By Jeffrey Barg

Published November 1997

OTHER COVERAGE OF PHYSICIAN UNIONS

• Physician unions take root in Pa.

• Physicians seek antitrust waiver

• Surgeons fight Blue Cross rate cuts

• Medical society explores regionalization and MD unions

• Legal issues of physician unionization

• Physician unions gain steam

• A Pennsylvania physician guild

• Building a physician union in the Delaware Valley

• The legalities of physician unions

• Prospect of physician unions in Pa.

• React to this article in the Discussion Forum.

Nancy W. Dickey, M.D. is President-Elect of the American Medical Association. She recently spoke in Philadelphia about the AMA’s new Division of Representation.

PND: What is the AMA’s new division of representation?

ND: They are prepared to send a team out to work with, educate and facilitate the county and state associations or independent groups of physicians to function as physician representation or as an independent bargaining unit.

PND: What was the genesis of this division?

ND: The marketplace is probably the genesis of the need. The changes that are occurring in the marketplace in that the number of physicians that are employed, the number of physicians who have contracts and therefore are impacted by the opportunity or lack thereof to negotiate their relationship is increasing extraordinarily rapidly. Twenty years ago, a physician didn’t need much collective bargaining. He agreed which insurance plans he was going to see on an assignment basis, which ones he would see and charge the remainder to the patient. That has changed over the last several years and even more rapidly in the last five years. Secondly, as we evaluated at the request of our House of Delegates the issues of unionization, we continued to have concerns with both the philosophy of unions, which tends to be an organized group to take care of the employees’ wages, vacations, working conditions, etc., and the tools that they’ll probably use believing that striking is not an ethical response. And so the question was, how can we facilitate physicians being able to care for their patients and have productive relationships with large entities that render contracts and hire physicians if we don’t support the concept of unionization? And the answer was that we believe in many instances you can get the impact desired through collective bargaining without all of the philosophies and by-products of unionization.

PND: What are the differences between collective bargaining supported by the AMA and a union?

ND: Many of the things that collective bargaining can do can be done either by a union or a group of physicians. For example, in Connecticut, they have a PSO that has recently formed that represents the physicians with insurance companies regarding rates and contract issues but is also able to address issues that are much more patient-oriented than physician-oriented: issues of utilization, review process and quality insurance mechanisms, appeals process for patients whose request for treatment is denied. Many of those are issues that are much more compatible with the visions and history of the medical association than they are with the union, who traditionally is looking out almost entirely for the economic well being of the employee. There are some concerns with the traditional union organization and the fact that they have a different perspective and vision than physicians and the profession of medicine have had, and whether those two can live compatibly together or if they are not compatible, which one can take precedence. As I talked to physicians, most of them say, and I presume it to be true, that the issues they primarily want collective bargaining for are issues of patient care, autonomy, quality and oversight issues with third party payers, managed care companies—and not issues of payment and time off and hours worked and number of patients seen. Those are things that can be addressed through a bevy of things including collective bargaining, but also including legislation or negotiation with the physician liaison. For example, with the Medicare carriers, the carrier committees. And I think, frankly, there’s a blurry boundary there that makes many people say, "I’m not sure I see the difference." And at that boundary there may be precious little difference. But clearly in our perspective, unions tend once you move away from that boundary to become much more self-serving to the individual, less committed than medicine is to the patient, toward the third party, more committed to economic issues like vacations, time off and income. As we head to the boundary between the two, I think it becomes a little more difficult to clearly delineate the two.

PND: Would this collective bargaining only be possible for employee physicians or would it also include independent contractors?

ND: It depends on the entity doing the collective bargaining, but certainly using the example of Connecticut, the PSO is not simply a group of employed physicians, it’s a group of independent contractors. So it does offer the opportunity to be able to do things that unions cannot do.

PND: Do you have anything specifically geared toward residents in terms of fostering collective bargaining?

ND: We chose not to send in an amicus brief when a Boston group appealed to the NLRB to be considered for recognition of unionization, but agreed on behalf of residents to assist them in forming house staff organizations that could represent the house staff with the hospitals and the academic entities to address employment conditions, issues in colleges and education issues to help protect them from retaliation. We look forward to a fairly extensive hearing of that process and the expectations of it at the December interim meetings, where my understanding is that an open meeting will be convened to discuss the role of collective bargaining with AMA officials and residents present to help explore how that may help address some of the issues.

PND: Do you consider efforts by traditional unions to organize physicians to be a threat to organized medicine?

ND: No, I don’t think so. Again, I think our concern with unionization has to do with the ability to maintain the commitment to professionalism and an ethic, should there be a conflict between the goals of the union and the goals of the profession, and the utilization of techniques that withhold service in an effort to improve the economic well-being of the employee, in this case, a physician. I think organized medicine does far more than just collective bargaining. And so I don’t think it’s threatened by the approach of unions. I simply think it would be extraordinarily limiting if county or state associations perceived themselves as nothing more than a union.