As most physicians will tell you, unionizing means resorting to the ultimate weapon used by unions — the strike — and that is unthinkable. What’s the point of joining a union if you do not intend to strike? Besides, it’s all just so unprofessional.
However, an increasing number of doctors are saying that it has all, most notably managed care, gone too far and that joining a union is the one action that will capture the HMO bean counters’ attention.
The recent wave of physician unionism across the country indicates that doctors are so angry and frustrated that they are willing to try unionizing as a last resort. Whether this turns out to be a good decision or not depends on whether those who join are able to move past their frustration and turn their energies toward creating an effective organization. But, that’s getting ahead of the story.
A reasonable place to start in deciding whether unionism is a viable option is to consider what the alternatives might be. When one considers the situation more closely, one can see that doctors confront a difficult, forced choice between two alternatives, namely to opt for identifying with corporate management or with labor. In the past, doctors avoided the issue by asserting that medical professionalism required doctors to be responsible to their patients first, and to other authorities second. By law, doctors were defined as small businesspersons and there was no need to press the matter. Now, that has all changed.
How it all Started
It started to change, innocently enough, when doctors banded together into groups sometime after the World War II reconstruction period ended during the 1960s. Doctors moved away from solo, fee-for-service practice, which is the structure of practice central to the definition of medical professionalism. Establishing group practices was a rational response to the increasing cost of maintaining an office, especially the escalation of administrative demands associated with medical record keeping. Initially, office managers, together with one or two clerks, could handle the administrative load for a group of physicians.
However, things not only got more complicated, they began to change at a rapid pace. That brought in an entirely new occupational group — practice managers, who soon evolved into entirely new kinds of organizations, known as Physician Practice Management companies.
At the same time, managed care organizations were entering into a particularly active phase, expanding, merging, and changing in the tireless pursuit of efficiency. That shift appears to have made doctors less efficient. Physicians responded in a perfectly rational and reasonable manner, by joining together to form even bigger groups to deal with the increasingly larger and more centralized, therefore more powerful, health care delivery organizations.
And, that in a nutshell explains why doctors now confront a forced choice in how they are defining themselves. It is because doctors’ organizations suddenly became so large that they began to attract the government’s attention.
The government became concerned that doctors’ groups were becoming monopolistic. It started with one or two doctors who were asked to leave such groups and responded by taking the groups to court, arguing that they were being prevented from earning a living. That touched off government anti-trust legislations.
Managed care organizations were quick to take advantage of the same argument. The fact that most participants (doctors, patients, and health centers) in the health care delivery system are now involved in contractual arrangements with large organizations means that the stakes have been raised, and more disagreements leading to legal disputes have come before the courts. This has put pressure on everyone to make their organizational objectives clear and put into contractual language.
The effect of this has forced doctors to choose between the available legal options in iidentifying the nature of the organizations that they chose to form to represent them and their occupational interests.
One option is to assume a corporate, business identity. And, many doctors have done just that. They have accepted the designation assigned to them by the government — as businesspersons — and operated under the rules governing commercial entities. They have contracted with managed care organizations over covered lives, accepting a high level of financial risk as an incentive arrangement, in setting the per patient per month payment. The government, meaning the Justice Department and the Federal Trade Commission, has supported this approach. It considers joining a group that competes with other physicians’ groups to be an excellent arrangement allowing the market for physicians’ services to operate based on fundamental supply and demand principles. That is good business practice, which is, of course, the essential problem in the view of others. Critics argue that good business practice is not the same as good medical practice.
Profit Versus Patient
The critics say that competition, in this case competition among doctors, requires hold-ing costs down to keep prices down. Hold-ing costs down is not bad in and of itself. It becomes objectionable, however, when it is achieved through the restriction of services — more precisely, restriction of efficacious services. While drawing the line on what is or is not efficacious is clearly debatable, the principle remains. The problem that a number of medical professionals have pointed out is that doctors who choose to embrace business principles which place greater value on efficiency rather than effi-cacy, risk being viewed as having a greater commitment to maximizing their profit than to their patient’s health.
The other forced-choice option is aligning oneself with workers rather than management. How is this an improvement, especially given that talk of unionizing brings to mind factory workers with smutty faces on the picket line with the threat of violence hanging heavy in the background? That has certainly been a problem for doctors. The imagery associated with unionism in this country brings industrial unionism to mind, which includes the tactics used by industrial unions to achieve better wages and working conditions for their members.
