Kaiser Permanente’s historic labor management partnership is on shaky ground this week as the window of opportunity narrows to negotiate a new contract for over 75,000 healthcare workers represented by the Coalition of Kaiser Permanente Unions and avert an October strike, according to union leaders and labor experts.

Over a dozen union leaders, labor relations professionals and former Kaiser consultants told Healthcare Dive that the bargaining process has become increasingly dysfunctional and protracted this summer, in contrast to most negotiations in the past.

The coalition has not carried out a strike in over 25 years. Labor experts attribute the period of stability to Kaiser’s unique national labor management partnership, formed in 1997, which brought the workforce into company decision-making processes from the ground up.

Until recently, the partnership negotiated effectively, driven by a shared vision for the company, said John August, former head of the union coalition when it was a broader group of 34 unions and current director of healthcare and partner programs at Cornell University’s Scheinman Institute on Conflict Resolution.

Management had shared financial information to inform bargaining, and union members — who were often covered by Kaiser plans — were invested in the health system’s mission of providing affordable, high quality care, said Adrienne Eaton, dean of the Rutgers School of Management and Labor Relations and co-author of the 2009 book Healing Together: The Kaiser Permanente Labor-Management Partnership.

“People felt like they had achieved a good, amicable relationship,” August said. “The performance agenda really meant a lot to everyone, and, as a result, Kaiser became a leader in the industry in terms of quality and affordability.”

The working relationship typically allowed for smooth bargaining and, in the past, contracts had often been negotiated “significantly before [their] expiration” dates, according to Hal Ruddick, executive director for the Alliance of Healthcare Unions, a venture of 53,000 Kaiser employees not affiliated with the current negotiating coalition.

However, this year negotiations are coming down to the wire.

Leaders for the Coalition of Kaiser Permanente Unions – the group currently negotiating its contract — and Kaiser executives have met eight times since talks kicked off in April to bargain about staffing, wages and benefits, according to both parties. They haven’t made a deal — and tensions have been escalating.

On Sept. 22, the Coalition released a statement that Kaiser was negotiating in “bad faith,” and issued a 10-day strike notice, alerting Kaiser that members in California, Oregon, Colorado, Virginia, Washington and Washington, D.C.  would hold an unfair labor practice strike, and some sympathy strikes, beginning Oct. 4 if an agreement is not reached. The Coalition added that it is prepared to hold an additional, potentially longer strike, which could include workers from Washington state, in November.

Kaiser Permanente leadership has continued to express confidence that parties can still achieve a contract and urge employees to reject a strike as negotiations continue.  

“Given the progress being made in national bargaining over the weekend and Monday, there is no reason to strike,” said Hilary Costa, communications manager for Kaiser, told Healthcare Dive on Wednesday. “The best place to reach an agreement is at the bargaining table. We will ask our employees to reject any call to walk away from their jobs.”

This is not the first time in recent years that the labor partnership and Kaiser have bargained into the eleventh hour. In 2021, the Alliance of Healthcare Unions and Kaiser narrowly averted a strike of 28,400 workers in southern California, after parties agreed to a contract days before a strike was set to begin.

At the time, labor experts and union members said the labor-management partnership was deteriorating. Now, Eaton characterized the state of the partnership as even worse: It is barely “limping along.”

The current contract stalemate, according to multiple experts, is the result of a communications breakdown between the two parties — and infighting among the unions themselves — that has been in the making since 2018.

"[Negotiations have] taken a kind of very militant stance," Eaton said, "Politics and personalities within the union [have] made it more difficult to reach an agreement."

A “culture shift” at work

The bedrock of Kaiser’s labor management partnership, according to Eaton and August, was commitment to collaboration that began at the top. 

Following years of acrimony in the 1990s, including layoffs and strikes, then-CEO David Lawrence realized the standard tough-on-labor approach would be a “dead end” for the system that would lead to “continued labor strife in every corner of our organization,” he said at the time, according to a research report Eaton co-authored.

Lawrence hired consultants to teach employees and managers a new way to cooperatively interact. Employees and managers took courses on problem solving, conflict resolution, consensus decision making and unit-based teams — versions of which are still offered today. The emphasis on partnership created transparent bargaining that was “unprecedented,” Eaton said. 

When Lawrence departed, new management continued the labor partnership, August said, because it proved beneficial to all. Both Kaiser and the unions were growing. 

However, Kaiser union members said there has been a shift in Kaiser’s approach to labor relations in recent years.

“There used to be this real collaborative problem solving approach. My manager would approach me and say, ‘Hey, look, we've got this problem. How do we fix it? Here's my ideas.’ And they would ask for my ideas, too,” said Maria Jostes, a workplace safety consultant and union member who has worked at Kaiser for more than 30 years. In the last five or six years, she told Healthcare Dive that there’s been, “a culture shift from folks at the very top.”

