Pluralistic: Nurses whose shitty boss is a shitty app (17 Dec 2024)


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A nurse, pouring medicine out of a bottle; she is terrified because she is being held a gunpoint by a male figure whose head has been replaced with the staring eye of HAL 9000 from Kubrick's '2001: A Space Odyssey.' The background is a sepia-toned early 20th C wartime infirmary, crowded with wounded men. In the top left corner there is a subtle 'code waterfall' effect as seen in the credit sequences of the Wachowskis' 'Matrix' movies.

Nurses whose shitty boss is a shitty app (permalink)

Operating a business is risky: you can't ever be sure how many customers you'll have, or what they'll show up looking for. If you guess wrong, you'll either have too few workers to serve the crowd, or you'll pay workers to stand around and wait for customers. This is true even when your "business" is a "hospital."

Capitalists hate capitalism. Capitalism is defined by risk – like the risk of competitors poaching your customers and workers. Capitalists all secretly dream of a "command economy" in which other people have to arrange their affairs to suit the capitalists' preferences, taking the risk off their shoulders. Capitalists love anti-competitive exclusivity deals with suppliers, and they really love noncompete "agreements" that ban their workers from taking better jobs:

https://pluralistic.net/2023/04/21/bondage-fees/#doorman-building

One of the sleaziest, most common ways for capitalists to shed risk is by shifting it onto their workers' shoulders, for example, by sending workers home on slow days and refusing to pay them for the rest of their shifts. This is easy for capitalists to do because workers have a collective action problem: for workers to force their bosses not to do this, they all have to agree to go on strike, and other workers have to honor their picket-lines. That's a lot of chivvying and bargaining and group-forming, and it's very hard. Meanwhile, the only person the boss needs to convince to screw you this way is themself.

Libertarians will insist that this is impossible, of course, because workers will just quit and go work for someone else when this happens, and so bosses will be disciplined by the competition to find workers willing to put up with their bullshit. Of course, these same libertarians will tell you that it should be legal for your boss to require you to sign a noncompete "agreement" so you can't quit and get a job elsewhere in your field. They'll also tell you that we don't need antitrust enforcement to prevent your boss from buying up all the businesses you might work for if you do manage to quit.

In practice, the only way workers have successfully resisted being burdened with their bosses' risks is by a) forming a union, and then b) using the union to lobby for strong labor laws. Labor laws aren't a substitute for a union, but they are an important backstop, and of course, if you're not unionized, labor law is all you've got.

Enter the tech-bro, app in hand. The tech-bro's most absurd (and successful) ruse is "it's not a crime, I did it with an app." As in "it's not money-laundering, I did it with an app." Or "it's not a privacy violation, I did it with an app." Or "it's not securities fraud, I did it with an app." Or "it's not price-gouging, I did it with an app," or, importantly, "it's not a labor-law violation, I did it with an app."

The point of the "gig economy" is to use the "did it with an app" trick to avoid labor laws, so that bosses can shift risks onto workers, because capitalists hate capitalism. These apps were first used to immiserate taxi-drivers, and this was so successful that it spawned a whole universe of "Uber for __________" apps that took away labor rights from other kinds of workers, from dog-groomers to carpenters.

One group of workers whose rights are being devoured by gig-work apps is nurses, which is bad news, because without nurses, I would be dead by now.

A new report from the Roosevelt Institute goes deep on the way that nurses' lives are being destroyed by gig work apps that let bosses in America's wildly dysfunctional for-profit health care industry shift risk from bosses to the hardest-working group of health care professionals:

https://rooseveltinstitute.org/publications/uber-for-nursing/

The report's authors interviewed nurses who were employed through three apps: Shiftkey, Shiftmed and Carerev, and reveal a host of risk-shifting, worker-abusing practices that has nurses working for so little that they can't afford medical insurance themselves.

