NOVEMBER 1997 · VOLUME 18 · NUMBER 11

---

L A B O R

---

A WOMAN GAVE BIRTH in a hospital. It was a fairly routine delivery, but there were complications, an infection. Her health maintenance organization (HMO), U.S. Healthcare, had a rule: mandatory discharge within 24 hours of delivery (a practice since made illegal). By the time the parents, at home, discovered how sick their baby was, it was too late. The child died. Had the newborn been in the hospital, monitored by skilled nurses, the infection would have been caught immediately.

Angry doctors had this true story aired on television and radio in southern New Jersey, as part of a campaign to "get some balance back into the health care delivery system." Incidents such as these are prompting doctors to take a once-unthinkable step: they are joining unions.

"When management just doesn't want to listen, physicians who are employees really have no other options," says a primary care physician in the Southwest who is urging his colleagues to unionize. The doctor asked that his name not be used, fearing retaliation from his HMO.

"We work at a large medical center, a group practice HMO, and we're owned by a total bottom-line insurance company. They're continuing to take resources from the hospital, the practice, the institution, to the point where we're concerned about the type of care we can deliver."

Unionization is accelerating because 42 percent of doctors in the United States are salaried employees now, up from 24 percent in 1983. "A doctor is not a small business owner anymore," says Dr. Ida Hellander, director of Physicians for a National Health Program in Chicago. "They work for a big corporate owner. The analogy we've always used is: do chefs run McDonald's?"

There is "a phenomenal increase in interest among doctors in organizing at all levels," says John Ronches, a leader of the New York-based Committee of Interns and Residents union. We can't keep up with the demand." The director of health care organizing for the Service Employees International Union, Dave Snapp, concurs: "I get calls from people I never would have talked to before as a union organizer."

CORPORATE TAKEOVER

The corporate takeover of medicine has made it harder for many patients to receive high-quality care. The merger of Aetna and U.S. Healthcare put that corporate giant in control of the care of one in 12 people in the United States. For-profit corporations now represent 14.5 percent of the health care market, and their competitive thrust has changed norms throughout the field. Two interrelated forces are depressing quality of care and shrinking doctors' professional flexibility and autonomy. The growth of the for-profit hospital sector -- led by Columbia/HCA -- has led to hospital closures, staff layoffs and the replacement of registered nurses with less skilled and lower-paid personnel. At the same time, health insurers and HMOs have clamped down on the expenses of doctors' care in non-profit and for-profit hospitals, often at the expense of adequate care.

Under "managed care" regimes, corporate bean counters peer over doctors' shoulders at treatment decisions. Doctors find their judgments second-guessed and countermanded, sometimes by an insurance company representative with no medical training. They resent both the degradation of patient care and their own loss of autonomy. Says Ronches, "For people who went into medicine thinking they were going to help people who are ill, it's a great shock."

The pressures to cut care to cut costs is often overt and structured into doctors' contractual arrangements with HMOs. "At U.S. Healthcare and other for-profits, each doctor is given a certain amount of money for each patient every month, to take care of that person and 'keep them healthy.' This is called capitation," explains Susan Steigerwalt, a high blood pressure specialist in Detroit who is former president of Physicians for a National Health Program. "But if you refer your patients to specialists more often than what the company considers to be acceptable, or if your patient goes to the emergency room more than they think is acceptable, then a portion of the money that they pay you is withheld."

"Conversely," Steigerwalt says, "if your patients don't go to the emergency room and your average per month cost for specialty care is low, you'll receive a bonus at the end of the year. We call it 'fee-for-non-service.' So, taking care of the same group of patients, you could either make no money, theoretically, or up to $250,000, depending on how you practice."

The bottom line, Steigerwalt concludes: "It pits the patient's interests against the doctor's." She adds, "Even an ethical physician has a difficult time."

Some companies have imposed "gag rules" on their doctor-employees, forbidding them to mention treatments that are not available within the HMO -- or to criticize their employer publicly. In a widely publicized incident, David Himmelstein, a national leader of Physicians for a National Health Program, was thrown out of the U.S. Healthcare network for speaking out against the abuses of managed care.

Steigerwalt says there is a connection between good working conditions for doctors and high-quality care for patients; one example would be a negotiated limit on the number of patients a doctor must see per hour. "Quality of care issues are very real under conditions of speedup," she says.

HIGHER PAY?

It is the demand to be allowed to do their job right, insist doctor unionists, not more money, that is motivating them to sign union cards. This may sound odd, coming from a group that's fought hard in the past, through the American Medical Association, to preserve its six-figure incomes. Ronches believes that physicians have complex motivations for unionizing. "I don't know of anyone who's said their income is gone. It's more that they're put in the position of having to choose, sometime in the not-too-distant future, between providing appropriate care and maintaining their economic situation."

Money was certainly not the issue in Tucson, at the Thomas-Davis Medical Center. There, the doctors who voted 93 to 32 to join the Federation of Physicians and Dentists (FPD) were millionaires. They were also the first doctor-employees of a for-profit managed-care company in the United States to unionize. They had sold their group practice for a tidy sum, in 1994, to Foundation Health Corporation, the California company that became their employer. They were dismayed when, according to Jack Seddon, the FPD's executive director, management "bled off two-thirds of every dollar of income, leaving very little to operate the clinic."