Jostes attributed the change to the unexpected passing of former CEO Bernard Tyson in 2019. Eaton echoed Jostes’s comments, noting that Tyson had been “beloved” by much of the workforce.

Since Tyson’s passing, Alliance and Coalition representatives told Healthcare Dive that the company has made a series of decisions that made them question Kaiser executives’ investment in the labor management partnership.

One example included the narrowly-averted 2021 strike bargaining sessions, which Ruddick said began contentiously.

Another includes Kaiser’s announcement in April that it planned to acquire Geisinger, a non-unionized health system, to form a new nonprofit called Risant Health. The announcement raised “huge concerns” for union members, according to Caroline Lucas, executive director for the Coalition of Kaiser Permanente Workers.

“If Kaiser's future growth strategy is in a non-union non-partnership environment, it definitely calls to question their commitment to us,” Lucas said. Kaiser’s Costa said, “we disagree with the Coalition’s position on Risant Health.”

In current negotiations, coalition members allege management snubbed collective bargaining representatives by not sitting in person with bargaining teams, according to Jostes, Lucas, and Jeffrey Sanders, a contract specialist for SEIU Local-49. 

In a statement to Healthcare Dive, Kaiser expressed commitment to the labor-management partnership, stating that it had hired more than 9,800 people this year into jobs at Kaiser represented by the Coalition.

Splits in the partnership

Eaton said that the unions are also not “without fault” for the current breakdown in the partnership. Prior to 2018, the Coalition and Alliance were a joint unit, representing 34 unions. They negotiated a single national contract.

However, the unions parted ways in 2018, in part because the Alliance unions had a “fundamental disagreement” with Coalition leaders about how negotiations ought to occur, Bloomberg Law reported at the time. Twenty-two unions left to form the Alliance and thirteen unions remained in the Coalition (those numbers have since shifted as union allegiances changed).

Since 2018, August said that, “bargaining… has been made more complicated” for Kaiser. Kaiser now negotiates separate contracts with the Coalition and the Alliance. August said the two groups have been tacitly competing to “show that they’re doing better” than the other, creating headaches for the healthcare conglomerate.

In labor relations, the term is “whipsawing,” Eaton said. Unions leverage a previous contract within their employer’s network to negotiate an equal or better deal.

“It puts extraordinary pressure on the next deal that comes,” Eaton said, because the employer likely understands that whatever they agree to in this round of negotiations will become baseline terms for the next negotiation cycle with their other unions. The split of the broader union coalition of prior eras has been difficult for Kaiser because of this, she said.

During negotiations since the Kaiser split, both the Coalition’s 2019 contract negotiations and the Alliance’s 2021 contract negotiations reached the point of strike authorizations, however, ultimately neither strike happened.

There are signs of continued infighting. One labor union in the current Kaiser negotiations has already voted to leave the Coalition and return to local bargaining. On Sept. 18, UFCW Local 555 members voted to leave the Coalition and issued their own strike notice to Kaiser.

Miles Eshaia, press contact for UFCW Local 555, told Healthcare Dive that members voted overwhelmingly to leave a process that wasn’t working for them, adding that their member issues were not “getting the attention they deserved” at the bargaining table. 

“We've been working on this thing for months, and we didn't think we were gonna get a deal through the Coalition,” Eshaia said. “It was in our members best interest to return this to local-employer-to-employee bargaining.”

Dive Brief:

• Eighty-one percent of nursing home facilities nationwide and 90% of for-profit facilities would need to hire additional registered nurses or nurse aides to meet the minimum nursing staff hours standards proposed by the CMS earlier this month, according to a KFF estimate published Monday.
• The CMS introduced the guidance in response to longstanding concerns that inadequate staffing levels negatively affect nursing home residents’ care. The rule would require nursing homes to have a minimum of 0.55 RN and 2.45 nurse aide hours per resident day, and an RN on staff 24 hours per day, 7 days per week.
• Industry leaders immediately pushed back on the proposal, arguing that a nationwide nursing shortage would prevent facilities from meeting staffing targets. Staffing levels currently vary by type of facility and geography. In over half of states, less than a quarter of nursing facilities would meet the requirements under the proposed rule, according to the KFF study.

Dive Insight:

The COVID-19 pandemic had an outsized impact on the nursing home industry, as workers left positions in record numbers due to burnout, low wages and increased stress associated with caring for vulnerable populations during a public health emergency.

As of June, employment levels in long-term care facilities remained depressed at 11% below pre-pandemic levels industry-wide and 3% below pre-pandemic levels for workers in elder care facilities, according to the Bureau of Labor Statistics.

In light of current workforce shortages, industry leaders have argued that the CMS staffing proposal, which would be the first federal regulation mandating specific staffing levels in nursing homes, is untenable. 

