Physician unions: any doctor can join, but who can bargain collectively?

Employees in the health care industry, including physicians, have recently taken more interest in unions and collective bargaining. At the present time the health care industry is approximately 20 percent unionized. Labor leaders believe that existing conditions are fertile ground for significant union activity that has been on a recent upswing after a decline during the early 1980s. While current attention is being drawn to the shortage of and increased union organizational activities by nurses, physicians may not be far behind. It is conceivable that by the year 2000 the majority of physicians in the United States will work in full-time salaried positions. In addition, the antitrust laws that currently restrain independent physicians from collective bargaining are being challenged and are likely to change as more physicians become salaried and begin to resemble other professional employee groups. The ruling determining that interns and residents are students rather than hospital employees is also certain to be challenged and changed, especially as pressures on the National Labor Relations Board (NLRB) are brought by house staff union organizations. After a 1987 ruling that the NLRB had been improperly interpreting the 1974 amendments to the Taft-Hartley Act, the NLRB was ordered to exercise its rule-making power in defining bargaining units for health care workers in acute care hospitals. Physicians would then be one of eight occupations defined as a separate health care bargaining unit.     

Cost implications of hospital unionization: a behavioral analysis.

The growth of unionization among hospital workers was sharply accelerated by the 1974 amendments to the National Labor Relations Act covering voluntary hospital workers. With continuing inflationary pressures in the hospital sector, the cost implications of the recent and projected growth of hospital unions is of some concern to policymakers. This article presents estimates of union cost impacts based on data from hospitals in Maryland, Massachusetts, New York, and Pennsylvania. Cross-sectional regressions with data for 1975 yield positive union impacts of 3.3 percent on total costs, 4.1-5.9 percent on cost per case, and 6.1 percent on cost per day. Reestimation of the model with data on changes over the 1971-1975 period yields similar results. We also find that the cost impact of unionization varies with the pattern of coverage (being lower for service employees and RNs) and with the extent of cost-based reimbursement. This suggests that future cost impacts of union growth may be moderated as prospective payment systems for hospitals become more widespread.     

Monopsony power and relative wages in the labor market for nurses

This paper examines the thesis that monopsony power is an important determinant of wages in nursing labor markets. Using data from the 1985-93 Current Population Surveys, measures of relative nurse/non-nurse wage rates for 252 labor markets are constructed. Contrary to predictions from the monopsony model, no positive relationship exists between relative nursing wages and hospital density or market size. Nor is support found for the presence of monopsony power based on evidence on union wage premiums, slopes of experience profiles, or the mix of RN to total hospital employment.     

A new channel for health promotion: building trade unions

PURPOSE: Labor unions are a largely unevaluated channel for health promotion interventions for working class populations, who are at increased risk for smoking and poor diet. We conducted qualitative and quantitative research to understand the meaning and function of union membership in workers' lives and applied this information to health promotion intervention design. METHODS: Cross-sectional data included a survey conducted with a nationally representative sample of unionized construction workers (n = 1109; 44% response rate), and 16 focus groups (n = 88) conducted in multiple regions around the country. RESULTS: The vast majority of survey respondents held strongly positive views of their union. Focus group findings revealed the meaning of the union in members' daily lives, how members view information from the union, and their perceptions of the union's limitations. CONCLUSIONS: The findings provide a compelling rationale for considering unions as a channel for health promotion interventions.     

Classic or new monopsony? Searching for evidence in nursing labor markets

The market for registered nurses (RNs) is often offered as an example of "classic" monopsony, while a "new" monopsony literature emphasizes that firm labor supply is upward sloping independent of market structure. Using data from multiple sources, we explore the relationship between nursing wages in hospitals and measures of classic and new monopsony. Wage level analysis fails to provide support for classic monopsony, the relative wages of RNs in 240 U.S. labor markets being largely uncorrelated with hospital system concentration. Longitudinal analysis shows nursing wages declining with increases in hospital concentration. We interpret these results as providing support for classic monopsony effects in the short run, but question whether wage effects are sustained in the long run. No relationship is found between nursing wages and a new monopsony measure of mobility, but support for new monopsony is found for women elsewhere in the labor market. RNs display greater inter-employer mobility than do women (or men) in general. Two conclusions follow. First, upward sloping labor supply need not imply monopsonistic outcomes. Second, absent more compelling evidence, nursing should not be held up as a prototypical example of monopsony-classic or new.     

