Proposed legislation in Pennsylvania and Texas as well as existing laws in Washington state give independent physicians the ability to bargain collectively with HMOs, free of federal antitrust limitations. And neither the Justice Department nor the HMOs -- nor even some doctors -- are happy about this.
One internist in a small general hospital in New York state (who wished not to be named) sees the need for reform. "I know from personal experience that being a physician no longer carries with it the intellectual and financial rewards that it perhaps once did. By improving working conditions and reimbursement, we would once again be able to attract more ... people into the field."
Due to the increasing control that HMOs wield over health care, more and more independent doctors want the right to negotiate collectively with the people who are paying for their services. Historically, this meant the patients themselves. For that reason, the American Medical Association (AMA) has traditionally maintained that doctors, who are supposed to have the patient's best interests in mind, had no business joining unions.
The History of Physician Unions
The idea of physicians joining a professional trade union is not a new one. In her book "When Physicians Join Unions," Grace Budrys, Ph.D., looks at the factors that led to the original surge of physician unions in the early 1970s.
Budrys found that a few fledgling physician unions were formed at that time as a response to increased government intervention in medical decision making. However, almost all those unions had folded by 1990. In 1997, only 6% of doctors belonged to the few medical unions in existence.
Because of consolidations that have left most health care in the hands of six major insurance carriers, many doctors are again feeling frustrated. They claim HMOs are preventing them from pursuing necessary treatments. Meanwhile, HMOs assert that they need to oversee treatments to keep costs from rising out of control.
Practitioners who started prior to the advent of HMOs feel the changes the most, says the internist in New York. "The stress level increases daily as autonomy decreases and as paperwork increases, and morale disappears. Physicians face a catch-22 as they worry that they will be dropped by the HMO for ordering too many tests while at the same time worrying that some [lawyer] will accuse them of not being vigilant enough and start litigation."
There is increased pressure on self-employed doctors to join HMOs, either as full-time employees or as contractors. But by unionizing, some hope to counteract what they see as the "take it or leave it" attitude of the HMOs.
Now, even the traditionally conservative AMA is on their side. Last June, it voted for the first time to "develop an affiliated national labor organization to represent employed physicians" and to advocate federal legislation that allows independent physicians to bargain collectively with insurers and health care plans nationally.
Easier Said Than Done
The problem is that under current U.S. labor laws, only nonsupervisory employees can form unions. Self-employed doctors fall under the heading of independent contractors and are barred from forming unions because of federal antitrust laws.
Joel Klein, Assistant Attorney General of the Antitrust Division, says the official Department of Justice position asserts that allowing independent physicians to unionize "would allow non-employee, health care professionals collectively to raise their fees to health insurers without fear of antitrust liability ... It would be both unwise and harmful to consumers to grant them a special exemption."
AMA chairman Randolph Smoak, M.D., sees things differently. "This will not be a traditional labor union. Your doctors will not strike or endanger patient care. We will follow the principles of medical ethics every step of the way."
What does this mean for physicians? Says the internist in New York: "There's a saying in health care: Monitor yourself or someone else will do it for you. Perhaps physicians are learning this the hard way. They need to come up with a more organized plan to monitor their own quality and cost of care. That will be a big improvement for all."