Mark Parkinson, president and CEO of the American Health Care Association, which represents over 14,000 skilled nursing facilities and assisted living centers, said in a statement that the policy would require homes to “hire tens of thousands of nurses that are simply not there.”

“It then penalizes us and threatens to displace hundreds of thousands of residents when we can’t achieve the impossible,” Parkinson said in a statement. 

However, others didn’t think the proposal went far enough and had hoped the CMS would require 4.1 hours of nursing care per resident per day, a number first proposed by a CMS-funded 2001 study measuring the relationship between nursing care and patient outcomes. 

Dr. Bianca Frogner, director of the UW Center for Health Workforce Studies at the University of Washington, told Healthcare Dive that concerns about a labor shortage in the industry are not overblown. 

Currently, nursing facilities are competing with hospitals for talent, as RNs are steered toward hospital settings during their training. Larger systems also typically pay higher starting wages, she said.

When RNs do work in nursing homes, Frogner explained it can be a fraught environment where nursing assistants turn over at rates of 100% to 300% annually. The stress “reverberates through the system, because it conveys a feeling that nursing homes are not desirable places to work,” she said. 

Attracting more RNs and nursing assistants would cost the industry an estimated $40 billion dollars over the next ten years, KFF estimates — a cost that is likely to be passed on to public and private payers, including residents and their family members. Already, residents paid $45 billion in out-of-pocket costs for care in nursing homes and other institutional long-term services and support settings in 2020, according to KFF.

Even with a sizable financial investment, Frogner is skeptical that nursing homes will be able to attract talent without additional investments in training and benefits, like healthcare or transportation.

“Even if they did offer good pay, they are struggling to find a pool of workers who can even fill these jobs,” Frogner said.

There are currently no firm answers as to how the CMS will audit compliance, and it’s unclear whether future federal budgets will have funds for nursing facility inspections and enforcement, according to KFF.

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By West Monroe

The healthcare AI market is booming, reaching about $11 billion globally in 2021 and projected to hit an astonishing $188 billion by 2030, with a remarkable annual growth rate of 37 percent. A substantial part of this market is dedicated to AI in medical imaging, valued at $1.7 billion in 2022 and expected to soar to $20.9 billion by 2030, aligning with broader AI trends in healthcare.

Medical imaging involves using technology like MRI, ultrasound, X-rays, and CT scans to visualize the human body for diagnostic, monitoring, and treatment purposes.

The healthcare industry has seen a surge in AI and machine learning (ML)-enabled medical devices, with an 83% increase in FDA approvals in 2021 compared to 2018. To capitalize on this market, MedTech companies must prioritize innovative data solutions and enhance user experience to drive MedTech AI development.

Current Medical Imaging AI Use Cases

Over 500 FDA-approved AI-enabled medical devices are available, with several notable applications:

1. Image Augmentation: AI improves image quality and resolution. Subtle Medical's AI solution enhances PET and MRI scan quality, reducing scan times by 25%. GE Healthcare's AIR Recon DL AI boosts MRI image quality and cuts scan times by up to 50%.

2. Diagnostic Assistance: AI streamlines diagnostics, enhancing accuracy. Medtronic's GI Genius assists in identifying colorectal polyps during colonoscopies, leading to a 13% increase in detection and removal rates. ScreenPoint Medical's Transpara Findings aids radiologists in mammogram result analysis, increasing efficiency.

3. Process Automation: AI optimizes radiology workflows with efficient speech recognition, case prioritization, workload balancing, and real-time clinical decision support. Nuance's PowerScribe One automates reporting, reducing errors. 3M's M*Modal Fluency for Imaging combines speech recognition with AI-driven clinical insights.

Trends in Medical Imaging AI

AI's integration with Augmented Reality (AR) is a significant trend, creating immersive 3D models from medical images for enhanced surgical precision, as seen in robot-assisted kidney surgery using NVIDIA Holoscan.

Another trend is the convergence of AI, Precision Medicine, and Radiomics, improving imaging interpretation, particularly for complex pathologies like brain tumors. AI facilitates tumor genotyping, precise tumor volume delineation, and clinical outcome prediction.

Emerging fields like Radiogenomics link genomic features with imaging biomarkers, personalizing treatment strategies and aiding in early risk identification.

AI's role in infectious disease imaging is growing, automating identification and interpretation of imaging biomarkers, accelerating diagnosis, treatment, and disease control.

Challenges

While AI in medical imaging offers promise, challenges hinder its development:

1. Limited Data Access: Siloed healthcare data makes it difficult to amass large datasets for AI algorithms, limiting AI's utility.

2. Data Deidentification: Non-standardized deidentification of radiologic data poses challenges, affecting AI algorithm training and accuracy.

