With more docs becoming employees, is unionization far behind
Push for doc employees could lead to union growth
Repeatedly during the yearlong debate that led to last month’s landmark healthcare reform law, President Barack Obama and others praised health systems that employ physicians and embrace their leadership and cooperation in giving patients coordinated, efficient care.
The incentives for hospitals and physicians in systems such as the 20-hospital Mayo Clinic, Rochester, Minn., and three-hospital Geisinger Health System, Danville, Pa., the thinking goes, are better aligned to encourage high quality with less waste.
But as more organizations look to emulate those successes—for example, seven-hospital Carilion Clinic, Roanoke, Va., and just this month Carle Foundation, Urbana, Ill., with the purchase of the 300-plus-physician Carle Clinic Association—is it possible that executives will find themselves late one night staring across a table at their physician-employees in collective bargaining?
Physicians to date have shown little interest in organizing aside from those who work for state, county and city facilities, and some residents and interns. Healthcare labor lawyer Roger King, however, takes the notion of an expanded field of physician unions seriously enough that he included it in a list of things to watch in 2010 written for the American Hospital Association’s Health Care Labor Report.
“The focus has been on the economic model and the governance model: How do we bring practices within the hospital or the system for referral purposes and quality purposes,” says King, a partner in the law firm Jones Day. “There are additional consequences, or additional considerations, to this discussion.”
Negotiating with a physicians union would likely be much more difficult than what hospitals face when they grapple over contracts with nurses or allied health workers, King says, beginning with the complexities of how physicians are reimbursed.
“We’re going to be bargaining about salary structures, incentive systems, how do we tie to quality—if at all—and productivity,” King says. Perhaps physicians would attempt to set doctor-to-patient ratios or the numbers of ancillary staff, he muses. “Physicians by nature are independent, entrepreneurial types,” King acknowledges. But, he adds, “Bring them together and the potential for dissatisfaction in a collected sense could be considerable.”
Physicians have long argued that independent practices should be able to band together to avoid being outgunned in negotiations with health plans, but that kind of cooperation among competitors is viewed by federal antitrust authorities as price-fixing.
There is no such barrier, however, against physicians who are hospital or system employees forming unions to push their concerns with management. In the late 1990s, the American Medical Association formed a labor organization called Physicians for Responsible Negotiation, which had little success and was cut loose in 2004. The organization then joined hands with the Service Employees International Union but fizzled out.
An AMA spokesman suggested the notion that physicians have been flocking to hospitals is often overstated. A recent paper prepared for the AMA, based on 2007-08 survey data, indicates only about 16% of physicians were employed by hospitals. A 2007 report by the Center for Studying Health System Change put the figure at 12% in 2005, only slightly higher than the 10.7% in 1996.
AHA statistics, though, show a steady increase in hospitals employing physicians in integrated-salary models, with 1,583 in 2008 compared with 1,312 in 2004, and physician-recruiting firm Merritt Hawkins & Associates says the portion of its search assignments that are from hospitals has grown to nearly 50% from 23% five years ago.
The Merritt Hawkins numbers are skewed toward hospitals and systems because they have the money to hire recruiting firms, but something real is driving the dramatic increase, says Tommy Bohannon, vice president of hospital-based recruiting. “A hospital that is already down that road or just starting to go down that road, they’re well-served to do whatever they can to make physicians feel as much a part of the decisionmaking process as possible,” Bohannon says.
Barry Liebowitz, a physician who’s president of the SEIU-affiliated Doctors Council, says he expects the direction of healthcare will mean more employed physicians, with the cost of doing business rising for independent practices and reimbursement falling. “Once you’re employed, you can be organized, you can be a union,” Liebowitz says. “I would expect in this climate, this is going to be a growth industry.”
The Doctors Council represents about 4,000 physicians in public facilities and medical schools in New York and New Jersey but also in the three-hospital Cook County Health & Hospitals System in Chicago and its suburbs. Other physicians are represented by the Union of American Physicians and Dentists in California and the Federation of Physicians & Dentists in Florida, both affiliated with the AFL-CIO and the American Federation of Federal, State, County and Municipal Employees. The Committee of Interns and Residents, also affiliated with the SEIU, represents about 13,000 housestaff members in several states and Puerto Rico.
Though Liebowitz is passionate about the value that unions offer physicians beyond bargaining power, such as helping doctors become a grass-roots voice in their communities, he also says the best health systems, using the Mayo and Cleveland clinics as examples, don’t give physicians reasons to organize.
Another reason unions may not get traction may be that physicians who end up or remain employees are the ones who want to be there. William Atchley has been receiving his paychecks and benefits from seven-hospital, Sentara Healthcare, Norfolk, Va., since 1995, when his group of about 60 physicians became Sentara Medical Group, which now has about 400 physicians.
“It’s all about selecting physicians whose expectations and values are in alignment with the healthcare system,” says Atchley, who is chief of the Sentara Medical Group’s hospital medicine division.
The Doctors Council’s Barry Liebowitz, front, says, “I would expect in this climate, this is going to be a growth industry.”