Podiatrist union President John Mattiacci, D.P.M.

By Paul Kengor

Published February 1997

OTHER COVERAGE OF PHYSICIAN UNIONS

• Physician unions take root in Pa.

• Physicians seek antitrust waiver

• Surgeons fight Blue Cross rate cuts

• Medical society explores regionalization and MD unions

• Legal issues of physician unionization

• Physician unions gain steam

• AMA collective bargaining program

• A Pennsylvania physician guild

• Building a physician union in the Delaware Valley

• The legalities of physician unions

• How to organize a physician union

• Federation of Physicians and Dentists web site

• Union of American Physicians and Dentists web site

• React to this article in the Discussion Forum

The practice of medicine has traditionally been one of the nation’s most independent professions. Consequently, the concept of physician unions may strike many physicians as foreign. Yet, a case can be made that conditions in the state’s health care industry are ripe for the formation of physician unions. There is growing unionization of other health care professionals, such as nurses and podiatrists. Additionally, a growing number of physicians are employed, rather than practicing as independent contractors. Many are employed by large, sometimes national, companies. Without bargaining clout, they often feel powerless.

Importantly, some state medical societies are buzzing about unions. The Philadelphia County Medical Society is responding with a February 6 seminar on the subject.

Health care unionization is not alien to Pennsylvania. John Haer of the Service Employees International Union says about 12-15 percent of the nation’s health care workers are unionized, with Pennsylvania being a bit higher. Currently, the Pennsylvania Nurses Association is engaged in unionization efforts at Allegheny General Hospital. RNs at Philadelphia’s Episcopal Hospital recently voted to unionize, as have those at Temple University Hospital and Allegheny University Hospitals, MCP, before them.

A major boost to unionization came on October 24 of last year, when associations representing most of the nation’s podiatrists announced they were forming the first nationwide labor union for doctors. The group, called the First National Guild for Health Care Providers of the Lower Extremities, will be associated with the AFL-CIO, and is expected to enroll 10,000 of the nation’s 14,000 podiatrists. Initial reports were that the group would be based in Harrisburg, but the union’s President John Mattiacci, D.P.M., is also considering Philadelphia as a possible headquarters location.

There has been movement elsewhere. A group of 142 staff doctors at Tucson’s Thomas-Davis Medical Center is in the process of voting on forming a collective bargaining unit to negotiate with their employer clinic and its owner, Foundation Health Plans, a California-based HMO. Feeling threatened by managed care, the doctors are seeking to join the Tallahassee-based, 3000-member Federation of Physicians and Dentists.

Justification for Unions

There are a number of key reasons explaining the move toward unionization. Not surprisingly, the impetus generally is the loss of physician autonomy and the infringement into the doctor-patient relationship by employers, rather than income considerations. "I believe financial is not the issue," says John Krah, executive director of the Allegheny County Medical Society (ACMS). "It’s really the ability [of physicians] to care for their patients."

Mattiacci drives home the autonomy point: "When I was addressing the Michigan society, I was told by doctors there that a managed care company sent a rep saying the doctors weren’t treating patients quick enough. The company wanted the doctors to treat at least four patients an hour. So the rep actually sat there with a stop watch and timed the doctors."

Such stories mask angry emotions. "Medicine should focus on the physician-doctor relationship," states Jim Deegan, spokesman for the Pennsylvania AFL-CIO. "That should be sacred, or at least there should be a deference to that. The HMO or insurance company is infringing on that...Dollars and cents are important, but treatment should come first. I don’t know if that’s always the case, now that we’re moving to a more profit-oriented approach."

Deegan’s views on insurance companies are mild compared to those of Robert Weinmann, M.D., president of the 5000-member, California-based Union of American Physicians and Dentists: "What the insurance industry is doing is not illegal, it’s just piracy."

Mattiacci is equally tough: "This isn’t capitalism; it’s insurance companies." He believes insurance companies are totally distorting the marketplace. "They don’t want to pay for anything that hurts their bottom line." He adds sarcastically, "They want us to add a ‘Kevorkian ward’ to the hospital." In a typical assessment, he concludes: "Physicians don’t like the way medicine is being taken away from them and being controlled by big business."