Take Shiftkey: nurses are required to log into Shiftkey and indicate which shifts they are available for, and if they are assigned any of those shifts later but can't take them, their app-based score declines and they risk not being offered shifts in the future. But Shiftkey doesn't guarantee that you'll get work on any of those shifts – in other words, nurses have to pledge not to take any work during the times when Shiftkey might need them, but they only get paid for those hours where Shiftkey calls them out. Nurses assume all the risk that there won't be enough demand for their services.

Each Shiftkey nurse is offered a different pay-scale for each shift. Apps use commercially available financial data – purchased on the cheap from the chaotic, unregulated data broker sector – to predict how desperate each nurse is. The less money you have in your bank accounts and the more you owe on your credit cards, the lower the wage the app will offer you. This is a classic example of what the legal scholar Veena Dubal calls "algorithmic wage discrimination" – a form of wage theft that's supposedly legal because it's done with an app:

https://pluralistic.net/2023/04/12/algorithmic-wage-discrimination/#fishers-of-men

Shiftkey workers also have to bid against one another for shifts, with the job going to the worker who accepts the lowest wage. Shiftkey pays nominal wages that sound reasonable – one nurse's topline rate is $23/hour. But by payday, Shiftkey has used junk fees to scrape that rate down to the bone. Workers have to pay a daily $3.67 "safety fee" to pay for background checks, drug screening, etc. Nevermind that these tasks are only performed once per nurse, not every day – and nevermind that this is another way to force workers to assume the boss's risks. Nurses also pay daily fees for accident insurance ($2.14) and malpractice insurance ($0.21) – more employer risk being shifted onto workers. Workers also pay $2 per shift if they want to get paid on the same day – a payday lending-style usury levied against workers whose wages are priced based on their desperation. Then there's a $6/shift fee nurses pay as a finders' fee to the app, a fee that's up to $7/shift next year. All told, that $23/hour rate cashes out to $13/hour.

On top of that, gig nurses have to pay for their own uniforms, licenses, equipment and equipment, including different colored scrubs and even shoes for each hospital. And because these nurses are "their own bosses" they have to deduct their own payroll taxes from that final figure. As "self-employed" workers, they aren't entitled to overtime or worker's comp, they get no retirement plan, health insurance, sick days or vacation.

The apps sell themselves to bosses as a way to get vetted, qualified nurses, but the entire vetting process is automated. Nurses upload a laundry list of documents related to their qualifications and undergo a background check, but are never interviewed by a human. They are assessed through automated means – for example, they have to run a location-tracking app en route to callouts and their reliability scores decline if they lose mobile data service while stuck in traffic.

Shiftmed docks nurses who cancel shifts after agreeing to take them, but bosses who cancel on nurses, even at the last minute, get away at most a small penalty (having to pay for the first two hours of a canceled shift), or, more often, nothing at all. For example, bosses who book nurses through the Carerev app can cancel without penalty on a mere two hours' notice. One nurse quoted in the study describes getting up at 5AM for a 7AM shift, only to discover that the shift was canceled while she slept, leaving her without any work or pay for the day, after having made arrangements for her kid to get childcare. The nurse assumes all the risk again: blocking out a day's work, paying for childcare, altering her sleep schedule. If she cancels on Carerev, her score goes down and she will get fewer shifts in the future. But if the boss cancels, he faces no consequences.

Carerev also lets bosses send nurses home early without paying them for the whole day – and they don't pay overtime if a nurse stays after her shift ends in order to ensure that their patients are cared for. The librarian scholar Fobazi Ettarh coined the term "vocational awe" to describe how workers in caring professions will endure abusive conditions and put in unpaid overtime because of their commitment to the patrons, patients, and pupils who depend on them:

https://www.inthelibrarywiththeleadpipe.org/2018/vocational-awe/

Many of the nurses in the study report having shifts canceled on them as they pull into the hospital parking lot. Needless to say, when your shift is canceled just as it was supposed to start, it's unlikely you'll be able to book a shift at another facility.

