital operator's plans to eliminate nursing positions at Borgess. Ascension, which owns five hospitals in southeast Michigan, cut 250 jobs in that state by the first of the month and a total of 500 by mid-March.

That's right around the time Pennsylvania nurses and technologists represented by SEIU Healthcare PA began picketing at CHS-owned hospital Wilkes-Barre General. Those workers, many of whom traveled from First Hospital in Kingston and Moses Taylor Hospital in Scranton (two other CHS properties in the state) for the rally on March 15, protested high staff turnover and shortages, mandatory overtime and expired contracts at all three hospitals.

Simultaneously, CNA nurses in the midst of contract negotiations with St. Joseph Hospital, Eureka organized a protest against what union reps called "chronic understaffing" at the California hospital. St. Joseph's had been in compliance with that state's staffing standards, per the California Department of Public Health.

Two days later, 300 AFSCME members picketed Minneapolis-based Hennepin Healthcare over contract negotiations. Workers protested the hospital's proposal to cut performance-based raises and benefits for workers — salt in the wound after Hennepin spent $220 million building its new Hennepin Healthcare Clinic & Specialty Center.

April

Contract disputes dominated the month, starting with Oregon nurses picketing at Providence Medford Medical Center and followed by a one-day strike launched by Massachusetts Nurses Association members at Greenfield-based Baystate Franklin Medical Center on April 11.

On April 18, frustrated SEIU-UHW technicians protested Tenet-owned Hi-Desert Medical Center in Joshua Tree, California. The union claimed its contract was not equal to contracts negotiated at other Tenet properties in California. A day later in Chicago, SEIU members rallied for better pay for front-line workers at Illinois Health and Hospital Association facilities.

At Detroit Medical Center's Huron Valley-Sinai Hospital in Michigan, more than 100 members of the fledgling Professional Nurses Association of Huron Valley-Sinai Hospital (an MNA affiliate) held an informational picket on April 25 calling for safe staffing ratios. The union made staffing its flagship issue in bargaining for its first contract at Huron Valley-Sinai Hospital.

Back in Pennsylvania, roughly 360 SEIU nurses and mental health professionals working under expired contracts at Moses Taylor and First Hospital organized a one-day strike on April 29. Strikers were barred from work the following day.

May

On May 2, SEIU-UHW members set the stage for what would be dozens of statewide protests in California, starting with Kaiser's South Sacremento Medical Center. Workers for the hospital giant demanded fair wages and job security in the face of outsourcing and cuts.

Following the Kaiser protest, nearly 10,000 service workers at UC Davis in Sacramento began a three-day strike that brought 29,000 nurses, case managers and other union healthcare workers to the picket line. Strikers demanded job security and better pay for custodial, groundskeeping and security workers.

On the other end of the country, New York-based nurses and emergency medical service workers at Stony Brook University Hospital followed suit by protesting over unfair wages, high turnover and increased hours.

Earlier in the month, nurses represented by the Pennsylvania Association of Staff Nurses and Allied Professionals picketed Pottstown Hospital, owned by Reading, Pennsylvania-based Tower Health. Union nurses, who were in the middle of contract negotiations with Tower, cited unsafe staffing levels and burdensome on-call policies.

Pennsylvania nurses also closed out the month with a one-day strike at Wilkes-Barre General, the third CHS-owned hospital in the state. Nurses cited unsafe staffing levels and mandatory overtime.

June

June was the calm before the storm, with 150 nurses and hospital workers at Washington state's Providence Regional Medical Center Everett holding lunchtime pickets early in the month over minimal staffing levels and long hours without breaks. The nurses, represented by United Food and Commercial Workers Local 21, had been working under an expired (but extended) contract since October 2017.

July

With the summer swelter came a windfall of union activity. While July started with CHS reaching an agreement with SEIU nurses at First Hospital in Kingston, Pennsylvania, the rest of the month saw a flurry of strikes and rallies across the country.

The storm started in Oregon, where Kaiser nurses rallied for better nurse-to-patient ratios, before sweeping east to New York. On July 10, SEIU members at Catholic Health's Mount St. Mary's Hospital in Lewiston, New York, picketed over staffing levels for nurses, lab technicians and service workers.

Two days later, downstate in Elmira, Communication Workers of America members hosted a rally for nurse staffing legislation. That same day, union nurses picketed at Osceola Regional Hospital in Florida with similar staffing demands.

July 12 also saw 1,800 nurses represented by the Vermont Federation of Nurses and Health Professionals Local 5221 launch a three-day strike against UVM in Burlington after demanding 10% more in pay raises than the hospital was willing to offer.

