Why Florida Physicians Need Unions
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Doctors
Beware!
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Edward
Annis, M.D. Edward Annis, M.D. is the Past President of the American Medical Association and the World Medical Association. Since 1963, he has been one of the country's most vocal supporters of the free market health care system. |
The reason the concept of unionization is popular is clear. The entire economics of medicine has changed. Up until the last decade, or in a few cases, the past two decades, medicine remained as one of the few remaining cottage industries. Physicians were in individual or small group practices, practiced medicine independently, and ran their own business. When the government's attempt to nationalize health care failed in the 1960s the void was filled by big business. The economics of medicine is now controlled by these big insurance companies. No longer is a physician a true individual entrepreneur. While society and the courts might still consider them that, the rules, contracts, fee schedules, "1-800-nurse" numbers, etc., make them employees in all but name, of the health care companies. Medicine has become a unique industry in which almost all of the economic might and economic control are on one side. Insurance companies are exempt from antitrust laws. Although considered natural competitors of each other, they often conspire and lobby to achieve their goals. Physicians on the other hand cannot even discuss economic issues such as fees and contracts together or they are in violation of antitrust laws, and as has been shown many times, will be vigorously prosecuted for this by the federal government. We are being forced onto a playing field in which not only are the teams involved vastly unequal, but the shape of the field itself, as well as the rules by which the game is played, are not only being made by the other side but often are kept secret! With these changes, medicine is now following the rules of the economic marketplace that it had long been exempt from. Predatory pricing, manipulative marketing, false and misleading advertising -- all normal ways of business practice -- now have appeared in medicine.
This has not occurred simultaneously throughout the country. Areas such as California, Minnesota and Florida have been most affected. In areas such as South Florida (Dade, Broward and Palm Beach Counties) physicians often have less than 10% of their practice in traditional indemnity practice, with the rest in HMOs and PPOs. Medicare HMOs are progressively dominating the scene. As more of a physician's practice becomes controlled by outside forces, the practitioner loses the individuality and control of his or her life that attracted many of them to medicine in the first place. In South Florida, the economic pressure managed care companies are putting on physicians is resulting in reimbursements that make it difficult to earn a living commensurate with the needs of the individual. With individual payments being so low, the pressure increases to see more patients per unit time and "stretch the envelope" in regards to what a physician can do. This often results in a style of medical care that the physician is consciously ashamed of. When one adds the control of decision making in medicine is being usurped by the managed care company, the degree of happiness and satisfaction a physician has with his or her mode of existence is reaching a nadir.
What can we do? Physicians clearly need help in dealing with this new changing economic environment. This is the attraction of unions. Physicians can join together under a "union banner" and achieve support, instruction and be represented by experienced and trained personnel for whom the "playing field" set down by the health industry is one they are not only familiar with, but play on all the time. Are union a panacea? Will they solve all of our problems? Will they allow the economics of medicine to return to what they were? Absolutely NOT. I perceive physician unions as a beginning -- as one part in a multilevel approach toward starting to even out the playing field.
For the practicing physician the courts have so far clearly held that, with or without a union, the negotiation of fees cannot be carried out in tandem with other physicians. This does NOT negate the value of a union. Fees are only one of many problems with managed care companies. Quality patient care, maintaining the "physician-patient relationship." And the ability to make independent decisions to take care of your patient are paramount. Contract issues, "delisting" patient choice, abusive paperwork, delayed payment, "down coding," etc. are also important to the employed physician as well, but these physicians can achieve much more. They can be represented in true collective bargaining by union. Physicians in a clinic in Tucson recently won this certification from the National Labor Relations Board and Formed a physician union to negotiate a contract with their employers. This is currently under appeal by the clinic, but certainly is a beginning. Physicians employed by governmental agencies are already unionized. Physicians employed by the State of Florida and those employed by the public Health Trust at Jackson Memorial Hospital in Miami are Unionized.
Other groups of physicians are, by contract, "independent contractors," but for all practical purposes are employed. Emergency room physicians, anesthesiologists, hospital-based physicians, academic faculty, etc., are fertile ground for unions to "expand the envelop" and organize. Many of these groups are true employees in all senses of the word except for their contracts. If it walks like a duck, talks like a duck and looks like a duck, it is a duck!
Physician unions can also achieve successes through legislation. As many abuses in managed care become more understood, unions and their members are becoming more dissatisfied with the limitations put on their health care. They are beginning to realize that the system we have now with managed care, benefits not the patient or the physician, but mostly the coffers of the insurance company. Unions and physicians are starting to have much more in common in our approach toward patient rights and curbing the excesses of managed care. We should be able to parlay this into legislative successes. Do we agree on everything? Of course not! This should not deter us from proceeding. Many cooperative ventures exist in which both sides "agree to disagree" and only leave on the table those items on which they can work together.