This is not the image of unionism held by people in other highly industrialized countries. In European countries people treat unions instrumentally. Whether they are professionals or not, they see themselves as having a legitimate interest in improving their wages and working conditions. Union representatives carry on those negotiations. The idea that members of a prestigious occupation will lose status if they join unions and use them to carry out negotiations with the organizations that determine wages and working conditions is not an issue. Indeed, virtually all European countries have strong doctors’ unions.
It is worth considering when and why European physicians formed unions. They did so as fee-for-service practice began to disappear. There was really little alternative. Everyone understood that large organizations, whether it was the central government as in Sweden or locally established sickness funds as in Germany, were not interested in negotiating with doctors on an individualized basis. As health care organizations in the U.S. become larger and more centralized, they, too, expect to deal with physician groups and organizations rather than individuals. Thus, the only question left is what kinds of organizations do physicians wish to assemble or, more precisely, which set of laws do they wish to be governed by. The choice is either anti-trust legislation or labor law.
Choosing to be governed by anti-trust legislation is not as complicated as choosing to be governed by the law. Since the law defines doctors as businesspersons, they are automatically covered by antitrust legislation unless they wish to arguee otherwise. Getting the doctors to treat their peers as employees protected by labor law and entitled to bargain collectively, even when they are salaried, is not nearly as easy to achieve.
Picking Sides
Is the fight to be defined as an employee or someone working under employee-like conditions worth it? Isn’t joining a union just replacing one set of problems with a new set? If the primary purpose is to achieve higher pay and better benefits for its members, won’t the public think that is inappropriate in the case of medicine?
We have not had enough experience to answer these questions conclusively, but the evidence thus far seems to indicate that the public usually supports the doctors rather than the organizations, usually managed care organizations, with which doctors have been negotiating. When disagreements over pay, benefits, plus all the other issues that the doctors find troubling about managed care restrictions have come before the public, the public has generally sided with the doctors. Doctors have rarely had to resort to strike threats. Managed care organizations have generally capitulated in the face of public support for the doctors’ cause.
This actually is not all that surprising when you consider how the public might perceive such events. Consider the context in which negotiations go on between unionized workers and management in contrast to negotiations between a managed care organization and doctors who operate as a corporate entity. In the former, everyone pretty much understands the issues that management and workers are bargaining over, but are more interested in the other issues (such as gag clauses, restrictions on referrals to specialists, and so on) that doctors have made public under such circumstances. By contrast, contracts between the managed care organization and doctors who operate as a corporate entity are never made public, are therefore more mysterious, and more likely to be suspect. It is not that the public is so eager to know how much money doctors make, it is that the public doesn’t know what incentives doctors are being encouraged to respond to. When doctors tell a patient that they are not recommending particular tests, procedures, or treatments that he or she may have heard about, is it because they aren’t really necessary or because the doctor will lose income by recommending it? After all, when a patient, as a buyer of services, sees himself or herself entering into a commercial relationship, it’s a matter of buyer beware. From the medical perspective, the problem is that the treatment plan may suffer when the patient doesn’t trust his or her doctor.
Since they have had so much more experience, it is worth considering how well the European physicians’ unions serve their members’ interests. Doctors win gains in negotiations when the public agrees with their cause, and lose when the public does not agree. The fact that particularly thorny negotiations are likely to be carried out in the public arena increases public confidence in the profession rather than detracting from it, precisely because there are no private agreements and hidden incentives to suspect. Doctors enjoy public trust, which makes medical work more rewarding whether that involves the doctor/patient relationship or efforts to attain funding for research on technical advancements.
This appears to be true even when they strike. From what we know, there is no evidence that they abandon patients who require emergency care and the mortality rate does not increase during strike periods. Routine medical care is suspended, which the public apparently regards as undesirable, but tolerable.
In summary, treating physician unionism as a radical statement growing out of frustration will produce a flashy, but unstable organization that is sure to lose steam as those who join it expend their energies in protest. It is far more likely to serve as an effective tool if one understands that its potential lies in being shaaped into a carefully legal instrument, designed to permit collective bargaining with large and powerful organizations over the long term.
Grace Budrys, PhD, is Professor of Sociology at DePaul University in Chicago, Illinois, and the author of When Doctors Join Unions,which charts the history of the Union of American Physicians and Dentists. Her book can be purchased online through Amazon.com (https://www.amazon.com) for $14.95.