3. Clinician Buy-In and Education: Slow adoption of AI is due to a lack of clinician knowledge about benefits, workflow integration, and clinical efficacy.

4. Computer Power and Cloud Costs: AI models demand substantial computational power, often beyond healthcare organizations' capacity. Cloud migration and storage costs can be prohibitive.

Solutions: Addressing Challenges

To overcome these hurdles, healthcare companies can:

1. Regulatory Compliance: Align with evolving regulatory standards, prioritize transparency, and maintain robust security measures like HIPAA compliance. See here for more on the regulatory landscape around medical imaging AI.

2. User Experience: Enhance user interfaces, involve users in design, offer training and support, and ensure reliable application performance.

3. On-Premises vs. Cloud: Perform cost/benefit analyses to choose the right tech stack, considering scalability, flexibility, and performance.

Conclusion

MedTech AI, especially in medical imaging, shows the transformative power of AI in healthcare. To unlock its potential, addressing technical, business, and regulatory challenges is essential. By focusing on regulatory compliance, user experience, and IT infrastructure, MedTech companies and healthcare providers can fully harness AI's benefits in patient care and outcomes.

To read more from this article, please click here.

Dive Brief:

• A “labordemic” of both clinical and nonclinical staffing shortages at nonprofit hospitals is likely to persist through 2024 and could stretch even longer in some markets, according to a report out this week from Fitch Ratings.
• While some hospitals have successfully built up permanent staffing levels by offering higher salaries and bonuses, those that struggle to recruit and rely on expensive contract labor will experience weaker margins this year and next, according to Fitch.  
• The report concluded that controlling expenses, especially by attracting and retaining permanent staff, is key to mitigating stress on margins. 

Dive Insight:

Nonprofit hospitals have been squeezed by labor costs for the past two years as healthcare workers left the profession and forced systems to turn to pricey contract labor.

In recent nonprofit earnings reports, hospitals have told investors that, while operating volumes have begun to normalize post-pandemic, the costs of recruiting and retaining talent has remained elevated. 

Most recently, Trinity Health, one of the nation’s largest nonprofit systems, reported growing expenses that outpaced operating revenue in its fiscal year 2023 as labor costs, particularly contract labor expenses, continued to rise.

The Fitch Ratings report released on Oct. 2 echoed the importance of mitigating expenses and added that labor costs may continue to plague hospitals next year.

While some hospitals have succeeded in recruiting new permanent workers and reducing their reliance on contract labor, the cost of recruitment is higher than it was pre-pandemic. 

Hospital employees’ average hourly earnings growth approached 3.8% in July, above the 2.3% average growth reported between 2010 to 2019, but slower than a high of 8.4% since the start of the pandemic.

Labor costs will likely negatively impact hospital margins, the report said. Median operating and operating EBITDA margins declined to 0.2% and 5.8%, respectively, in the 2022 fiscal year compared to the year prior. 

With labor costs relatively inelastic, hospitals can “use other levers to control expenses” including by examining payer contract negotiations and supply chain efficiencies as well as eliminating less profitable service lines or exiting financially challenging markets, according to the report.

Dive Brief:

• California Gov. Gavin Newsom on Friday signed a law raising the minimum wage for thousands of healthcare workers in the state from $15.50 an hour to $25 per hour.
• State lawmakers argued in the law’s text that competitive wages are necessary to attract and retain healthcare workers who provide critical services, noting that “even before the COVID pandemic, California was facing an urgent and immediate shortage of healthcare workers, adversely impacting the health and well-being of Californians.”
• Although wage increases will begin rolling out next year, the timeline for implementation depends on facility type. Large health systems with more than 10,000 workers and dialysis clinics must implement the law fully by 2026, while rural independent hospitals and those with a high mix of Medi-Cal and Medicare patients have until 2033 to implement the new wage minimums. 

Dive Insight:

The law, backed by California healthcare unions, broadly defines healthcare workers as full-time or contract employees of a healthcare facility, including those in roles supporting the provision of healthcare, such as janitors, clerical workers, food service workers and medical billing personnel. 

The wage increase is projected to impact approximately 469,000 employees, many of whom are currently living on the margins, according to an analysis from the University of California, Berkeley’s Labor Center.

Nearly half of California’s healthcare workers do not presently earn enough to cover basic needs, such as housing, and are enrolled in public safety net programs, according to the UC Berkeley Labor Center.

Newsom signed the bill into law on the same day that Kaiser Permanente unions announced they had secured a tentative $25 per hour minimum wage for over 60,000 California-based Kaiser employees, pending ratification from members. California healthcare workers were represented by SEIU-United Healthcare Workers West president Dave Regan during Kaiser bargaining.

