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Physician unions: Bad for them and us

By James Unland

In many areas of the U.S. physicians are seriously talking about—and, in some cases, acting upon—the formation of unions. Some of these physician unions are being established to be stand-alone entities, whereas others are intent upon becoming locals of national labor organizations, most notably the AFL-CIO. Although the actual numbers of physicians in unions to date remains quite low, unionization could become widespread within a relatively short time unless the leaders of such efforts are persuaded to stop and think about why physician unions are ill-advised for them as well as for us, the consumers.

No question about it, many physicians are justifiably frustrated and angry. They are exasperated with day-to-day dealings with a host of middlemen in the insurance industry who are, essentially, practicing medicine by telling doctors what they can and can’t do and in come cases even what they can and cannot say to patients. They are bedeviled by constant interference from insurance and HMO bureaucrats in the management of medicine, in clinical decisions and in the physician-patient relationship. It is a shameful state of medical practice and a humiliation for a physician to have to pick up the phone to call a managed care clerk for treatment pre-authorization, to find out where to send a patient for a test or to get permission to prescribe a drug not on the “approved” list. It is an outrageous insult to our supposedly modern medical system when physicians are prohibited from talking about treatment options to their patients and when our tax dollars are now required to pay legislators to legislate “gag” clauses in managed care contracts out of existence.

It is symptomatic of tragically upside-down reasoning and low self-esteem when physicians think they now need to form unions in order to better negotiate with the payors. Those involved in these efforts need to stop now and think again, for they run the danger of doing themselves and the rest of us an enormous, irreversible disservice.

Much of the physicians’ frustration and anger is legitimate and, in fact, is shared by consumers themselves, many of whom—according to well-documented nationwide surveys—regard insurance companies and Wall Street health care corporations as “calling the shots” in our health care system. Physicians and consumers are all harmed when insurance companies practice medicine, and those physicians who are trying to unionize their colleagues often justify such efforts by indicating that they need unions to better negotiate with insurance companies and HMOs.

The facts of life, however, are that not only are physician unions the wrong solution, they would be counterproductive and would, ultimately, produce a result exactly opposite from the original intent. It is symptomatic of tragically upside-down reasoning and low self-esteem when physicians think they now need to form unions in order to better negotiate with the payors. Those involved in these efforts need to stop now and think again, for they run the danger of doing themselves and the rest of us an enormous, irreversible disservice.

Three suggestions come to mind.

First, physicians need to recall why the insurance middlemen are practicing medicine: HMOs and other forms of “managed” care are an outgrowth of and direct reaction to the undisciplined heyday of fee-for-service medicine. Following studies that documented multiple forms of medical overutilization—to the extent that in the mid-1980s it was found that nearly half of surgeries and tests were unnecessary—businesses and consumers searched for a way to rein in physicians. Let’s be honest; in many ways, physicians brought the practice of medicine by insurance companies onto themselves by not regulating their own overutilization of a fee-for-service system. Managed care has accomplished one positive change in attitude: physicians and hospitals finally recognize that some discipline is needed, that a reasonable amount of specialty-based standardization of medical management can be a good thing and that self-policing in the medical industry is long overdue. Unfortunately, this enlightenment came in most quarters after the middlemen had already virtually taken over control of the practice of medicine.

Second, physicians need to understand that they hold the key asset in our health care system: the physician-patient relationship. When patients have health problems, whom do they see? The Chairman of Aetna? A utilization review clerk at U.S. Healthcare? A hospital administrator? Of course not. Patients turn to physicians. Only physicians can diagnose illnesses, prescribe medication, administer treatment, admit someone to a hospital—in short, provide and oversee the provision of health care services, personal human services. Beyond this, physicians are in the best position of anyone to develop workable treatment protocols, conduct meaningful peer review and undertake the many other projects and tasks that bring value and progress to our health care system. Physicians work in the most intimate personal service business of all; they and they alone have the relationship of trust with patients that is, truly, the most precious asset in our health system. Physicians need to recognize this asset and embrace a new “life view” of themselves that will, in turn, motivate them to lead the health care revolution that needs to take place in this nation—a revolution that is still well within their grasp.

