Introduction:
A
sense of powerlessness and disenchantment is pervasive in medicine today.
Many physicians seek and desire representation through collective action
as a way of voicing their anger over the intrusive control exercised by
their employers and/or the payers of their services. In particular, the
focus is on managed care systems that continue to aggressively dictate
payment and coverage terms in their contracts with physicians. At the core
of the physician’s frustration is their loss of decision making powers
and the lack of control over the quality of patient care and secondly their
disadvantage in negotiating contractual terms for their services. The argument
continues that it is difficult for them to serve their patients interests
in an environment which is hostile to these interests. Increased patient
loads; late payments; gag clauses; complicated referral processes; and
staff shortages have been offered as a partial list of items contributing
to sub optimal working conditions. Further, physicians express concern
that the system lacks a meaningful avenue through which due process of
their grievances can be heard.
Currently,
about 55% of all physicians are private practitioners. Although all physicians
including those who are salaried employees, have some degree of dissatisfaction
with the current system, the loudest voice comes from the private practineers
who must do direct business with the HMO’s inorder to have a viable medical
practice. When an HMO presents a private practitioner with a contract including
a fee schedule for service, the physician has little choice other then
to sign the agreement. Not to sign means losing whatever percentage that
particular HMO represented of their practice the previous year to a physician
down the street. And unfortunately there is always one more physician down
the street.
It
is out of this enormous sense of frustration over the lose of patient management
decisions and fair compensation for their service provided that the old
concept of physician unionization has re-emerged. Physician unionization
is seen by its supporters as a means of leveling the playing field with
the HMO’s.
At
the center of the discussion on physician unionization is the issue of
collective bargaining and violation of antitrust law. The listed web sites
and selected articles which are all accessible on the internet begin to
explain the complexity of the issue and the obstacles which must be overcome
in order for unionization to become a viable choice.
1.American
Medical Association, www.ama-assn.org.
The
AMA is the principal organization representing physicians needs in North
America. Approximately one third of all physicians are members. There are
two publications which are associated with the AMA: 1. American Medical
News, a weekly newspaper which covers relevant current medical topics distributed
to all AMA members. Several articles on unionization have appeared in this
newspaper. 2. Journal of the American Medical Association. This medical
journal published in association with the AMA has also included articles
on the unionizationmovement. Articles
about this topic can be accessed through this web address. Thisweb
site also provides links to other web sites which contain information relevant
to this topic. Several are organizations started by the AMA. Four stars
2.Physician’s
News Digest, http://physiciansnews.com
This
is a weekly publication which deals with medical issues relevant to physician’s
practices. It actively publishes articles about the unionization movement
and is affiliated with the AMA. Four stars
3.Coudert
Brothers Practice Group, http://www.coudert.com/
This
is a law firm that has as one of its divisions a member who is active in
the area of physician unionization. By accessing the law firm’sweb
site, all relevant articles written by this member can be accessed in their
entirety. These articles were found to be relevant, comprehensive, and
well written. Use the search engine to find the articles. Four stars
4.American
Academy of Family Physicians, http://home.aafp.org
This
is the web site of a professional society representing family practice
physicians. They publish a journal entitled “Family Practice Management”.
They have several relevant and comprehensive articles which have appeared
in their journal. Further, these articles can be accessed in their entirety
from the web site. Four stars
5.Physicians
for Responsible Negotiation (PRN), http://www.4prn.org
PRN
was created by the AMA to “empower” physicians. The organization has bylaws
which are accessible at the web site. It clearly defines what rights under
the law physicians have in any conflict with an employer or payer. It also
provides links to other physician unionization web sites. After exploring
all the sites within the PRN site itself, it was found to be more smoke
then substance, with very little contribution towards an understanding
of the movement or their role in achieving any goal. One star
6.Union
of American Physicians and Dentists, http://www.uapd.com
The
UAPD was founded in 1972 as a union representing physicians and dentists.
It represents approximately 5000 physicians and dentists. 55% of the members
are employed by an organization, 45% are self-employed. There was very
little useful information at this web site. Much of the information is
dated and is heavily geared toward the legislative environment in California.