Later in the month, over 2,400 United Nurses and Allied Professionals members at Rhode Island Hospital and Hasbro Children's Hospital in Providence began a three-day strike that resulted in a prolonged lockout for nurses, technicians and therapists.

Picketing also took place at HCA-owned hospitals MountainView in Las Vegas and Corpus Christi Medical Center in Texas, part of a campaign organized by the National Nurses Organizing Committee to pressure the Tennessee-based hospital operator into addressing high turnover and understaffing.

The month came full circle with a nurses rally in Harrisburg, Pennsylvania, where union nurses delivered petitions in support of safe staffing legislation in that state.

August

About 300 Michigan union nurses and their supporters kicked off August with an informational picket at McLaren Macomb, one of seven McLaren Health Care hospitals. Workers in the midst of contract negotiations demanded wage increases and safe staffing ratios, as well as preventative measures against workplace violence.

Back in Pottstown, Pennsylvania, nurses, technicians and service workers picked up their fight against Tower Health by picketing for safe staffing and better working conditions at Pottstown Hospital. Coincidentally, the hospital is a former property of CHS, which owns three other hospitals in the state where safe staffing has been a hot button issue for nurses.

September

September was relatively quiet, save for continued protests against Kaiser in Oakland. Early in the month, more than 1,000 SEIU workers took to the streets to protest job cuts at the health system. The rally ended with a confrontation with law enforcement and a statement from Kaiser reassuring the public that it is "growing and adding jobs."

October

Nurses in western Pennsylvania have been battling UPMC for collective bargaining rights for years, but the health system is infamous for weeding out organizers and cracking down on collective action. The system is a constant target of the NLRB for civil rights violations. Still, about 50 nonunion workers, with organizing support from SEIU, managed to strike in early October for their right to form a union and simultaneously launch a political action committee called People Over Profits, which is "aimed at building power for working people in Pittsburgh and shaping a future that puts community before corporations."

Mid-month, 200 Kaiser employees delivered some tens of thousands of employee-signed petitions to executives at the health system in Oakland and Pasadena, demanding an end to the organization's job cuts and outsourcing.

With two months left in the year, a three-day strike across California brought 2018's union activity full circle when an estimated 39,000 workers represented by AFSCME and UPTE-CWA picketed UC's five academic hospitals across the state.

November

A week before Thanksgiving, 35 nurses at the University of Illinois Hospital and Clinics went on strike after demanding better job protections and wages. A few days later in Ohio, more than 100 nurses and SEIU supporters in Lorain held a silent rally after contract negotiations with Mercy Health soured.

The month closed out with another strike in Pennsylvania, when more than 300 nurses at independent community hospital Indiana Regional Medical Center launched a one-day strike over contract negotiations. The nurses found themselves in a week-long lockout after the hospital paid a temp agency $1.5 million for a week's worth of replacements, an action threatened when the strike was authorized in October.

December - 2019

Aside from planned demonstrations at Kaiser facilities this month, there are a number of potential strikes on the horizon — at least according to online postings from healthcare temp agencies and staffing crisis management firms.

As of publishing, U.S. Nursing Corporation has posted action alerts for potential openings in Oregon in anticipation of a nurse strike in "Fall 2018" and an expected two-week opportunity in New York sometime in January or February. HealthSource Global Staffing, another temp agency for healthcare workers, is currently recruiting for potential strikes in New Jersey, California and New York.

Article top image credit: UFCW Local 400

Dive Brief:

• Physician wages have increased 20% since 2015 and 4% in the past year, according to a new report from Medscape. In 2019, the average physician salary was $313,000, with primary care doctors earning about $104,000 less than specialists.
• The survey of nearly 20,000 doctors across 30 specialties also found that the gender pay gap in medicine is worsening, with male physicians earning 25% more than their female colleagues in 2019, up from 18% the year before. There are also racial disparities. White physicians earned on average $38,000 more a year than black physicians.
• The amount of time doctors spend on paperwork has also increased, with nearly three-quarters reporting more than 10 hours a week spent on administrative tasks and more than a third with 20 hours or more. That’s a stark contrast from 2012, when about half of physicians said they spent one to four hours a week on paperwork.

Dive Insight:

The findings on the wage difference for male and female doctors contrasts with another recent compensation survey that found the gender pay gap narrowing just slightly. Medscape researchers said that while female physicians do spend less time with patients and tend to choose lower-paying specialties, those factors don't fully explain the pay gap.