Third, physicians need to recognize that they are not picking grapes or working on an assembly line. Not only do they have the most precious asset in our health care system—the patient relationship—but they are also the main drivers of resource utilization. In short, physicians are supposed to be the most important decision-makers in our entire health care system, not the puppets of corporations practicing medicine or trophies of the AFL-CIO.

Instead of forming unions to clamor for salaries, benefits and petty privileges, physicians need to take steps to reestablish the direct link of service and accountability with consumers. If this is approached properly, consumers will respond. Consumers are worried about the increasing “corporatization” and “Wall-Streetization” of health care. Consumers want doctors to restore the direct link to them, but they also want medicine practiced responsibility and they do not want to return to irresponsible, unrestrained fee-for-service medicine. The best way to restore balance and rationality to our health care system is not for physicians to form unions but, rather, for physicians to take the lead in establishing broad-based, inclusive provider networks that are underpinned by a direct link—a “direct contract”—between the providers of health care and the consumers, whether “consumers” be individuals, small companies, larger self-insured corporations, or Medicare and Medicaid recipients.

Several occurrences are fueling the momentum toward direct contracting. First, there has been a growing anti-HMO backlash among health care consumers themselves; this has been supported in many states through legislation (1) eliminating HMO contract “gag clauses,” (2) promoting consumers’ and physicians’ rights of appeal to HMOs and (3) insisting upon full disclosure to consumers of contractual relationships, including financial incentives, between HMOs and providers. Second, health care providers are aggregating into networks of physicians and hospitals. Third, corporations and unions are beginning to encourage direct contracting. Fourth, the increased corporatization and “Wall Streetization” of health care is causing concern that, rather than creating more efficiency in the system, added layers of profit-taking are being introduced without creating new net value and, in fact, burdening the system even more in order to feed stockholders. Fifth, the technology now exists for providers to organize and operate as insurers. Finally, many members of Congress have been giving the concept of direct contracting favorable attention.

People are not stupid; they know that commercialized “managed” care is not the answer. Witness all of the anti-HMO groups and anti-managed care press that have sprung up in just the past year. Shouldn’t the provision of medical care be the most consumer-friendly personal service business of all? Do physicians really think that a union is going to make consumers any less cynical and angry than they are now?

In fact, the real danger is that physician unions will cause further erosion of the physician-patient relationship.

What are unionized physicians going to do—go on strike? Withhold care? Leave their offices, vacate emergency rooms and abandon surgical suites to go out and play golf while their union representatives are negotiating with payors, hospitals or whomever? Do physicians plan to negotiate union contracts from cell phones in their Porsches, golf carts or sail boats? Would this sit well with consumers or cause them trust physicians more?

No. Not only that, it is likely that widespread physician unionization would cause consumer frustration with insurers and physicians to reach the point where there would be public support for nationalizing the health care system. Then what are the doctors going to do—strike against the government? With nationalized health care, everyone loses. Far from giving physicians more control over their own destinies, unions would accelerate a move toward socialized medicine that would result in far less control by physicians and, tragically, a total erosion of the physician-patient relationship accompanied by grave reductions in health services.

Physicians need to regain more control over the practice of medicine, but they need to do it the right way: by recognizing their assets and forming direct linkages with the people they serve in what is the most important, one-on-one relationship of trust, compassion and competence that there is. The power of physicians lies in (1) the physician-patient relationship and (2) the ability of physicians more than anyone else to advance the state-of-the-art in health care delivery. In the face of a favorable legislative environment and a growing anti-managed care attitude, the time has never been better for physicians to seize upon their assets and team up with other providers to create direct link of service and accountability to consumers.

Yes, physicians need to go into action, but not by insulting their fine intelligence and education by forming unions. Rather than embracing the AFL-CIO, physicians need to embrace their customers—the people they serve—by creating new structures of direct service and accountability to consumers, so that caregivers are able to function in a health care system that permits them to care.

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