There were no articles detailing the current state of the physician unionization
movement. Overall the site was not a strong resource to gain an understanding
of the concept and movement of physician unionization. One star
1.Collective
Negotiation and Physician Unions, By Michael L. Ile, JD, Nov. 3, 1989,
JAMA, vol262.no.17,pg. 2444, http://www.ama-assn.org
Although
this article is over ten years old, it masterfully defines why this problem
has generated the current interest in physician unions. It further delineates
the complexity of antitrust law which is the principal roadblock in forming
a union and the penalties for violation of the antitrust law. It also makes
the distinction between employed and self-employed physicians. Finally,
it defines the AMA’s position at that time with regard to the union movement.
Five stars
2.Physician’s
Union: Handle with Care, By Elinor R. Hoffmann, Esq., March, 1998, Managed
Care Interface, vol.11, no.3, p.81http://www.coudert.com/physcare
This
is an article written by a lawyer, which in great detail traces the origins
and the history of the Sherman Act (antitrust law), which was inacted in
1890. Over the last century there were many amendments to the original
law to create a more fair and equitable piece of legislation. Antitrust,
the ability of one group to “fix a price” is the central stumbling block
to physicians unionizing. This article, through the siting of case law
and the elaborating on the historical highlights makes a very confusing
issue understandable to the lay reader. Five stars
3.Is
there a Physician Union in Your Future? By Robert Carlson, Jan. 1999, Family
Practice Management, http://home.aafp.org
This
is a very comprehensive article which touches on many of the issues which
are foremost in physician’s concerns about unionization. Points which were
raised include why is this such an important issue now, why would established
unions be interested in including physicians as partners, are doctors comfortable
with being in a formal union, what is antitrust, and were does the AMA
stand on this issue? All of these issues are tactfully and clearly addressed.
Five stars.
4.A
Union Answer, by Craig Havighurst, Jan. 11, 1999, American Medical News,
The
article looks at several antidotal situations including the Medolia Healthcare
System
in Seattle, Washington and the Allegheny Health and Research Foundation
in Pennsylvania where employed physicians have looked toward unionization
to get a more equitable deal from their employers. They conclude, doctors
are more inclined today to look toward unions, because no other avenue
has provided a satisfactory answer to their problems. Three stars
5.IVE
Bargaining Program, Nov. 1997, Physician News Digest,
This
article is a one on one interview between Nancy W. Dickey M.D, President
of the AMA and the Physician News Digest. Dr. Dickey makes the case that
collective bargaining is a more appealing alternative then unionization
of physicians. In 1997, the AMA had no interest in becoming involved in
the physician union movement because they did not see it as part of their
mission to represent physicians in business negotiations. This article,
in a round about way, attempts to stake a position that unionization is
not an activity that the AMA is interested in becoming involved in. Since
1997, out of necessity, the AMA has slowly become more sensitive to the
membership’s concerns that the AMA becomes more actively involved in the
physician unionization movement. Two stars
Physician
unionization is a relevant topic to manage health care. Currently the movement
has reached a legal dead end because of the Sherman Act.
There
are two suggested paths to overcome what otherwise appears to be a legal
impasse.
1.Doctors
can go forward with unionization and confront the HMO’s collectively. This
would force a public debate of the physician’s grievances with the HMO’s,
with the hope of winning public support for their compromised position.
If they were to lose in the public forum however, they will be in clear
violation of the antitrust law and the consequences would be severe.
2.Petition
congress for an amendment to the antitrust law. The literature is pessimistic
about a favorable outcome. All corners of society are pleading for reductions
in the cost of health care. Such favorable legislation would only fuel
the fires of greater medical expenditures.
Ultimately,
without a congressional amendment to the Sherman Act, any attempt by physicians
to unionize for the purpose of collective bargaining is unlikely to succeed.
Self-employed doctors in independent practice do not qualify for the labor
exemption from the antitrust laws and do not qualify for protection of
the National Labor Relations Act. They are classified as independent contractors,
not employees. Therefore, they may not engage in collective bargaining
with health plans.
| Note: The information below may contain additional relevant materials and documents. Some of the information may be duplicate. The evaluations depend on both the student doing the review and the information contained at the time of the review. Sites are subject to change! |