Mobility for care workers: Job changes and wages for nurse aides

The long-term care industry in the United States faces serious recruitment and retention problems among nurse aides. At the same time, these low-wage workers may feel trapped in poorly-paid jobs from which they would do well to leave. Despite this tension, not enough is known about how workers fare when they leave (or stay in) such care work. Using longitudinal data from the Survey of Income and Program Participation for the years 1996–2003, we examine the relationship between different job and occupational mobility patterns and wage outcomes for nurse aides, focusing on which job transitions offer better opportunities to earn higher wages and on whether job transition patterns differ by race. Our results confirm high turnover among nurse aides, with 73 percent of the sample working in occupations other than nurse aide at some point during the survey time frame. About half of respondents that transition out of nurse aide work move into higher-paying occupations, although the percentage of transitions to higher paying occupations drops to 35 percent when nurse aides that become RNs are excluded. Among black workers especially, wage penalties for moving into other jobs in the low-wage labor market appear to be rather small, likely a factor in high turnover among nurse aides. The findings illustrate the importance of occupation-specific mobility trajectories and their outcomes for different groups of workers, and for understanding the constrained decisions these workers make.     

Hospital wage gradients within U.S. urban areas.

Average wages from 2,275 general hospitals in metropolitan areas across the U.S. were used to test for a wage gradient descending from hospitals in the central city through those in urbanized and finally non-urbanized areas of each county-defined metropolitan area. Significant gradients were found in MSAs of all sizes. Urbanized-area wages were 3 to 6 percent lower than those in central cities of the same metropolitan area. Non-urbanized suburban wages were 10 to 12 percent lower than those in central cities. The explanations for the gradients differ somewhat between large and small areas. For example, while the relative mix of high-wage and low-wage occupations in each hospital is a significant explanatory variable for wages in all metropolitan area sizes, the relative use of part-time workers is not significant in those metropolitan areas with fewer than 250,000 people. Relative crime in each hospital's city is highly significant in explaining relative wages only for areas with populations of more than one million.     

Who pays for public employee health costs?

We analyze the incidence of public-employee health benefits. Because these benefits are negotiated through the political process, relevant labor market institutions deviate significantly from the competitive, private-sector benchmark. Empirically, we find that roughly 15 percent of the cost of recent benefit growth was passed onto school district employees through reductions in wages and salaries. Strong teachers’ unions were associated with relatively strong linkages between benefit growth and growth in total compensation. Our analysis is consistent with the view that the costs of public workers’ benefits are difficult to monitor, contributing to benefit oriented, and often under-funded, compensation schemes.     

Market share and the illusion of power. Can Blue Cross force hospitals to discount?

Researchers in health care financing have claimed that large private insurers like Blue Cross frequently exercise monopsony power to obtain discounts from normal hospital charges. They claim that the monopsony power derives from a large Blue Cross share of a given hospital 'cost shifting', whereby hospitals offset the discount by raising charges to less powerful customers. This paper re-examines both theoretically and empirically the conditions necessary for a private insurer to extract discounts from a hospital. We demonstrate that the theoretical conditions necessary for Blue Cross to force a discount do not exist in the Indiana market. Using revenue data from 110 Indiana hospitals we reject the traditional claim that Blue Cross pays less than other insurers as a function of market share.     

