In an attempt to level the playing field for physicians and resident fellows who have struggled against the growth of managed care, the American Medical Association's House of Delegates voted June 23 to create a national labor organization for physicians who are not self-employed.
AMA President Dr. Thomas Reardon explained the decision as "a reflection of the feeling of helplessness that many physicians feel in trying to deal with managed care [plans]."
Since health plans have a legal obligation to their stockholders, many physicians feel as if their primary obligation is not to their patients but to the bottom line. Often, doctors say, health insurers cut costs by paying only for the least intense or least expensive level of treatment.
"I think that there were enough physicians that felt that the time was right, and this was a necessity...," said North Carolina Medical Society President Dr. C.K. Rust.
Reardon stressed that union participation is only one option available to physicians and residents and that the AMA's labor organization is inherently different from a traditional union. "We will follow ethical guidelines: We will not strike and we will not withhold treatment," he said.
Although the AMA will not actively organize physicians into local collective bargaining units, Reardon explained, the national organization will serve as an adviser for the NCMS and other state organizations. "If a physician group in Durham said, 'We are being treated unfairly,' the AMA would be the catalyst to give the expertise to say, 'Here's how you organize,'" he said.
The NCMS is still considering its stance on unionization and its new ability to establish local organizing units. In other industries, North Carolina unions are relatively infrequent and are not as powerful as in northern states.
NCMS has also identified about 108,000 physicians who might be eligible for union membership, but it is still trying to determine exactly which doctors would be affected directly. For example, because Duke physicians are also faculty members, the National Labor Relations Board might not allow them to participate in a collective bargaining group, said Dr. Ralph Snyderman, president and CEO of the Health System.
"We have been advised that we would not have the option to be part of such an organization," he said.
However, other medical professionals beyond Duke's borders have said more legal interpretation is needed before this possibility is eliminated.
"It is certainly complex and every relationship needs to be examined," said Carol Scheele, director of the NCMS managed care department. "It is our understanding that physicians employed by [educational] institutions would be eligible to join the AMA-affiliated organization.... We also know that there is a lot more to learn."
Although the NCMS is looking into its unionization options, the delegation sent to represent the NCMS at the June AMA meeting voted against the national labor organization.
"Each individual physician voted his own conscience," Rust said. "[They] felt that we needed to look into [the issue] and see what options are available to us in North Carolina."
Robert Seligson, the executive vice president and CEO of NCMS, acknowledged the AMA's position that managed care is becoming too powerful and one-sided. But, he added, "For the most part, our physicians don't want the profession associated with the word 'union.'"
Still, Seligson said this reluctance does not indicate that the NCMS will not move on the issue of physicians' rights. "NCMS is going to continue to push for doctors to have a fair negotiating process," he said. Rust, the NCMS president, recently appointed a collective bargaining task force to explore available options.
Physicians at the Medical Center have expressed general interest in the idea of unionization. Dr. Richard Draffin, an assistant clinical professor of diagnostic pathology, attended several portions of the AMA meeting. "The time for this idea has come," he said. "Physicians have been placed in an untenable position in trying to provide quality care."
Some, however, raised concerns about public perception of a physicians' union, especially considering how well paid many doctors are.
"I see a need for physicians to organize, because insurance companies have become such a powerful bargaining voice," said Dr. Elizabeth Livingston, an associate professor in the Division of Maternal and Fetal Medicine, OB/GYN. "But it could be perceived as a self-serving tool to protect economic interests and might contribute to mistrust and do physicians harm."
Although he believed there was merit in the proposal, Snyderman said, "It's uncertain how developing a unionization effort will impact [the field of medicine]."
At its June meeting, the AMA also stressed its commitment to pursuing antitrust relief for medical professionals beyond physicians who are not self-employed. Therefore, it is actively pursuing the Campbell bill, legislation introduced to Congress by Rep. Tom Campbell, R-Calif.
"The Campbell bill allows self-employed private practitioners in a community to come together and negotiate with health plans," said Reardon.
The recent actions of the AMA reflect a drastically changing medical climate, said Sen. John Edwards, D-N.C., at a forum on patients' bills of rights: "To me, [the decision is] just symptomatic of a real health care crisis in this country. The very idea 20 years ago that doctors would be unionizing would be unheard of."
Richard Rubin contributed to this story.
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