Keith Dveirin, a pediatrician who is now in the midst of negotiating the FPD's contract, explains why he helped lead the union drive. Management, he says, "was making it more difficult to refer patients to specialists, even within our own clinic. They were increasing the number of patients any physician was required to take care of dramatically, to unsafe levels that don't have a basis in the medical literature for our field. They were cutting the availability of after-hours urgent care services. It was clear we weren't going to be able to have any input in how things were run. We felt doing all these things at the same time would compound each other."

Even with the union's 3-to-1 margin of victory, the HMO's owners at first refused to bargain. A federal judge issued an injunction ordering management to the table. Besides the usual issues of pay and work hours, the union wants a patient bill of rights. It would include doctors' right to discuss all treatment options with patients, a ban on economic incentives to limit care and limits on the number of consecutive hours doctors can work.

GROWING MOVEMENT

Meanwhile, the success in Tucson inspired doctors in other cities to contact the FPD. Seddon says the union has organizing drives under way in two western cities and has filed for a certification election at a Las Vegas psychiatric hospital. Approximately 45,000, or 7 percent, of the nation's 640,000 physicians belong to unions. Most are public employees. Although the Tucson doctors work for a private company, their union, the FPD, is part of the American Federation of State, County and Municipal Employees (AFSCME), the AFL-CIO's second-largest union. AFSCME represented 3,000 doctors until August 1997, when California's 5,000-member Union of American Physicians and Dentists (UAPD) voted to join with AFSCME.

It is in the private sector, however, among the growing number of physicians who are salaried HMO employees, that the future of doctor organizing will be told. Altogether, 300,000 doctors are salaried, and therefore eligible to form unions.

Self-employed doctors in private practice, on the other hand, have been prevented by anti-trust law from bargaining collectively to set fees. In October, hoping to set a legal precedent, the United Food and Commercial Workers (UFCW) union petitioned the National Labor Relations Board (NLRB) on behalf of 400 self-employed New Jersey physicians who work for the for-profit HMO Amerihealth. The doctors approached the union looking for help, according to Arthur Nahas, who does family practice and sports medicine, when a small group "decided enough was enough." They quickly signed up 235 physicians.

"Our premise is that we are not independent contractors," Nahas explains. "We are employees, even though we're not salaried as such. The salary concept is more of a tax and IRS issue; labor law really defines the employer-employee relationship. Because the HMOs do dictate many of the ways in which we can practice and treat our patients, it is in fact, according to labor law definition, an employer-employee relationship."

If the NLRB rules after a December 8 hearing that the doctors may hold a union representation election, it will open up possibilities for much wider doctor organizing.

Unfortunately, although interest among doctors is spreading, the labor movement has no coordinated plan for organizing them into one union. Besides AFSCME and the UFCW, the Service Employees International Union (SEIU) is also targeting physicians. The SEIU recently affiliated the Committee of Interns and Residents (CIR), which itself had jumped from 6,000 members to 9,000 in a year and a half.

CIR's Ronches notes that a quarter of all physicians now practicing have passed through residents' unions, mostly CIR, in their younger days. He believes that that positive experience -- unionized residents work shorter hours and earn 10 to 15 percent more than non-union ones -- will make doctors sympathetic to organizing as the ills of corporatized medicine come to bear on their work lives.

Snapp believes that seeing doctors unionize will spur lower-paid staff to sign union cards as well. This is what happened in Tucson; a few months after the doctors voted for the FPD, the 458 other Thomas-Davis employees voted to unionize as well. Snapp explains, "You've got the guy who says, 'I'm a senior registered radiological technician and I don't think it's professional to have a union.' Then the nurses and the doctors organize, and it's, 'Why am I sitting this one out?'"

OVERHAUL THE SYSTEM

Collective bargaining may ameliorate some of the abuses of corporate medicine, but a workplace-by-workplace approach will not overhaul the system. A growing movement of doctors is speaking out against the excesses of managed care and the "industrialization of medicine." Beginning in Massachusetts, they formed the Ad Hoc Committee to Defend Health Care and collected nearly 2,000 doctors' signatures on a "Call to Action." Tacitly recognizing past excesses, the petition condemns not only pursuit of corporate profit in health care but pursuit of personal fortune as well. It calls for access to health care as the right of all. With nationwide conference calls, the movement has spread to 15 states. The Call, with signatures, will be published in the Journal of the American Medical Association in December. Ida Hellander sees both the Call to Action and the growing union movement as welcome developments, but not enough. Her group, Physicians for a National Health Program, wants the United States to adopt the Canadian "single-payer" model, where all citizens have the right to free care, paid for by taxes, and the profit motive is eliminated.

Unions, Hellander counsels, may tend to focus solely on the issues in a particular workplace and care of the insured patients who belong to particular HMOs, leaving aside the millions of uninsured.

"Forming unions is an attempt to gain control within the current system," she says. "We're pushing for a whole new system."