The amount of time doctors spend on administrative tasks is concerning, as that burden can lead to burnout and job dissatisfaction. HHS under the Trump administration has taken on the issue through an initiative it calls Patients over Paperwork — attempting to pare back tasks providers face on reporting requirements, for example.

But in line with other research, the Medscape survey shows doctors are mostly happy with their jobs and burnout is on the decline. Half of doctors surveyed said they were "satisfied" with their own job performance and 42% were "very satisfied." The majority of physicians said they would choose medicine as a career again.

"Despite frustration and burnout, physicians work hard to do a good job, and find patient care to be the best reward," Leslie Kane, senior director of the business of medicine for Medscape, said in a statement.

They still report some gripes, however. Doctors said they were worried most about excessive rules and regulations, and 15% said having to work with an EHR was the most challenging part of their job. Other frustrations cited were long hours, difficult patients and lack of fair reimbursement.

Medscape found that most of the top states for physician pay are in the South, a change from previous results that showed Indiana and Connecticut ranking highest. For 2019, the highest-paying states were Oklahoma, Alabama, Nevada, Arkansas and Florida.

The highest paid specialties were orthopaedics and plastic surgery, with pediatrics and public health at the bottom of the list.

When asked about payment models, 28% of doctors said they participated in an accountable care organization and 11% used a direct primary care model. Few physicians reported having a cash-only (6%) or concierge (2%) practice.

More than 70% said they will continue taking new and current Medicare and Medicaid patients. Similar to other years, about one-fifth of doctors said the would drop insurers that paid poorly.

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Dive Brief:

• Members of the New York State Nurses Association are planning a strike at Mount Sinai, Montefiore and NewYork-Presbyterian health systems after contract negotiations stalled over staffing levels.
• NYSNA revealed it was giving the systems 10-day notice of the strike, alleging the hospitals' refusal to hire more bedside caregivers forces nurses to care for as many as 19 patients at a time, putting patients at risk.
• The New York City Hospital Alliance, which includes the three systems, immediately filed an unfair labor practice charge claiming NYSNA is refusing to bargain in good faith by "preconditioning negotiations over nurse staffing issues." 

Dive Insight:

Hospitals across the country are dealing with contract and labor disputes — and in some cases even strikes. Whether the issue is staff levels and working conditions or wages and benefits, such disputes can be costly for health systems and affect patient care and safety.

The New York City Hospital Alliance, like many health systems negotiating new contracts with nurse's unions, is refusing to meet NYSNA's staffing expectations. The union has been picketing for safe staffing since the expiration of their contract, originally signed in 2015. The Alliance claims NYSNA's strike order based on staffing demands is "unlawful" and "bad faith bargaining."  

Kaiser Permanente is facing National Labor Relation Board prosecution over charges it refused to negotiate a new contract covering 85,000 employees across eight states and the District of Columbia. In the complaint, SEIU United Healthcare Workers West and the Coalition of Kaiser Permanente Unions alleged Kaiser tried to set bargaining conditions that would ban unions from any political actions that could impact the organization.

Last year, nurse-patient ratios disputes rattled for-profit systems Tenet and Community Health Systems and nonprofits University of California Health and Kaiser Permanente, and led to a midterm ballot initiative in Massachusetts.

More than 10,000 NYSNA members work across the three health systems, and more than 97% voted to authorize the strike — a landslide. 

In justifying the strike, the union cited reports released last month documenting some 3,800 "protests of assignment" signed by more than 20,000 nurses working at the three hospitals in 2018. Among the conditions blamed on low staffing were patients left on stretchers in hallways for days at a time, unsafe staffing in nurseries and insufficient nurses to admit and discharge patients.

One story from Montefiore complained of "50 patients in a waiting room with a wait time of 6 hours and 24 minutes … RNs covering 19+ patients resulting in no time to medicate or document in accord with policies."

The union said it does not welcome the strike, but feels compelled to take action to ensure patient safety. "We are patient advocates. We are raising a red flag. We are saying enough is enough," NYSNA said.

Article top image credit: UFCW Local 400

Dive Brief:

• A new study on nurse staffing in BMJ found that the hazard of death increased by 3% for every day a patient experienced nurse staffing levels below England's ward mean. Researchers looked at over 138,000 patient stays in English hospitals between 2012 and 2015.
• Relatively, researchers found that each additional hour of nurse care made available over the first five days of a patient's stay was associated with a 3% reduction in the hazard of death. The study concluded that lower RN staffing combined with higher levels of admissions per RN are associated with an increased risk of hospital mortality.
• Hospitals in England, researchers note, have the some of the lowest nurse-to-patient staffing ratios in Europe due to retention difficulties and government austerity measures, despite laws limiting ratios to roughly eight patients per nurse. 

