With more docs be­com­ing em­ploy­ees, is union­iza­tion far be­hind

Push for doc em­ploy­ees could lead to union growth

Modern Healthcare - - Front Page -

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.”

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