In Senate analyses of the minimum wage bill conducted in May and September, lawmakers said that SEIU-UHW’s organizing elsewhere in the state had motivated the state-level analysis of pay. The union spearheaded several similar local ordinances last year, including in Los Angeles and San Diego. 

SEIU California, which sponsored the bill, released a statement on Friday saying that raising healthcare workers’ wages is a matter of equity. Three out of four workers who will see increases in wages thanks to the new law are women, and 76% are workers of color, according to SEIU California. Almost half of all healthcare workers affected are Latino, the union said.

“Governor Newsom signed SB 525 into law because he heard our call for change to a status quo that has left us exhausted and struggling to pay our bills,” Dr. Kelley Butler, resident physician at San Francisco General Hospital and member of SEIU California, said in a statement. “I’m proud of our collective advocacy as a union and proud of our Governor for doing right by the California healthcare workforce and the patients it serves.”

The law went through several edits since the beginning of the legislative session to make it more palatable to healthcare facilities, which largely opposed its passage earlier this year. An earlier version of the bill, debated in May, tasked all healthcare providers with instituting the new minimum by June 2025.

The final version of the law has a phase-in approach that grants some workers the new minimum by 2026 and leaves others waiting ten years to reap the full sum. Healthcare facilities that are in financial distress can also apply for a waiver program to temporarily delay payroll hikes. Tribal clinics are excluded from the new pay requirements entirely. 

The California Hospital Association, a lobbying organization, ultimately supported the law, saying in a statement that it provided “stability and predictability for hospitals” by providing more reasonable phase-in requirements and “preempting city and county minimum wage measures for 10 years and local compensation measures for six years.”

The dialysis industry also got on board after lawmakers added an amendment which prevents SEIU from pushing for ballot measures targeting dialysis centers. The union’s unsuccessful lobbying for changes in the dialysis industry has cost the healthcare industry over 100 million dollars in recent years, according to reporting from CalMatters.

Dive Brief:

• Healthcare workers faced an escalating mental health crisis between 2018 and 2022 driven by increased burnout, harassment and a lack of support from employers, according to new survey data published by the Centers for Disease Control and Prevention on Tuesday.
• More than 45% of healthcare workers reported feeling burned out often or very often in 2022, with the percentage of workers reporting feeling frequently burned out increasing from 11.6% in 2018 to 19% last year. 
• Reports of harassment more than doubled during the study period and the number of workers very likely to seek another job increased by almost 50%. In contrast, turnover intention declined for workers in other essential industries.

Dive Insight:

The CDC study compared U.S. healthcare workers’ mental health and well-being metrics to those reported by workers in other essential industries, finding health workers' mental health deteriorated at higher rates. 

Debra Houry, chief medical officer for the CDC, warned on a Tuesday call with reporters that COVID-19 has intensified longstanding industry challenges among healthcare workers like compassion fatigue, depression, anxiety, substance use disorders and suicidal thoughts.

“To label our current and long-standing challenge a ‘crisis’ is an understatement,” said Casey Chosewood, director and senior medical officer at the CDC’s Office for Total Worker Health, during the media briefing. “Many of our nation’s healthcare systems are at their breaking point. Staffing crises, lack of supportive leadership, long hours of work and excessive demands and flexibilities in our nation’s health systems all must be addressed.”

Healthcare workers most at risk of reporting negative mental health outcomes included those who experienced harassment on the job or working in negative conditions. 

Among healthcare workers who reported being harassed, 85% reported anxiety symptoms, 60% were depressed reported depression symptoms and 81% were burned out, the report found. Negative working conditions, including being short-staffed, were also associated with higher rates of depression and turnover intention.

Burnout can further exacerbate short staffing concerns, because some workers who seek to depart their job are considering exiting the industry entirely, the CDC’s Houry said in the media briefing.

“Some are not just jumping from hospital to hospital, but they are quite concerned about the system in general,” Houry warned. “So clearly, this reiterates the need to sound the alarm that the focus needs to be on long-term systemic fixes.”

Employers can proactively address healthcare workers’ mental health problems by creating conditions that allow workers to participate in decision-making, increase trust in management, offer supervisor assistance and support for productivity, and decrease harassment, according to the CDC.

The agency’s National Institute for Occupational Safety and Health will launch a national campaign for hospital leaders this fall that helps providers “think differently about how to identify and remove barriers to health worker well-being,” Houry said.

The initiative builds on other government programs addressing burnout. Last year, President Joe Biden provided $103 million in awards to combat burnout and promote mental health and wellness among the healthcare workforce. 

Also last year, the U.S. Surgeon General released an advisory on burnout among healthcare workers, noting that employers could play a critical role in reducing distressing work environments that contributed to burnout. 

In legislatures across the country, advocates for nurse and hospital associations are clashing over proposed nurse staffing bills, many of which require nurse-to-patient ratios.