Indeed, the trends are there to make unionization ripe. Most prominent is that for the first time more than 40 percent of doctors (nationally) are employed, according to American Medical Association data. Of these, 32 percent are on hospital payrolls and only 8 percent work for HMOs. Unions have targeted hospital-employee physicians.

An article in the August, 1996 Journal of the American Medical Association concurs that, from 1983 to 1994, the proportion of patient-care physicians practicing as employees rose from 24.2 percent to 42.3 percent, the proportion self-employed in solo practices fell from 40.5 percent to 29.3 percent, and the proportion of self-employed in group practices fell from 35.3 percent to 28.4 percent.

AMA data illustrates that physician participation in managed care has increased steadily throughout the 1990s. Nationally, the proportion of physicians with managed-care contracts rose from 61 percent in 1990 to 83 percent in 1995. While the data is not broken down by state, it shows similar dramatic increases in regions like the mid-Atlantic, New England, and "East North Central."

In addition to reaffirming the trend toward greater managed care, the AMA concludes from its research: "Not only are physicians signing more managed care contracts, but the contracts they are signing shift a greater portion of the risk to physicians and their practices."

Physician Unions in Pennsylvania?

Another key component pushing unionization is frustration with medical societies’ perceived inability to better the lot of many physicians. Victor Greco, M.D., president of the Pennsylvania Medical Society, concedes that such frustrations probably exist. "But physicians are frustrated with managed care plans, HMOs, restrictions on Medicare and Medicaid. Doctors are increasingly in a straight jacket...This is a general frustration, not just with medical societies. Our group has done a tremendous amount in the last few months alone."

Some feel union proponents should take their concerns to medical societies instead. But Mattiacci of the podiatrist union is skeptical: "The statement that medical societies can handle this is amusing." He cites their declining membership and maintains they "have no teeth." He points to their alleged ineffectuality regarding malpractice reform.

There is also a likelihood that unions could compete with medical societies on physician advocacy issues. Raymond Lodise, M.D., president of the Philadelphia County Medical Society, foresees such a threat. "As unions would gain in strength and physicians would begin to see the effects they’ve long clamored for, then medical societies would lose their purpose and disappear. These groups are already losing membership because they don’t speak the language their members want to hear...Within five years, the county medical society would become either more of a regional medical society or possibly even turned into a five-county union. There would be no way that the structure that we currently have would continue to function."

Yet, judging from comments of medical society members, this competition may not be jading their perspective on unions. John Krah of the ACMS says that if local physicians "seriously consider" the union option, his group would respond with educational seminars, bringing in experts from unions, the legal professions, and so on. "We’d provide the role of facilitating information and education rather than being an organizer."

The chances for the formation of a physician union seem higher in the Philadelphia area than Pittsburgh area. In Pittsburgh, John Krah of the ACMS states, "I have not had any physicians come to me and seriously say, ‘We should start a union.’ But I have heard them in conversation say, ‘Boy, we need a union,’ after seeing how collective bargaining has worked for other industries, like nurses, teachers and so forth." He has heard "hearsay" that some residents at University of Pittsburgh Medical Center have bandied the idea around, but has seen nothing come from it.

Indeed, most of the noise for unionization is coming from the east. Lodise realizes the din is strongest in eastern Pennsylvania and believes a union has the best chance of beginning there first, then possibly going statewide.

Alan Axelson, M.D., president of the Allegheny County Medical Society, perceives an east-west split. He feels it stems from the fact that unionization sentiment in general takes place among industries that are rapidly evolving. While that is taking place throughout health care, Axelson feels it is "especially happening in the Philadelphia area." Like John Krah, Axelson has not heard the cries for unionization in western PA that others are hearing in eastern PA. "The ACMS is paying close attention to what is happening in Philadelphia," he admits. He says that the task of a medical society is to keep pace with the changes, and that his group has done that locally. He speculates that in Philadelphia things may have changed so quickly in the industry that the societies are struggling to keep up.

Barriers to Unionization

Obviously, large employers will resist moves. Another significant impediment to physicians unions is federal antitrust and labor laws. These laws prohibit independent doctors who are not part of an economically integrated unit from coming together ("conspiring") to set prices or divide up markets. Doing so can result in substantial fines and even prison sentences. While many physicians hope unions will enable them to collectively negotiate with health plans, antitrust and labor laws state that unions can provide this function only to doctors who are not trustees or supervisors of an employer group.

