Thirty years ago, when the vast majority of American physicians worked in independent, often smaller, medical practices, primarily on a fee basis, the idea of physician unions would have seemed alien to many healthcare professionals. But the landscape has changed dramatically since then and large numbers of doctors are now employed by hospitals, health systems, medical groups and health plans. So the question is no longer abstract or strange.
And now a team of two lawyers and a doctor has written an article that has been published in the JAMA Network online, in which they analyze some elements and complexities of unionization, while making clear that they believe unionization can be a useful tool for certain groups of doctors.
In the article by Daniel Bowling, III, JD, Barak D. Richman, JD, Ph.D., and Kevin A. Schulman, MD, entitled “The Rise and Potential of Physician Unions,” these three experts provide a nuanced view of the issues involved. Bowling is a professor at Duke University School of Law (Durham, NC); Richman is affiliated with the Clinical Excellence Research United in the School of Medicine at Stanford University (Stanford, California), and is also a professor at Duke University Law School; and Schulman is in both the Clinical Excellence Research Unit in the School of Medicine at Stanford and the Graduate School of Business at Stanford University.
The three experts write: “The consolidation of hospital systems and physician practices under one corporate umbrella has led to major structural changes in medical practice. In 2012, 60% of US practices were physician-owned, 23.4% of practices had some hospital ownership, and only 5.6% of physicians were direct hospital workers.1 In response to the COVID-19 pandemic, the proportion of physicians employed by hospitals or health systems by 2022 52.1% and 21.8% by other corporate entities, for a total of an estimated 74% of practicing physicians.2 Many physicians are now employed by consolidated corporate health care systems that span across many different communities and increasingly spread across multiple states.”
And, they write, “This rapid transformation has largely been followed by an aggressive strategy, proposed by hospital and business leaders, that seeks scale and exploits market power. However, it is also a strategy that is increasingly at odds with the interests of the doctors who work in these organizations. The strategic differences are reflected in many key policy differences, ranging from payer contract strategies, incentive structures and service line prioritization. These differences suggest the potential for growing challenges to American medicine.”
The three experts see three key elements that doctors should consider when considering forming a union. “First,” they write, “doctors must determine whether collective bargaining is in their best interest, unlike any doctor who contracts individually for their services. If collective bargaining is seen as beneficial, doctors must determine who represents the union: all physicians within a system or just those of a specific hospital?All physicians in different specialties or only specific departments?The latter concern reflects the potential challenge when different clinicians have different remuneration and governance interests within one organization.
Next, doctors should ask themselves whether collective bargaining on salary makes sense. What if primary care physicians and specialists join the same union to negotiate a fee-for-service payment model with a hospital, but then decide to strategize separately when operating on a capped payment model? The potential complexity can be many.
Meanwhile, they write: “Third, and most important, physicians should consider the benefits of collective mobilization to shape hospital policy. Collective bargaining can help address strategic issues of great concern to employees, such as in 2022 when nurses at Sutter Health went on strike due to staff shortages and access to adequate personal protective equipment.9 Policy regarding the practice of medicine could benefit from explicit through collective bargaining. Physicians and hospital managers may disagree on patient discharge policies, documentation standards, quality improvement programs, and post-visit service requirements.
Importantly, they write, “Unions are not a panacea. They are a tool available to certain physician associates and may be sought as a response to growing tensions within large hospital systems. However, they may not provide as much leverage for inputs.” in the strategy as physician-led organizational structures such as physician-owned practices or other professional business models, they note, “While there is some concern that unionization could harm patient care by disrupting the patient-physician relationship, it is It is important to recognize that many corporate strategies of consolidated healthcare systems are also potentially harmful to patients, and that unionization could be a lever that physicians can use to curb that potential harm.”
So ultimately, they believe, the working conditions evolving in health systems will inevitably bring the union discussion to the fore again and again. “Conflicts between physicians and hospital leaders over governance, compensation, work rules, and strategy are likely to increase the likelihood of physician union discussions in response,” they conclude. “While unions offer advantages over individually negotiated employment contracts, they may be limited in their ability to address the profession’s higher governance issues.”