Since the beginning of the year, at least 18 states have introduced or advanced nurse staffing bills, according to data from the American Nurses Association. And in March, Congress reintroduced federal legislation to set minimum nurse-to-patient ratios nationwide.

But the proposals are being met with resistance and lobbying from hospital associations, who argue the laws would impede their ability to provide patient care.

 

For lawmakers like Minnesota Rep. Sandra Feist, the COVID-19 pandemic put frontline providers’ concerns front and center. Feist, a Democrat who introduced the “Keeping Nurses at the Bedside Act” in March, was motivated to act by hearing first-hand accounts from nurses. She told Healthcare Dive by email that nurses reported that staffing levels were “the main cause” driving Minnesota nurses to “leave the bedside in record numbers.” 

Those concerns echo nationwide, as hospital nurse turnover remained elevated in 2022 at almost 23%. Since 2020, staffing shortages have created bottlenecks for care and strained relations between labor and management, becoming a source of friction driving historic nursing strikes across the country.

Mary Turner, president of the Minnesota Nurses Association and an advocate for safe staffing legislation, told Healthcare Dive that her organization surveyed bedside nurses who exited the profession over the past year, and 80% would return to the bedside “if staffing improved.”

Uneven adoption

Across the country, at least 16 states have successfully passed laws or regulations related to nurse staffing levels, which require nurse-to-patient ratios, staffing committees with nursing representation or disclosure of staffing policies.

Last week, Oregon legislators passed a bill that would require staffing committees and set minimum nurse-to-patient ratios in acute settings including emergency departments, intensive care units, labor and delivery units and operating rooms. Hospitals that violate the law could face up to $5,000 in penalties per offense. The bill now heads to the desk of Gov. Tina Kotek, a Democrat, for signing.

And in April, Washington passed a safe staffing law that requires nurse staffing committees and mandates reporting of staffing plans.

But other states have pushed back on nurse staffing mandates.

In Connecticut, the legislature rejected original language in one bill that mandated nurse-to-patient ratios, citing prohibitive costs to hospitals. Instead, Gov. Ned Lamont signed a law offering nurses more input in creating staffing plans.

In Minnesota, Feist’s legislation, which required staffing committees to consist of 35% direct care nurses, passed both the House and Senate but fell apart at the final hour after pushback from the state’s largest private employer, academic medical system the Mayo Clinic. The nonprofit threatened to send billions of dollars of investments out of state if the hospital was required to abide by the law. 

Nurse representation on staffing committees was dropped. Instead, Gov. Tim Walz, a Democrat, signed the revised Nurse and Patient Safety Act into law three weeks later. The law includes provisions addressing workplace violence, health professional education loan forgiveness and creates a study on staffing and retention.

Nurses’ unions argue staffing ratios enhance patient care — using quantitative metrics, like readmittance and mortality rates, as well as patient experience reports to bolster their claims— while hospital associations say the set standards limit flexibility and are out of date with current care models.

Staffing ratios “do not consider advanced capabilities in technology or interprofessional team-care models. These newer models incorporate nurses at various levels of licensure, but also respiratory therapists, occupational therapists, speech-language pathologists, physical therapists and case managers,” said Robyn Begley, chief nursing officer of hospital lobby the American Hospital Association.

Opponents point to the nationwide staffing shortage, arguing that staffing laws might exacerbate the problem. Begley said mandated staffing laws could “increase stress on a health care system already facing an escalating shortage of educated nurses” and do “not create more nurses.” 

Advocates, including MNA’s Turner and Anne Tan Piazza, executive director at the Oregon Nurses Association, argue that there isn’t a shortage of nurses — there’s a shortage of nurses willing to work in unsafe conditions.

Paradoxically, requiring more nurses on staff could, in their view, help alleviate the staffing shortage.

Linda Aiken, professor of nursing at the University of Pennsylvania and founding director of the Center for Health Outcomes and Policy Research, who has studied staffing ratios for three decades, agrees. She said the first nurse ratio law passed in California in 2004. At the time, she recalled, there were similar concerns over staffing shortages.

“The number of hours of nursing care started going up immediately, which means more nurses came back in the field,” Aiken said. “Today, patients in California get three more hours of [registered nurse] care on average than patients in other states because of that legislation.”

Aiken added that patient care — regardless of the restrictions imposed on California providers — has improved. She pointed to peer-reviewed research demonstrating elevated care for poor and minority patients as well as those at safety net hospitals. Plus, she said, no hospitals closed.

Yet in states like Maine, Michigan, Missouri, Pennsylvania and New Jersey, nurses and hospitals remain at odds, waiting on the outcome of staffing bills as they move through state legislatures.