The largest obstacle to unionization may come from physicians themselves. This barrier might be dubbed the "psychological" or "professionalism" factor. Reflecting this view, Axelson notes that unions tend to polarize. Says Axelson, "Health care should be a professional endeavor that uses science, ethics, and the public good rather than economic power. And unions often employ economic power."

Joseph Giordano, M.D., immediate past president of the Mercer County Medical Society, who is "ambivalent" about unionization, notes that the "professionalism" of medicine has stemmed from its individuality, and that individuality is often sacrificed in unions.

Lee McCormick, M.D., who heads the 40-physician Prime Medical Group in Pittsburgh adds, "I feel unionization diminishes a profession." Noting that the key reason for unionization is to engage in collective bargaining, he adds, "The problem is that a union can negotiate with the threat of a strike, and I don’t feel [physicians] can seriously threaten to strike."

The strike issue is especially sensitive. John Krah remarks, "From a public viewpoint, people might understand the income and patient arguments [from physicians], but there’d be a dramatic drop in respectability among the public if they saw us walking a picket line."

The threat of strike is not fiction. In Ontario, Canada, striking doctors are refusing to see nonemergency patients.

Weinmann of the California-based union feels the "professionalism" and strike issues are overplayed: "A lot of [physicians] think they’re above that. That’s Jimmy Hoffa stuff. Strikes. Actually, our strike ratio is less than one percent. We succeed in our negotiations. We don’t tell employers to do things they can’t do. We don’t tell insurers to become charitable organizations. We’re reasonable and know the industry...We also make sure that true emergencies get triaged. We don’t like strikes because they hurt the wrong people."

Weinmann adds that there are different labor tactics available to physicians in unions aside from strikes, such as giving the patient care but not filling out a chart, meaning the patient doesn’t get billed. Most non-union doctors, he says, wouldn’t know how to handle such a situation and "would get themselves in trouble if they did that."

Lodise concedes that, "Historically, the only way people have listened in this country is through a strike. It started with steel workers and coal miners and then moved to teachers and ballplayers." Lodise seems sympathetic, not to the idea of a strike, as much as the threat of a strike. He adds, "There’s not a physician worth his salt who won’t handle an emergency. But not everything is an emergency. I’m talking about routine, everyday stuff. Shutting that down—or threatening to do so—would really affect the economy and wake people up. The threat of being able to do that is enough to make people say, ‘Hey, let’s take another look at this.’"

Finally, another touchy issue with unionization is the question of affiliation. Tying a physician union to a group like the AFL-CIO has advantages, such as a 13-million member partner to lobby for you, with offices scattered throughout the country. This enables a relatively small physician union to greatly expand beyond its local headquarters. Yet, affiliating with such groups invites constraints. To cite one example, the AFL-CIO is politically controversial, often bankrolling almost exclusively Democratic party candidates. AFL-CIO President John Sweeney announced on March 25 last year a plan to return the U.S. House of Representatives back to Democrat hands, and pledged $35 million for a media campaign to do so, much of it coming from union dues. During the last election it orchestrated a series of anti-Republican Medicare commercials so controversial that many markets refused to run them.

As a result, affiliating with a group like the AFL-CIO may bring some political baggage. Giordano has such concerns about affiliation, citing not only the political agendas—noting that one of every ten delegates to the 1996 Democratic National Convention were members of the National Education Association—but also the reputation of groups like the Teamsters and some of their past tactics and thuggery. "Some of the teachers’ unions in Philadelphia joined the teamsters," says Giordano, recalling the days when he taught school in Philadelphia in the 1970s. "And some of the [teamsters] and their work with longshoremen involved a lot of violence. That contributes to the de-professionalization of a profession."

Some are speaking of alternatives to unionization. McCormick suggests changing antitrust laws to allow physicians to join together to negotiate contracts. He says that recent changes have softened laws in that regard, but not enough. Greco agrees: "We have been trying for a couple of years to get legislation passed to ease up on antitrust legislation. It’s unfair that HMOs and insurance companies have liberal antitrust laws, but physicians have one hand tied behind their backs. The federal government has to understand this. They have to allow physicians the ability to form groups to bargain on these issues."

Alternatives may exist, but, in the meantime, the union issue is not going away.