Local labor unions' positions on worksite tobacco control

OBJECTIVES: This report describes local unions' positions on tobacco control initiatives and factors related to these positions. METHODS: A national random sample of local union leaders was surveyed by telephone. RESULTS: Forty-eight percent of local unions supported worksite smoking bans or restrictions, and only 8% opposed both a ban and a restriction. CONCLUSIONS: Support for tobacco control initiatives among local unions was higher than might be expected on the basis of previous evidence. Engaging unions in smoking policy formation is likely to contribute to the larger public health goal of reducing smoking and exposure to second-hand smoke among workers.     

An English/Spanish safety climate scale for construction workers

BACKGROUND: Workers in the construction trades experience high rates of traumatic injury. An increasing number of workers in this industry speak only Spanish, including members of construction trade unions. This brief communication reports a dual language safety climate scale developed during a larger training intervention study. METHODS: Construction workers in two unions self-completed a previously validated 6-item safety climate scale modified for the construction trades. A seventh item was developed midway through the study and incorporated into the version completed by half of the respondents. For one union with a sizeable number of Spanish-speaking members, a dual-language (Spanish/English) version was administered. Follow-up telephone interviews conducted 3 months after the self-completed survey also included the safety climate scale. RESULTS: Cronbach's coefficient alpha was 0.85 for the 6-item scale and 0.85 for the 7-item scale. Similar coefficient alpha scores were found for the subgroup of Spanish-speakers on the 6- and 7-item scales. Spanish speakers with low education were less likely to respond to the scale when self-completing but not when it was administered by telephone in Spanish. CONCLUSION: This safety climate scale elicits consistent and reliable response from unionized construction workers when administered in English or in Spanish. Spanish literacy may be a consideration for the use of this scale among foreign-born Hispanic workers.     

Why the health care industry should fight union organization and the high cost the industry will pay if its fight is unsuccessful

The health care industry is being hit hard with an aggressive effort by outside unions to organize health care employees. The interest of health care workers in union organization and their receptiveness to the unions' messages has grown substantially over the last five years--with negative effects on health care workers and the health care industry as a whole. This article addresses union trends in health care, discusses specific cases and their outcomes, and makes recommendations on what the health care industry can, and should, do to preserve a union-free work environment.     

Public health sector unions and deregulation in Europe.

Deregulation and liberalization of health services take several forms in Europe: public-private partnerships; contracting out of services; and corporatization of health care institutions. The impact on health workers includes changes in terms and conditions of employment, breakup of collective bargaining agreements, and often more stressful working conditions. The author examines four types of trade union responses to deregulation. National health trade union action has used campaigning, awareness raising, and judicial review. Health workers' unions in alliance with other trade unions have taken part in wider campaigns against privatization and in promoting public services. Health workers' unions joining with social movements have become involved in wider alliances that link with broader public policy issues such as poverty reduction and urban/regional regeneration. European-wide action, seen through the work of the European Federation of Public Service Unions, has concentrated on the development of an alternative health policy, and the promotion of social dialogue at a European level. Trade unions must adopt a range of approaches to challenge the effects of deregulation. Increasingly, trade union members need to be aware of how to take action at both the national and European levels.     

What Differences Unionizing Teachers Might Make on Child Care in the USA: Results from an Exploratory Study

This exploratory case study assesses the impacts of unionizing teachers in 12 child care centers in Seattle, Washington. Open-ended, qualitative interviews with teachers, directors, and parents assessed participants' perspectives on the impact that unionization has had on wages, benefits, working conditions, and turnover in the unionized centers. Participants reported significant changes they attributed to unionizing in the following areas: winning a pilot Career and Wage Ladder which has increased wages, improved benefits including a pension plan and additional teacher planning days, decreased staff turnover, improved teacher/director communication, more systematic policies and procedures, and enhanced teacher ownership of job. Although teachers observed no negative effects, some directors and parents were more ambivalent about union impacts. Specific challenges to widespread child care unionization are discussed.     