Despite the setbacks some localities have encountered, nurse staffing advocates are focused on passing legislation they view as vital to protecting patients and nurses.

“We have to work damn hard to get change. And it sometimes can take a decade,” Turner said. “Are we going to see it in the next year or two? Maybe not. But we're starting the process.”

UPDATE: Oct. 13, 2023: Kaiser Permanente reached a tentative deal with the coalition of unions representing 75,000 employees on Friday morning, following the largest-documented healthcare strike in US history earlier this month. 

“The frontline healthcare workers of the Coalition of Kaiser Permanente Unions are excited to have reached a tentative agreement with Kaiser Permanente,” the union coalition announced on X, formerly known as Twitter. “We are thankful for the instrumental support of Acting U.S. Labor Secretary Julie Su.”

Kaiser confirmed the tentative agreement in a separate X post.

Dive Brief:

• A historic three-day strike at Kaiser Permanente hospitals concluded Saturday without resulting in a new contract deal for employees. More than 75,000 workers represented by the Coalition of Kaiser Permanente Unions have returned to their jobs — at least for now. On Friday, the coalition said it may issue another 10-day strike notice for a longer work stoppage if a deal isn’t reached.
• Kaiser and the unions will meet to negotiate contract terms this week on Thursday and Friday. U.S. Department of Labor Secretary Julie Su plans to join the bargaining sessions, Labor Department press secretary Veronica Yoo said in a statement.
• The strike, which began on Oct. 4, caused disruptions to some Kaiser patient services, the nonprofit said on its website last week. More than half of the company’s 106 laboratories in Southern California were closed on Friday, and some laboratory services continue to be disrupted this week. Almost two dozen medical offices were also closed last week in Oregon and Washington, and an additional 11 facilities temporarily shut down departments.

Dive Insight:

Coalition members authorized a strike in a series of local votes held around the country last month. Members accused Kaiser of failing to pay wages that kept pace with inflation and said the nonprofit health system’s staffing levels were insufficient to meet patients’ needs.

“We need to have solutions for our staffing crisis,” Jeffrey Sanders, a contract specialist for SEIU Local-49 and member of this year’s bargaining team, told Healthcare Dive last month.  “We need to have our workers earning a livable wage where they can take a job without having to work multiple jobs, without having to live out of their cars.”

Since the onset of the COVID-19 pandemic, healthcare workers have quit the field in droves as they burned out, retired early or exited the field for more profitable industries. Though the immediate pressures of the public health emergency have abated, recruitment and retention remain difficult for nonprofit health systems like Kaiser, according to a report from Fitch Ratings released last week.

Kaiser has argued it’s hiring aggressively and leads the industry in pay. The health system said it has hired over 10,000 people into union-represented jobs this year. Kaiser said it has also agreed to “increased wages across the board for all Coalition-represented employees” during bargaining sessions. Previously, the coalition had advocated for annual pay increases from 5.57% to 6.5%, according to an Oct. 1 update. Kaiser had not previously agreed to that amount.

The parties have come to some tentative agreements during the protracted bargaining process, which has now entered its seventh month.

Hilary Costa, communications manager for Kaiser, said on Oct. 4 that the parties agreed to update the Performance Sharing Plan to include both a minimum payout opportunity and a potential for up to a $3,750 payment. Kaiser will also invest in tuition assistance and training programs. On Oct. 2, the unions announced Kaiser had tentatively agreed to a 40% increase to union members’ education fund.

However, the parties remain apart on other issues. The coalition, which represents employees in positions ranging from licensed vocational nurses to call center representatives, is seeking protections from outsourcing. 

“Outsourcing of critical health care duties has become a key sticking point in negotiations in recent days, as Kaiser executives have refused to put limitations on subcontracting and outsourcing, which keep experienced health care workers in jobs and provide strong continuity of care for patients,” the coalition said in a statement released Friday.

The Department of Labor, which has recently weighed in on strikes in other industries including the historic United Auto Workers strike, said in a statement that it welcomes labor and management returning to the table Thursday.

“As the President and the Acting Secretary have said, collective bargaining works, even when it takes time. We are glad to see the parties going back to the bargaining table,” a spokesperson for the department said by email.

Elsewhere in the country, healthcare workers are also taking to the picket line in protest of staffing levels and wages. On Monday, 1,500 registered nurses and healthcare workers represented by SEIU-UHW, the largest union in the Kaiser coalition, launched a five-day strike at St. Francis Medical Center in Los Angeles. In New Jersey, the strike of over 1,700 nurses at Robert Wood Johnson University Hospital entered its third month this week as management and labor fail to agree on safe staffing reform. 

Dive Brief:

• Two out of three physicians are considering an employment change, according to a survey and report out Thursday from Doximity.
• About 36% of respondents said they were considering early retirement due to overwork, with women physicians more likely than men to report that they were overworked and considering an employment change.
• Compensation was stagnant or down across many specialties in 2022, after rising across all specialties the prior year.

