As dissatisfaction with managed care grows, so does interest in unions and other collective bargaining arrangements.
Many doctors see these arrangements as a means to regain leverage against hospitals, clinics and managed care groups, attain financial control, maintain physician autonomy, and increase the amount of time spent with patients. However, issues such as the impact of unionization on the medical profession, the possibility of striking, and the ethics behind collective bargaining remain a heated debate.
A Brief History
Following World War II, legislation was passed that exempted insurance companies from anti-trust laws and allowed them to share data and set prices. This positioned independent contractors as competitors and, as such, prohibited the contractors from fixing prices.
Physicians, at the time, didn’t see a need for collective bargaining — they practiced independently, set their own fees, and determined which insurance plans they were going to work with on an assignment basis. However, during the 1970s and 1980s, as managed care started to rear its head, physicians’ attitudes began to change.
With fees and reimbursement cut by HMOs and PPOs and an increasing trend toward interference in medical decision-making by prior approvals and utilization reviews, physicians began feeling a reduction in income and erosion in autonomy and clinical authority. Physicians started looking for a way to regain control of their practices by forming Independent Practice Associations (IPAs), including network model HMOs, as one way to negotiate as a group with insurers.
In the years that followed, as managed care grew and power became concentrated in fewer and fewer hands, doctors became increasingly frustrated and took their first steps toward unionization. Unions hoped to circumvent physicians from anti-trust laws and enable doctors to collectively bargain.
Today, interest in unions has intensified. More than 42,000 physicians — or 5 percent of the nation’s doctors — are labor union members, many of which are interns or residents. Critics contend that with an increasing number of residents seeking the right to collectively bargain, medicine will see an unprecedented surge of doctors beginning their careers as card-carrying union members.
“To date, physician unions have not had a significant impact on organized neurosurgery,” said Robert E. Florin, MD, Chairman of the AANS Physician Reimbursement Committee. “However, with the Health Care Financing Administration (HCFA) recently implementing practice expense relative value units (RVUs) that will reduce total neurosurgical income by 15-20 percent over the next five years, neurosurgeons may turn to unions as a means to gain leverage.”
Why Unions?
Under current labor laws, only non-supervisory employees may form unions. Self-employed doctors are termed independent contractors and, as such, are barred from forming unions because of federal anti-trust laws against price-fixing and other collective actions.
Many physicians hope that representation through unionization will be an effective outlet for them to voice their anger over the intrusive control exercised by their payers. They say they are outraged at the insurance company bureaucrats who are “calling the shots”in the health care system, and argue that a physician’s primary responsibility is to his or her patient, not to the managed care industry’s bottom line. Through unions, physicians hope to bring their issues to the table when negotiating with health care contractors.
Arnold C. Lang, MD, and Guillermo A. Pasarin, MD, are two neurosurgeons who, frustrated with managed care and the corporatization of health care, joined a chapter of the Federation of Physicians and Dentists — a 3,500-member union based in Tallahassee, Florida, that is affiliated with the AFL-CIO. Today, they serve as the Vice Presidents of the Federation.
“I believe that the practice of medicine should rest in the hands of those responsible for patient care — physicians,” said Dr. Lang. “We have lost total control of our profession and unionization is about standing together to say ‘no more.”
Dr. Pasarin added,”In our specialty, patient care and medical services are increasingly being rationed by HMOs. Unions enable neurosurgeons to practice their craft without any extraneous factors.”
The Downside to Unionization
Physicians who decide to unionize, however, face many difficulties. The laws that define who can and cannot unionize sometime inhibit physician unions from gaining government recognition, which is essential when negotiating with employers. And, for those that do receive acceptance, there is stiff resistance from other physicians who are adamantly opposed to the ultimate weapon of unionization: a strike.
“While I understand the difficult working conditions we, as physicians, sometimes face, I do not see how a strike could ever benefit the best interest of our patients,” said James R. Bean, MD, Chairman of the Council of State Neurosurgical Societies (CSNS). “To withhold patient care is not only an abandonment of our ethics but a stain on our image as professionals.”
Critics also argue that instead of giving doctors more control over the practice of medicine, unions would result in medical and hospital services being administered via organized groups and paid for by funds obtained through assessments and taxation. They also contend that unionization would accelerate an erosion of the physician-patient relationship and drastically reduce health services.
“Widespread unionization is not the solution to the problem plaguing our health care industry, rather it would only serve to make the problem worse,” said Dr. Bean. “Neurosurgeons joining unions must realize their limitations. The pressure to raise primary care income at the expense of specialty income will guide policy, just as it does in any current multispecialty medical organization.”
Dr. Lang disagrees: “Neurosurgeons represent a small specialty and, as such, will benefit from a large, collective voice. Unions are not meant to be a substitute to organized neurosurgery, rather they are a means to help organized neurosurgery improve patient care.”
Union Alternatives?
The American Medical Association (AMA) is exploring alternatives to help doctors stand up to insurers and employers. “We believe you can get the impact desired through collective bargaining without all of the philosophies and by-products of unionization,” said AMA President Nancy W. Dickey, MD (Physician’s News Digest , November 1997).
To demonstrate this, the AMA has publicly supported the Quality Health Care Coalition Act of 1998 drafted by Representative Tom Campbell (R-CA). The bill exempts self-employed health care professionals, including doctors in private practice, from anti-trust laws and allow them to collectively bargain with HMOs.
“The AMA has long believed an anti-trust exemption for self-employed physicians is needed to level the playing field,” said AMA Trustee Donald J. Palmisano, MD, JD, in a recent testimony before the U.S. House of Representatives Judiciary Committee. “Too often, the individual physician and the individual patient stand alone against health plan bureaucracies. This must change. The Campbell bill improves patient care and redirects the medical decision making back toward the physicians and patients — where it belongs.”
The Battle Intensifies
As managed care continues to challenge the way physicians practice medicine, the battle over unionization will intensify. Supporters are on a mission to reclaim their profession. They argue that as long as HMOs remain monopolistic, physician unions will continue to survive and thrive.
Critics, however, disagree and believe that unions are not the solution to improving negotiations with payers. They believe that supporters need to realize that putting down their patient charts in exchange for picket signs would not only be a disservice to their patients but to the medical profession as a whole.