The case for unionizing doctors

Check out this article about why physicians should seriously consider joining unions. The article appeared in the December 2018 issue of the Minnesota Physician journal, which also includes an article written by health care members Dr. Emily Onello and Louise Curnow, PA-C about their experience organizing their union. 

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“Hospital administrators easily manipulated physicians, treating them as if they were hired hands. Insurance companies were dealing with them as if they were employees. Government programs … controlled key aspects of doctors’ work, told them how much they would be paid, and what procedures they would be paid for.”

—Sanford A. Marcus, MD, founding physician of the Union of American Physicians and Dentists (AFL-CIO)

Dr. Marcus’s reflection on why he spearheaded his physician’s union with the AFL-CIO in 1973 resonates today. As the health care industry has grown and consolidated into fewer large players, physicians face ever-increasing challenges to retain decision-making power over their schedules, their personal economics, and even their patient care practices. In the current environment of corporate mega-mergers, physicians are hired as employees, and pay is dictated by unstable and unfair reimbursement practices. It’s no wonder that as private practicing physicians and those employed by larger systems alike are struggling to meet their moral and professional obligation to deliver the best care to their patients, some are turning to organized labor to regain control over their professional environments.

“Large corporations are stripping physicians of professionalism and belittling our management role,” said Niran Al-Agba, MD and pediatrician in Washington State, who sees collaboration between unions and physicians as a path forward.

This diminished role in decision-making is taking a toll on our country’s physicians. According to this year’s edition of Medscape’s National Physician Burnout and Depression Report, an alarming 42 percent of respondents reported burnout, affecting physicians across a wide variety of specialties. The reasons for this turmoil run deep. The top seven factors cited by survey respondents: too many bureaucratic tasks such as charting and paperwork (56 percent); spending too many hours at work (39 percent); lack of respect from administrators/employees, colleagues, or staff (26 percent); increasing computerization of practice (24 percent); insufficient compensation (24 percent); lack of control/autonomy (21 percent); and feeling like just a cog in a wheel (20 percent).

Physicians won’t be surprised to see that 56 percent of their colleagues report having too many bureaucratic tasks like charting and paperwork, 39 percent think they spend too many hours at work, or 26 percent feel disrespected by employers and administrators. However, they may be surprised that solutions to these issues can be found in union contracts covering the wages, benefits, and working conditions of union physicians and other health care workers.

Niran Al-Agba, MD, ventured, “Physicians certainly qualify as an industry sector whose bargaining power has fallen below the value of their effort. That’s where a physicians’ union could come in.”

A labor union is a group of workers who come together to use their collective strength to achieve common objectives such as safer working conditions, higher pay and benefits, and decision-making power over the practices that govern their work. Generally speaking, individual employees—even those with exceptional educational and personal backgrounds, like physicians—have less bargaining power and fewer opportunities to negotiate and enforce fair working conditions than their union-represented counterparts.

Enforceable collective bargaining agreements

A collective bargaining agreement (CBA) is an agreement between a single employer and the union on behalf of a group of employees, or “bargaining unit.” The National Labor Relations Board (NLRB), which decided in 1974 that non-supervisory physicians were eligible to organize labor unions, determines and defines individual bargaining units by considering whether that group of employees has a “community of interest,” or common characteristics such as: skills and education; supervisors or human resources; and wages, benefits, and other terms of employment.

Once a majority of employees elects to form their union, leaders chosen by their physician peers bargain alongside professional union negotiators with hospital administrators in order to reach the terms and conditions of the CBA. In this way, frontline physicians identify the issues impacting their workplace and utilize their expertise to negotiate an agreement that is uniquely tailored to meet the needs of a particular group of health care professionals.

The unionized health professionals at Lake Superior Community Health Center (LSCHC), including physicians, went through this process when they joined the United Steelworkers Union in Minnesota. Emily Onello, MD, and Louise Curnow, PA-C, were strong advocates during the organizing campaign and served as frontline representatives on the bargaining committee, and entered union contract negotiations in 2013.

“We were already highly motivated to make improvements for our colleagues and patients,” said Curnow, “but knowing that it was illegal for the employer to retaliate against us for union activity gave us an extra boost.”

They worked with their fellow health care professionals (MDs, NPs, PAs, RNs, LICSWs) to bargain an agreement that addressed, among other things, a more fair pay system that better reflected the needs and insurance status of the clinic’s patient population and a scheduling system that recognized the negative effects on providers when the patient schedule overflows and provider admin time is minimal.