The impact of psychological trauma on wages in post-conflict Bosnia and Herzegovina

In the last three decades, armed conflict has increasingly been fought among civilian populations, resulting in greater physical and mental tolls. Soldiers returning from combat with psychological trauma are now receiving medical and policy attention for reintegration into the workforce. However, there is little attention on the impacts and options available to civilians who may face similar problems achieving labor force success after exposure to war-related trauma. Using the Bosnia and Herzegovina Living Standards Measurement Survey for years 2001–2004, we study wage attainment for 7659 respondents in relation to a series of psychological trauma measures which correspond to those used in PTSD diagnosis. In standard OLS regression, all subcomponents of PTSD have a negative impact; however, once unobserved individual heterogeneity is taken into account, some of the individual elements of psychological trauma have positive impacts on wage attainment. This is one of the first studies to find evidence of Posttraumatic Growth using information beyond psychometric instruments. The impact of the PTSD condition itself is insignificant in both models, and we do not find evidence of selection bias. We determine that the traditional means of predicting wages in labor economics are relevant in a post-conflict environment.     

Medicare hospital payment adjustments and nursing wages

Despite the importance of the nursing profession for healthcare delivery, costs, and quality, there is relatively little research on how provider payments to hospitals affect the labor market for nurses. This study deals with the hospital wage index (HWI) adjustment to Medicare hospital payments, an area-level adjustment intended to compensate hospitals in high-cost labor markets. Since the HWI adjustment is based on hospital-reported labor costs, some argue that it incentivizes hospitals in concentrated markets to pay higher wages to nurses and other workers (the “circularity” critique). We investigate this critique using market-level data on the relative wages reported by nurses and hospital-level data on the average hourly wage for healthcare workers. For identification, we exploit a 2005 change in the geographic area used to define labor markets, which resulted in exogenous changes in the ability of some hospitals to influence their area’s wage index. We find that worker-reported relative nurse wages and hospital-reported healthcare worker wages are higher in some locations where hospitals experienced increased opportunities to game the circularity of the wage index, but these effects appear to be driven by pre-existing wage growth. Medicare’s HWI adjustment method does not appear to suffer from inefficiency due to circularity.     

Organized doctors. Unionization of physicians a small but significant force as relationships with hospitals change

The number of unionized physicians is still small, but those doctors are becoming a force to be reckoned with as organizing continues to grow and the fledgling union formed by the American Medical Association becomes more established. "The state of the unions in healthcare is excellent," says Barry Liebowitz, M.D., (left) president of the Doctors Council, which represents 16,000 physicians nationally.     

How the occupational physician works with the unions

A few attitudinal and behavioural principles will bring abouta productive liaison between the occupational physician andtrade unions. An effective working relationship with these organizationsand employee associations can be developed, provided the occupationalhealth care professionals are impartial in their practice, theloyalty to medicine replacing any bias toward the favouringof a managerial view. Respect must be given union officials,for in their organization they have status and can advance ordefeat various health programs. Union representation on an occupationalhealth committee will gain union support and minimize the filingof health-based grievances. The presentation of occupationalhealth information at union meetings will communicate the goalsof in-plant programs and familiarize workers, through theiraccustomed channels, with the objectives of health care policiesand procedures.     

An analysis of hospital union election activity: 1985-1987--by hospital ownership, size, and system, and employee organization and bargaining-unit size

During the three-year period 1985-1987, there were 238 elections in nongovernmental, short-term hospitals to determine whether or not unions would represent the employees. Unions had a success rate of 47.1 percent, similar to that of earlier years. This study reports these election results by hospital and election characteristics. For hospitals, the analysis includes elections by census region, ownership, bed size, and multi-institutional characteristics. For elections, the analysis includes the nature and type of election, employee organization, and employee bargaining-unit-size characteristics. This study concludes that the number of union elections decline as hospital bed size increases, and the union success rate is curvilinear and higher in both small and very large hospitals; union success declines as bargaining-unit size increases. Investor-owned and nonprofit, religious hospitals that are members of multi-institutional systems have lower union success rates than nonsystem hospitals do in their ownership category. However, unions are much more successful in multi-union and decertification elections compared with single-unit elections and initial recognition elections.