The American healthcare industry is dominated by monopolies. First came the pharma monopolies, when pharma companies merged and merged and merged, allowing them to screw hospitals with sky-high prices. Then the hospitals gobbled each other up, merging until most regions were dominated by one or two hospital chains, who could use buyer power to get a better deal on pharma prices – but also use seller power to screw the insurers with outrageous prices for care. So the insurers merged, too, until they could fight hospital price-gouging.

Everywhere you turn in the healthcare industry, you find another monopolist: pharmacists and pharmacy benefit managers, group purchasing organizations, medical beds, saline and supplies. Monopoly begets monopoly.

(Unitedhealthcare is extraordinary in that its divisions are among the most powerful players in all of these sectors, making it a monopolist among monopolists – for example, UHC is the nation's largest employer of physicians:)

https://www.thebignewsletter.com/p/its-time-to-break-up-big-medicine

But there two key stakeholders in American health-care who can't monopolize: patients and health-care workers. We are the disorganized, loose, flapping ends at the beginning and end of the healthcare supply-chain. We are easy pickings for the monopolists in the middle, which is why patients pay more for worse care every year, and why healthcare workers get paid less for worse working conditions every year.

This is the one area where the Biden administration indisputably took action, bringing cases, making rules, and freaking out investment bankers and billionaires by repeatedly announcing that crimes were still crimes, even if you used an app to commit them.

The kind of treatment these apps mete out to nurses is illegal, app or no. In an important speech just last month, FTC commissioner Alvaro Bedoya explained how the FTC Act empowered the agency to shut down this kind of bossware because it is an "unfair and deceptive" form of competition:

https://pluralistic.net/2024/11/26/hawtch-hawtch/#you-treasure-what-you-measure

This is the kind of thing the FTC could be doing. Will Trump's FTC actually do it? The Trump campaign called the FTC "politicized" – but Trump's pick for the next FTC chair has vowed to politicize it even more:

https://theintercept.com/2024/12/18/trump-ftc-andrew-ferguson-ticket-fees/

Like Biden's FTC, Trump's FTC will have a target-rich environment if it wants to bring enforcement actions on behalf of workers. But Biden's trustbusters chose their targets by giving priority to the crooked companies that were doing the most harm to Americans, while Trump's trustbusters are more likely to give priority to the crooked companies that Trump personally dislikes:

https://pluralistic.net/2024/11/12/the-enemy-of-your-enemy/#is-your-enemy

So if one of these nursing apps pisses off Trump or one of his cronies, then yeah, maybe those nurses will get justice.

(Image: Cryteria, CC BY 3.0, modified)

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#10yrsago A modest proposal for Wall Street’s future https://web.archive.org/web/20141215195720/http://www.bloombergview.com/articles/2014-12-15/michael-lewis-eight-things-i-wish-for-wall-street

#5yrsago From Enron to Saudi Arabia, from Rikers Island to ICE’s gulag, how McKinsey serves as “Capitalism’s Consigliere” https://theintercept.com/2019/12/18/capitalisms-consigliere-mckinseys-work-for-insurance-companies-ice-drug-manufacturers-and-despots/

#5yrsago A profile of Cliff “Cuckoo’s Egg” Stoll, a pioneering “hacker hunter” https://www.wired.com/story/meet-the-mad-scientist-who-wrote-the-book-on-how-to-hunt-hackers/

#5yrsago With 5G, 2019 reached peak bullshit https://www.lightreading.com/5g/2019-the-year-telecom-went-doolally-about-5g

#5yrsago Kentucky’s governor insisted that investment bankers could provide broadband. He was wrong https://www.propublica.org/article/there-are-kentuckians-who-still-dont-have-broadband-because-the-former-governor-chose-an-investment-bank-over-experts#173512

#1yrago Debbie Urbanski's 'After World' https://pluralistic.net/2023/12/18/storyworker-ad39-393a-7fbc/#digital-human-archive-project

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