Dive Insight:

The study, while focusing on England, mirrors long-held concerns shared by many nurses, unions and advocacy organizations in the United States. The research is far from the first of its kind to look at patient safety risks associated with low nurse staffing levels, but it is particularly resonant given recent legislative efforts in the United States to set clear nurse-to-patient staffing levels. 

Those efforts have mostly been successfully stymied by the hospital industry — specifically hospital associations and lobbying groups, which have largely outspent campaigns waged by nurse unions and activists. As Massachusetts' failed midterm ballot measure emphasized, nurse staffing legislation is often a battle over public perception: One side argues low staffing levels are a public safety risk, especially in intensive care units, while the other side argues that hiring costs associated with ratio mandates are so unmanageable that they'll shutter hospitals.

While corroborating past findings, this particular study also offers some new information on the subject. The research demonstrates a direct association between nurse staffing and patient mortality at the patient level, but also provides depth on staffing variations (RNs, nursing assistants) and outcomes. The researchers also say their data show that the relationship between staffing and mortality is linear, with "no threshold effect over that range of variation." 

Short-staffed and burned-out nurses do pose real risks to patient safety, health outcomes and workforce retention in hospitals. A 2017 poll from Kronos Incorporated found 90% of nurses are considering leaving their current hospital for another job. Turnover rates among nurses already costing U.S. hospitals an estimated $9 billion per year. 

Nurse turnover, a new Press Ganey paper asserts, is a "systemic issue that must be addressed to protect health care organizations' ability to deliver safe, high quality, patient-centered care." The average cost of turnover for a bedside nurse, according to the report, ranges between $38,000 and $61,100, or $4.4 million and $7 million annually per-hospital.

The pressure is compounded by a looming nurse shortage, an increased need for nurses as they take on a bigger role in patient care and higher acuity severity. 

But staffing ratio laws also come with a price tag. The Massachusetts Health Policy Commission estimated earlier this year that November's ballot question would have cost up hospitals in that state up to $949 million a year while generating $47 million in savings related to reducing the "adverse effects" of current laws. 

The BMJ study proposes a solution: Researchers found that staffing-related mortality was minimized most when staffing levels were closest to those determined by The Stafford Group's Safer Nursing Care Tool. 

Article top image credit: Getty Images

Dive Brief:

• The National Labor Relations Board has charged Detroit Medical Center (DMC) Huron Valley-Sinai Hospital with multiple unfair labor practices. Nurses have been negotiating a union contract, including improved nurse-to-patient staffing ratios, since 2016. 
• DMC has denied the allegations, but one recovery nurse told Crain's Detroit Busienss that a corporate administrator squashed negotiations on orders from Tenet Healthcare Corp., the Dallas-owned hospital chain that owns DMC. 
• The NLRB complaint asks an administrative judge to reverse a number of hospital policies and reimburse nurses for any financial losses they may have been incurred.

Dive Insight:

The NRLB complaint lodges some serious allegations against DMC, including refusing nurses their right to meet with colleagues and labor representatives, threatening nurses with discipline in retaliation for their efforts to improve wages and working conditions and banning a union representative from entering hospital grounds. 

But the situation reflects trends found across the county. A small contingent of nurses in Pennsylvania, for example, went on strike earlier this month after the NLRB ruled that UPMC unlawfully prohibited off-duty workers from unionization efforts. UPMC has not moved on its anti-union stance despite years of efforts on behalf of its workers. 

As nurses across the country continue to rally for "safe staffing ratios" —  rules that would set a maximum number of patients an individual nurse can care for at once — hospitals have fought back by quashing union activity and pouring money into lobbying and advocacy efforts.

That's because the staffing regulations cost money and resources hospitals argue they don't have. Last week, a study from the Massachusetts Health Policy Commission found that implementing staffing ratios in that state could cost hospitals $676 million to $949 million a year. A ballot question in that state would force hospitals to hire as many as 2,286 to 3,101 additional full-time nurses to be in compliance. 

Advocates of staffing ratios say that a mandate adjusting for acuity and hospital setting can be cost-effective, produce better health outcomes and act as a job creation mechanism, which they argue has been the case in California. 

The nurse from DMC told Crain's that Huron Valley-Sinai nurses are hoping Tenet will allow for a contract for safe staffing. "It is not just a nurses contract, it is a patient contract," she said. 

That sentiment is echoed by nurses across the country who are fighting for staffing regulation. 