According to Curnow, “We were also able to have some small but meaningful impact on scheduling meetings during regular work hours and not during charting time, which provided us with better work-life balance.”

The ability of union physicians and practitioners at LSCHC to influence policies contrasts sharply with an experience earlier this year of Anh Le, MD, an internal medicine and pediatric trained physician practicing in California.

Without consulting physicians, Dr. Le’s employer implemented a new scheduling policy which, among other things, replaced already limited administrative time with additional patient visits. This is the time that “we often use to answer patient messages, review lab results, or even just to catch up on seeing patients,” Dr. Le said. Frustrated with the changes, she and her colleagues met with administration. Despite the well-reasoned data for why the new policy did not make sense for physicians or for patients, Dr. Le and her colleagues simply did not have the bargaining power to force administrators to adjust the policy.

If Dr. Le and her colleagues had been protected by a union contract, such a policy would have been a “mandatory subject of bargaining” under the National Labor Relations Act (NLRA) and the administration would have had to bargain with doctors before implementing a policy that so clearly changed their working conditions.

Dr. Le expands, “Physicians are highly driven and when we do not have enough time to achieve at the level we want to achieve for our patients, we burn out. If this trend continues, physicians are going to leave medicine.”

Beyond the bargaining table

The sphere of potential influence of physician unions extends far beyond the bargaining table and into state and federal governments, where lawmakers make many decisions impacting physicians. Long-established labor unions have proven programs with policy specialists, relationships with lawmakers, and grassroots mobilization capacity. Health care employers and industry associations already utilize their power to influence government. A formal relationship between physicians and unions could help reinstate physicians’ voices into debates about health care and advance pro-physician and pro-patient policies.

Private practice physicians

Since private practitioners, unlike physicians working for health care systems, are not employees, they are currently ineligible to organize unions under the NLRA. However, physicians in private practice could collaborate with unions on strategic initiatives.

One example of such collaboration might be for private practice physicians in a particular market to band together to negotiate with insurance companies for better reimbursement rates, as well as a procedure to challenge denied payments. In this scope, a partnership between a physician collective and unions could provide a necessary check to the unilateral power of insurance companies to deny reimbursement payments.

Unions as the future

Public support for unions is growing. According to a January 2017 survey conducted by the Pew Research Center, 60 percent of Americans view unionization favorably, the highest indicators in more than a decade. 

The confluence of public support, physician burnout, and the fractured state of our country’s health care system could signal an approaching surge in organizing for physicians. Union organizers, negotiators, and policy experts stand at the ready. The next step is one physicians must take:

"We are already strong. We have resiliency, " says Dr. Le. "However, we are not used to standing up for ourselves. I would like to believe that if we could stand together, we would be better able to reclaim our positions as the drivers of healthcare delivery in this country.”

Individual physicians may be reluctant to consider unionization, perhaps out of fear of retaliation or a sense that such a move would be inconsistent with their professional status. At the same time, the law is clear on their rights to seek union status. For health care professionals concerned about preserving their ability to deliver optimal patient care, devote adequate time to exercise professional judgment, and practice to the top of their license in the face of consolidation or evolving reimbursement structures, unionization may be a path worth considering.

For a step-by-step guide on how to organize a union within your organization, see Figure 1.

Summary

As physicians face increasing challenges to retain decision-making power over their schedules, personal economics, and even patient care practices, forming unions is an effective way to regain professional and personal control. Standard collective bargaining agreements address the staffing, scheduling, financial, and quality-of-life issues that physicians commonly name as contributing factors to burnout. Long-established lobbying and policy programs within unions can also provide physicians with political access and power they need to reclaim their places as the primary decision makers in patient care policies.

There is a clear path forward for physicians who want to form unions.

Mandy Rae Hartz, MA, leads the United Steelworkers Health Care Workers Council, which coordinates collective bargaining, education, policy, and communications for more than 50,000 union health care workers in the United States and Canada. For more than a decade, Ms. Hartz has empowered union health care workers in a wide variety of professional settings to win and enforce market leading collective bargaining agreements. She believes health care workers know best the challenges—and solutions—to improving health care delivery and that building strong, patient care-focused unions is the most effective way for health care professionals to make meaningful advancements in their work and personal lives. She holds a master’s degree in political science from American University and is a graduate of the Trade Union Program at Harvard Law School.

Figure 1. A step-by-step guide to organize your union