Can organized medicine achieve all of these goals without a union? It depends on the group of physicians you are considering. For the employed physician the answer is NO. The ability to enter into collective bargaining for these people is necessary and can only be done through a union. For those of us in private practice the answer is yes, but I believe only theoretically. Organized medicine has had the ability to do everything except negotiate fees for many years. The Florida Physicians Association (FPA), an organization set up to do just this, has been in existence for almost twenty years. It has had some successes but for the most part it has not even dented the surface of the need that exists. The new formation of the American Medical Association's Division of Representation is designed to do this but I do not believe it will be successful. It will have some victories, but the pressing need is LOCAL. Situations vary throughout the country and the need is different in different localities. An organization must be responsive and understand local needs to succeed. Organized medicine, despite its efforts, has not been able, in the past, to supply the vast needs of its constituents and I see no way it can do this alone in the future.
Are there risks with unionizing? Of course. The ethical issue of belonging to a "union" must be faced by some physicians. The question of whether to condone strikes or job actions must be openly discussed. If we affiliate with a national union, which will probably be necessary to achieve our goals, will we be able to maintain our independence? These are legitimate issues to debate but all have solutions. Is this at variance with the aims and ideas of the Florida Medical Association? ABSOLUTELY NOT!!! Our goals in unionizing are to protect the patient as well as ourselves. The FMA is already carrying out similar agendas. A physician union can, should — and I predict — will, work closely together to achieve our goals.
Before capitulating to attractive and persuasive scenarios, several considerations seem to be justified.
First: What unique powers do unions possess which are not available to individuals or to the organizations to which they belong? The answer of course, is that officially recognized unions have, under certain circumstances, the right to strike to obtain their objectives.
Second: Under present laws, can a medical society organize a union to collectively bargain payment rates with health plans of behalf of physicians? The answer is definitely Yes, if the physicians are non-supervisory employees of the health plan.
The basic and irrefutable premise is that no medical union nor any other organized union, such as unions affiliated with the AFL-CIO, can collectively bargain payment rates on behalf of self-employed physicians in independent practice.
Only non-supervisory employees qualify for collective bargaining under the National Labor Relations Act. This has limited the pool of physicians eligible for collective bargaining in the past as courts have found that physicians who supervise the work of care givers (nurses, technicians, etc.) are supervisory employees who are not eligible for collective bargaining.
Third: Because any strike or boycott to withhold medical care as a bargaining mechanism would compromise their ethical duties to patients, there is a long standing firmly held professional policy that a doctor strike is untenable in that it is directed primarily against patients and not against the power sources of their frustrations.
Fourth: In view of the foregoing other than strikes or boycotts, do unions have other powers denied to individuals or their organizations? This answer is definitely No.
Medical societies such as an A.M.A. and/or its component societies not only can but do aggressively assist physicians in many ways. They provide information about managed care and how to wisely negotiate contracts. They advocate on behalf of physicians and patients in legislatures and courts. They can and do express opinions about payment issues, such as opining that payments are too low and providing cost data to support that stand. They can express opinions and present physicians' complaints on all medical issues involving doctors and their patients, but may not threaten strikes or boycotts to obtain their objectives.
For over a decade, AMA policies have emphasized the need for education and instruction of physicians as to what they can do within existing antitrust legislation to enhance their collective bargaining capabilities. Efforts continue to obtain for the profession, the ability to fully negotiate with the government about important issues involving reimbursement and patient care.
Past AMA guidelines were restated by the policy making body during the meeting of the June 24, 1997 to read:
Resolved that the AMA seek means to remove restrictions, including drafting of appropriate legislation for physicians to form collective bargaining units to negotiate reasonable payments for medical services and to compete in the current managed care environment.
To attract members, some unions emphasize their relationship with the AFL-CIO and its influence in the Democratic Party and claim that they will be effective lobbyists. Doctors would be wise to remember the proverb: come into my parlor said the spider to the fly."
Space does not allow a listing of well-remembered personal reflections of how powerful labor union bosses in the `40's, the `50's, the `60's, the `70's, and at present, have played and continued to play major roles in the drives to socialize medicine.
On CBS National Television, I debated the man who Senator Ev Dirksen of Illinois told me was the most powerful non-elected main in the nation _ namely, Walter Reuther, head of the AFL-CIO. After our debate, I met with Mr. Reuther at his headquarters at Solidarity House on Jefferson Avenue in Detroit. His promise: We will not cease our efforts until every man, woman and child in this country is provided with a federally financed, federally administered program of Universal National Health Insurance.
Not long thereafter, Walter Reuther was killed in an airplane accident but his legacy of thought and promise has been nourished and kept alive by his successors. So Doctors -- Beware!