"How can you put a price on patient safety and patient mortality?" Sharon Mitchell, a nurse and safe staffing advocate in Pennsylvania, told Healthcare Dive.

Article top image credit: Flickr user Medill DC

Dive Brief:

• Failure to improve hospital work environments continues to put patients at risk, a new Health Affairs study finds.
• The researchers analyzed nurse and patient appraisals at 535 hospitals in four states between 2005 and 2016 to see whether their work environment had improved and the extent to which those changes affected patient safety.
• Just over a fifth (21%) of the hospitals showed significant improvements (better than 10%) in work environment scores, while 7% did worse. Where clinical care environments improved, nurses and patients cited positive strides on patient safety indicators.

Dive Insight:

Nurses are the backbone of the healthcare system and on the front lines of patient care. But burnout and managerial support work-life balance are concerns, as is not being allowed to practice at the top of their license.

In a 2017 survey, nearly half of nurses said they were thinking about leaving the field due to feeling overworked, workplace harassment or inadequate pay. About two-thirds blamed their heavy workload on the ongoing nursing shortage.

According to the study, a third of nurses rated their work environment as fair or poor in 2015 to 2016. Burnout was particularly high, with nearly a third of bedside nurses registering high on the Maslach Burnout Inventory, according to the study. 

Hospitals with improved workplace environments performed better on a number of patient safety indicators. The number of patients rating their hospital favorably increased 11% and those who would recommend the hospital grew 8%. At the same time, positive nurse appraisals on quality of care and patient safety each rose 15%.

By contrast, hospitals where work environments decline saw a 19% drop in nurses giving favorable grades on patient safety. 

The ramifications of a poor workplace environment can be far-reaching. Clinical safety interventions like surgical checklists and rapid-response teams are often undermined due to issues like staff shortages or missing equipment or supplies. According to the study, nurses are forced to drop what they're doing on average once an hour to deal with operational shortcomings.  

"Our findings confirm that nurses spend substantial time troubleshooting recurring operational problems, interrupting care and creating patient safety hazards," the authors write. "RNs are an expensive and scarce resource to use in this manner, when their greatest value is in direct patient care … [M]ore attention is needed to redesign work flows to permanently solve persistent operational failures that take nurses away from direct patient care."

The study has policy implications.

Including quality work environment indicators such as nursing leadership effectiveness and good nurse-physician relationships in regulatory incentives could spur needed changes, the authors suggest. CMS could also require public reporting of nurse staffing levels on the Hospital Compare website. Five states already have such policies. 

Encouraging a blame-free culture could also enhance safety and reduce adverse events by making nurses feel secure in coming forward about errors and hazardous conditions.

Article top image credit: Getty Images

Dive Brief:

• Healthcare employers are spending nearly 15% more on employee benefits and wellbeing than they did 15 years ago, according to an analysis by Bay Alarm Medical.
• The Bay Alarm subsidiary looked at Bureau of Labor Statistics data from the National Compensation Survey's Employer Costs for Employee Compensation report to see how much different industries were investing in insurance plans, retirement and savings, sick leave, vacation, overtime and other perks.
• In healthcare, the cost of benefits per employee was $10.24 per hour or $21,364 annually in 2018 — a 14.6% increase from 2004.

Dive Insight:

The findings underscore the financial pressures hospitals and health systems face with rising labor costs, shrinking volumes, lower reimbursements and declining operating incomes. 

In a 2018 Healthcare Financial Management Association/Navigant survey, 78% of healthcare leaders predicted their organization's labor budget would grow over the next 12 months and 18% said the increase would be more than 5%. 

In the same survey, 44% of leaders said they are targeting labor expenses to bring down operating costs. Other targets included purchased services and supply chain efficiencies.

Meanwhile, healthcare workers at organizations across the country are demanding higher wages and better medical benefits. 

Kaiser Permanente canceled some nonessential surgeries after nurses joined a picket line of 4,000 mental health workers who were protesting outsourcing at the health system. The previous month saw 300 nurses at Indiana Regional Medical Center in western Pennsylvania strike over benefits and wages. The hospital barred the striking nurses from returning to work for a week after paying $1.5 million for temporary replacement nurses to fill in during their absence.

Large employers were hit hardest by health insurance, according to the analysis. That stands to reason because the Affordable Care Act requires businesses with more than 50 full-time employees to offer health insurance.

Organizations of all sizes can rein in costs by not bearing the full cost of benefits, making employees aware of these costs, providing only benefits that are wanted or needed and avoiding sloppy recordkeeping, Bay Alarm Medical says.

Article top image credit: Fotolia