Dive Insight:

Physicians are reporting high levels of burnout and sentiments about leaving their jobs since the pandemic began, according to Doximity’s report.

Many physicians are now open to accepting lower pay in exchange for more autonomy and work life balance, Doximity found, with some 71% of physicians in another 3,000-respondent survey saying they have accepted jobs with lower pay or would be willing to.

The Doximity report also looks at annual changes in physician pay, and includes survey responses collected last year from over 30,000 physicians in the U.S.

The pay gap between male and female physicians fell slightly from 2021 to 2022, from 28% to 26%.

However, women physicians still earned about $110,000 less on average than their male counterparts in 2022, even when accounting for specialty, location and years of experience.

And women physicians earn about $2 million less than male physicians over the course of a career, a 2021 report from the nonprofit Rand Corporation published in Health Affairs found.

Pay gaps vary widely by specialty, though just two specialties had pay gaps of less than 10% — pediatric cardiology and nuclear medicine.

The specialty with the largest gender pay gap is oral and maxillofacial surgery, where women physicians earn $395,687 on average annually, while men earn $568,789.

While compensation was stagnant or down across most specialties last year, one area saw higher pay and growing demand.

Emergency medicine saw the largest annual increase in compensation in 2022, rising 6.2% to an average of $385,554.

It comes as interest in emergency medicine wanes, exacerbated by a growing number of residency positions left unfilled in the specialty, including in this year's match.

Primary care specialties were the most recruited and highest in-demand, falling in line with reports projecting a shortage of primary care physicians in the next decade.

Psychiatry was the second most recruited and child and adolescent psychiatry was the fifth. The coronavirus pandemic has led to an uptick in rates of anxiety and depression, especially among children.

Dive Brief:

• Pennsylvania unions have filed a complaint with the Department of Justice alleging integrated hospital giant UPMC is abusing its dominant market position to suppress wages and retain workers.
• On Thursday, SEIU Healthcare Pennsylvania and a coalition of labor unions filed a 55-page complaint against UPMC, the largest private employer in the state, saying the hospital system’s size has allowed it to stamp out wage growth, “drastically increase” workload and keep workers from departing to other jobs.
• The unions are asking federal regulators to investigate UPMC for antitrust violations, citing its dominance of the healthcare market in select regions of Pennsylvania. UPMC denied allegations of wage suppression.

Dive Insight:

The Pittsburgh-based system has seen a rise in labor complaints, according to the unions, as the system has grown into its 41-hospital footprint through a series of mergers and acquisitions. UPMC, which also operates 800 doctors offices and clinics and a handful of health insurance offerings, reported $26 billion in operating revenue last year.

Attempts in the last decade to organize UPMC’s hourly workers have been unsuccessful, according to SEIU.

Matt Yarnell, president of SEIU Healthcare Pennsylvania, called the complaints groundbreaking on a Thursday call with reporters, saying that no entity has ever filed a complaint arguing that mobility restrictions and labor violations are anticompetitive, and in violation of antitrust law.

The complaint alleges that, for every 10% increase in market share, the wages of UPMC workers falls 30 to 57 cents an hour on average. UPMC hospital workers face an average 2% wage gap compared to non-UPMC facilities, according to a study cited in the complaint.

In addition, the labor groups allege that UPMC’s staffing ratios have fallen over the past decade, resulting in its staffing ratios being 19% lower on average compared with non-UPMC care sites as of 2020.

The unions are going after UPMC for being a “monopsony,” or a company that controls buying in a given marketplace, including controlling a large number of jobs. UPMC has some 92,000 workers, according to the complaint, and has cut off avenues of competition through non-compete agreements, in addition to preventing employees from unionizing.

“If, as we believe, UPMC is insulated from competitive market pressures, it will be able to keep workers’ wages and benefits — and patient quality — below competitive levels, while at the same time continually imposing further restraints and abuses on workers to maintain its market dominance,” the complaint states. “Because we believe this conduct is contrary to Section 2 of the Sherman Act, we respectfully urge the Department of Justice to investigate UPMC and take action to halt this conduct.”

In response to the allegations, UPMC said it has the highest entry-level pay of any provider in the state, and offers “above-industry” employee benefits. UPMC’s average wage is more than $78,000, Paul Wood, UPMC’s chief communications officer, told Healthcare Dive in a statement.

“There are no other employers of size and scope in the regions UPMC serves that provide good paying jobs at every level and an average wage of this magnitude,” Wood said.

Healthcare workers are increasingly pushing for better working conditions and pay amid the COVID-19 pandemic, as hospitals grapple with recruitment and retention issues driven by burnout and heightened labor costs.