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Should Doctors Unionize?
Tim Norbeck is executive director of the Connecticut State Medical Society. He spoke to BNH regarding current issues in the medical community
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Business New Haven
7/12/1999
By: BNH
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Tell me about the issue of physician unionization, and where it now stands.
As more and more managed-care decisions are being made without physician input - or in spite of physician input - I think more and more physicians have felt that they are outside the system, that they can no longer represent their patients properly, and that patient care and quality of care are suffering because of physicians having their medical decisions and their medical judgment overruled by some health-care plans. This has led to a movement for physicians in unions.
Will the union be open to all physicians?
Unions can only help employed physicians. In other words, if a physician is self-employed - an independent practice - a union cannot collectively bargain for that physician. That would violate the law. The action the AMA took was basically a reaction to the anger and frustration and exhaustion physicians feel over the intrusion of third-party payers into the day-to-day practice of medicine.
What action is that?
That was to develop a national labor organization to represent employed physicians and, where allowed, residents as well. Again, antitrust laws do not allow independent physicians to collectively bargain. If the physician is an employed physician - employed by an HMO or a hospital or a medical school or a state or federal government or, in some instances, resident physicians in New York - then a union can step in and collectively bargain. They can address patient rights, patient-care issues or matters of employment. This really does not have any effect on the self-employed or independent physicians.
Is there a physicians' union currently in operation?
The AMA voted to form some collective-bargaining units, so having taken that action last week in Chicago, they will move forward with it and develop collective-bargaining agents or activities to help employed physicians. The object, obviously, is to give America's physicians the leverage they now lack to guarantee that patient care is not compromised or neglected for the sake of profits.
Why are independent physicians not allowed to collectively bargain?
We need to correct the antitrust laws, which right now do not allow physicians who are self-employed or independently in practice to get together and collectively bargain. The health plan can tell the physician, 'Look, this is the contract. You sign it or I'm sorry, we'll get other physicians who will.' That may take away a lot of physician autonomy. It may be a real concern for treatment decisions which are routinely overseen, sometimes overruled, by managed-care plans. Physicians feel today that they must be able to sit down at the negotiating table with other physicians, with health plans and talk about patient-care issues and decisions being overruled and those kinds of things.
Between whom and regarding what do you expect such talks would take place?
The bargaining would take place between physicians and the insurers and health plans. For the self-employed physicians we are looking to what we call the Campbell Bill. Tom Campbell is a California congressman who has introduced legislation that would allow physicians to collectively bargain together with health plans. That legislation is HR1304, and there was a hearing for that in Washington in mid-June and there should be another one in mid-July.
In what ways will the reforms advocated by the AMA be helpful to patients as well as physicians?
[HR1304] is very important for patients - extremely vital for patients, because physicians' treatment decisions and referrals are routinely being overseen and, sometimes, overruled by the managed-care plans, and that is definitely a concern on the part of patients. Also, patients don't have much choice today. There was a Rand survey that found out that only 17 percent of workers employed by private companies had a choice among plans. What that means is that in many cases the employer has only one HMO, and if you're the employee, that's your choice. It is no choice. You take that HMO or you don't get coverage. The reason why choice is important: without a choice of health plans, many patients say that they are far less likely to create a long-term relationship with a physician, which is a key component to high-quality health care. I know of many people who have had to change doctors three or four times in the last couple of years because their company changed to a different HMO and the doctor they had previously seen was not on the new HMO's panel. Those problems are getting out of control.
What other health-care issues do you see as being currently relevant?
The managed-care industry basically says that America wants a free market in health care, and that the Wall Street influence is good for the economy. But it is a plain and simple fact that America does not have a free market in health care, and we never did. Health-care consumers do not directly purchase their health care. As shown by the Rand survey, there is very little real choice for patients of health plans or even to choose their physician. People keep talking about HMOs and Wall Street being so good for the economy. It may be good for the economy, but it's certainly questionable whether it's good for health care. The imperative that Wall Street demands of hot growth companies - increase profits by eye-popping amounts year after year - doesn't really jibe with the business of delivering first-rate health care to the public. We feel, along with a growing number of Americans, economists and many others, that anything 'eye-popping' is bound to come directly from patient care at the expense of sick people and those that care for them, and go directly into the pockets of those investors on Wall Street, who view the nation's patients as just a commodity, either to yield a profit or to be sold short.
What other health-care issues do you think are significant right now?
Related to commodification is that, when you think about it, employees have become commodities to be auctioned of to the lowest bidder. That is a shock, and I think most of us as employees don't realize it. Someone can go to an employer and sell them on their HMO by giving them the lowest premium, which is often what the employer will take.
You've said that you believe unionization would raise the standards of care. What effect, if any, do you think collective negotiating will have on the cost of health care?
Well, it's been said by the HMOs , which certainly do not want physicians to unionize, that they're concerned about cost. One reason the insurers are crying about this is that if physicians were allowed to collectively bargain, that would eliminate the monopoly control that they now have over physicians and, basically, over patients. Whenever anyone begins to talk about patient protections, which the medical profession really feels that we need, the HMOs resist it, claiming that it will cost a great deal of money. They especially like to talk about how much it would costs if HMOs were allowed to be sued. Our feeling is that everybody else is responsible in society - physicians are, hospitals are - why are the HMOs to be given this exemption? They don't even consider that it may be fairer to the patient, but just complain about the money and the lawsuits, which it isn't completely clear would even be a problem.
What is the history of the unionization issue? Has it been brewing for long, or is it a relatively new idea?
It's been brewing for a while, mainly in New York. But most of the focus was on medical residents. The National Labor Relations Board considers, generally speaking, that residents are students, and do not have the right to collectively bargain. In New York the Committee on Residents was given that right many years ago. Now it's certainly gaining impetus because of the frustration that physicians feel, and many patients, too. But the physicians just feel so handcuffed for what they can do and what they can't do for their patients. Let me give you an example: medical necessity. That is one of the hot issues today in health care and HMOs and the insurance industry. HMOs and insurance agencies want the right to define medical necessity. I think most people would agree when I say that I certainly don't want an HMO determining when I need a medical procedure. We feel that medical necessity must be defined by physicians, as it was before managed care - not defined by HMOs according to the least expensive medical care. If the HMOs and insurance industries win the fight to define medical necessity, they will be able to control costs, but it might not be good for patients.
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