Maybe it's workers' anxiety and uncertainty associated with the struggling economy and the sweeping changes under healthcare reform. Maybe it's dissatisfaction with staffing ratios, hours and wages. Or, maybe it's simply poor management by hospital leaders.

Whatever the reason, healthcare labor unions continued to demonstrate remarkable success at organizing workers in 2010, just as they have for most of the last decade.

That's according to the new Semi-annual Labor Activity in Health Care Report from the American Society for Healthcare Human Resources Administration.

Since 2000, healthcare unions have on average won well more than 60% of organizing elections. In the last five years they've won about 70% of elections, demonstrating that the success they've had predates the labor-friendly Obama Administration.

In 2009, there were 220 union elections in the healthcare industry, and unions won 153 of them (70%). In 2010, there were 305 elections in the healthcare industry, and unions won 215 of them (70%).

The Service Employees International Union won 75% of its elections in 2010. It was involved in more elections (105) than any other union, accounting for 44% of all representative petitions filed in healthcare in 2010 compared with 27% in 2009. The relatively new National Nurses United proved even more formidable, winning 94% of its organizing elections in 2010, its first full year of operations.

"There is a lot of uncertainty in healthcare, with the reforms and the impact that that will have," says Jim Trivisonno, president of IRI Consultants, who compiled the report for ASHHRA. "People have to work harder than they have before. Organizations are looking to improve efficiencies through process improvements. There are major changes in the way patient care is delivered. There is electronic medical records implementation. Major changes lead to employee uncertainty."

So, if your hospital finds itself the target of a union organizing effort, the odds are not in your favor. However, that doesn't mean the battle is lost. What about that 30% of hospitals and healthcare entities that successfully thwart organizing efforts? Do they share any common traits?

"It's two things, and they are connected," Trivisonno says. "One is leadership and the second is culture. The leadership in organizations that embrace engagement and communication and leadership development create a firewall. Often unions can penetrate an organization not just because workers are feeling uncertain, but also because management isn't treating them well, or they are disengaged and don't understand what is going on."

"But the organizations that have a clearly articulated vision, and continue to communicate to their employees what is going on, those employees have fewer concerns, and they are less susceptible to unions," Trivisonno says. "No question that wages and benefits are a piece of it. But beyond that it boils down to the culture of the organization, building a firewall, and inoculating the organization because people believe in the leadership of the organization."

The bottom line: Workers don't organize in a vacuum. It's easy to accuse unions of sowing unrest in the workforce. It is probably more accurate, however, to say that union organizers are good at recognizing the discontent that already exists in a workforce – discontent that poor managers have either failed to notice or ignored. Remember the mantra: Management gets the union it deserves.

Federal inspectors said they see nothing illegal about a free local transportation arrangement that would shuttle patients from physicians' offices to an adjacent hospital.

The nonprofit hospital, whose name was redacted in the opinion, had asked the Office of Inspector General at the Department of Health and Human Services if the complimentary shuttle service the hospital wants to offer would violate anti-kickback statutes and other federal laws against self-referrals.

The hospital wants to make available a free wheelchair-accessible van, driven by a licensed EMT employed by the hospital, for patients and their families. The van would transport patients needing evaluation and treatment at the hospital and who are unable to transport themselves from the 41 physicians' offices located on or adjacent to the hospital's 108-acre campus,

The hospital said the shuttle is needed because its campus has limited parking far from public entrances; walkways are difficult for feeble, elderly patients to navigate; and there are limited public transportation services.

OIG said that the shuttle service would not violate anti-kickback or self-referral statutes if:

• The arrangement would not selectively limit eligibility to targeted populations of federal healthcare program beneficiaries. Patient eligibility would be uniformly determined by the physicians in accordance with the hospital's written policy.
• The shuttle service would be reasonable in cost and not include expensive transportation such as limousines.
• The arrangement would only be offered locally from the physicians' offices located on or contiguous to the hospital, at a distance of no more than a one-quarter mile.
• The service would not be advertised.
• The hospital certified that the availability of local public transportation and parking is limited.
• The cost of the transportation would not be included on any federal healthcare program cost reports or claims, nor shifted to any federal healthcare program.

Consumers are spending $363 billion -- 14.7% more -- on healthcare than what is conventionally cited in government accounts when unreported costs such as unpaid supervisory care from friends and relatives are factored in, according to a study from the Deloitte Center for Health Solutions. 

This unreported spending identified in the Deloitte report, The Hidden Costs of U.S. Health Care for Consumers: A Comprehensive Analysis  falls outside of traditionally counted healthcare costs such as doctors, prescriptions, hospitals, and health insurance coverage. Those additional costs identified by Deloitte bump consumer discretionary spending on healthcare from 16.2%, for items traditionally reported by the government, to 19.9%. That makes healthcare spending the largest single household budget item, surpassing housing and utility costs at 18.8%.

“There are two important takeaways from this report,” Paul Keckley, executive director, Deloitte Center for Health Solutions, told HealthLeaders Media. “One is that we have to define healthcare more broadly than doctors, hospitals, prescription drugs, and insurance. We have to define it the way consumers define it. When they are buying an over-the-counter remedy it could be instead of going to a doctor or a hospital.”

“Second, we have to tackle this question of supervisory care, of the lost wages that people are now bearing to take care of medical problems for family members,” he said.

Fifty-five percent in the unreported costs -- $199 billion – identified by Deloitte, were for the estimated value of supervisory care, or care given by unpaid relatives and friends, almost all of which was provided to people living in lower income families. Keckley called the estimate, based on lost wages of $12.60 an hour “very conservative.” The $199 billion also does not reflect the loss of sales and income taxes that would have otherwise been paid, he said.

The other $164 billion in expenditures includes:

• 15% for “functional foods” and other nutritional products, and vitamin and mineral supplements;
• 8% for complementary and alternative medicine services and products
• 8% for mental health services
• 6% for blood banks and health promotion programs
• 4% for homes for the elderly
• 3% for ambulance services

“This is hitting the pocketbook because these are part of the household budget,” Keckley says. “These are not touching insurance programs. The significance of the study is not just the $363 billion, which is a big deal, but that healthcare is now the No. 1 category of expenditures in discretionary spending in the household. It’s above housing costs. You can envision that certain households are having to make everyday decisions about forgoing other things like travel or even food because you have increasing number of dollars going to healthcare.”

Individuals living in families earning less than $10,000 per year accounted for 11% of all healthcare costs in 2009. The shares for families earning $10,000-$25,000, $25,000-$50,000, and $50,000-$100,000 were 21%, 25%, and 26%, respectively. The study also noted that:

• Total U.S. healthcare expenditures in 2009 were an estimated $2.83 trillion --a 26% increase from $2.25 trillion in 2005.
• U.S. healthcare spending is dominated by big ticket, “necessary expenditure” items of hospital care ($760 billion, or 27% of total expenditures), professional care ($832 billion, or 29%), and prescription drugs ($246.3 billion, or 9%).
• Total discretionary costs for direct and indirect healthcare totaled $1,892 per capita in 2009.
• One-person family units comprised 24% of total healthcare expenditures, with two-person families accounting for 37%.
• Healthcare costs for people 65+ made up 36% of the total ($1.01 trillion). Senior healthcare use concentrates on hospitals, long-term care, supervisory care, and physicians/clinical services.

Keckley says healthcare costs are “feeding on themselves” and growing so quickly that they threaten other vital areas of the economy. “Over 40 years there has been an average [annual] 4.9% increase. Not too many people have seen their wages grow at that level,” he said. “The more impact that healthcare has over the pocketbook, it is clear the economy doesn’t recover as fast. Seventy percent of the economy is built on consumer consumption. If more and more dollars are not spent in retail or travel or in various manufactured items, then the economy doesn’t recover the way people anticipate.”

“It is a conundrum. You have an industry that is a big part of the economy, almost 18%. It creates a lot of jobs. But if more and more of the economy is dependent upon healthcare to make itself affordable, then you’ve put it in conflict with itself,” he said.

To help decelerate healthcare costs, Keckley said, the public must change from passive patients to smart consumers. He said the healthcare reforms enacted last year provide consumers with tools that enhance transparency, rate physician and hospital quality, help select health plans, and explain treatment options and costs. “But you still run up against the question of ‘what is going to motivate a consumer to make better choices?’” he says. “That is probably the big hanging chad here. We don’t see that in the near-term. It is part of healthcare’s biggest challenge -- a transition from a patient-orientation to a consumer market. That is an industry challenge, a government challenge. It is also a personal challenge.”

And that challenge could prove daunting. Keckley says surveys have shown that consumers prefer to have their healthcare decisions made by doctors or others. “It may point back at the lack of will on the part of Americans to really be engaged in their own healthcare,” he says. “It may be easier to say ‘the system is not working than’ it is to say ‘and we are part of the problem.’”

The report may be viewed here.

The Institute of Medicine issued two reports on Wednesday that it said will provide an objective and consistent framework for clinical practice guidelines, and standardize systematic reviews of comparative effectiveness.

The eight standards promoted in Clinical Practice Guidelines We Can Trust include recommendations for establishing transparency in the practice, managing conflict of interest, external review, and group composition development.

"These standards are necessary given that there is little documentation to judge the quality and reliability of many of the existing clinical practice guidelines," said Sheldon Greenfield, MD, executive director, Health Policy Research Institute, University of California, Irvine, and chair of the IOM committee on guidelines.  "Practice guidelines provide valuable data and guidance that not only inform individual decisions about care but ultimately could also improve overall healthcare quality and outcomes." 

IOM's second report, Finding What Works in Health Care: Standards for Systematic Reviews, addresses the myriad and often competing guidelines for clinical recommendations by offering what it said are 21 standards to ensure objective, transparent, and scientifically valid reviews.

"This report presents the 'gold standard' to which those who conduct systematic reviews should aspire to achieve the most reliable and useful products," said Alfred O. Berg, MD, professor of family medicine, University of Washington School of Medicine, Seattle, and chair of the committee that wrote the report on systematic reviews.

"We recognize that it will take an investment of resources and time to achieve such high standards, but they should be adopted to minimize the chances that important health decisions are based on information that may be biased or erroneous," Berg said.

The studies were requested by Congress and sponsored by the Department of Health and Human Services.