Published April 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

• The legalities of physician unions

• Prospect of physician unions in Pa.

DISCUSSION FORUM

• Unionization is worth pursuing

• React to this article in the Discussion Forum.

Raymond J. Lodise, M.D., is president of the Philadelphia County Medical Society and organizer of both a regional medical society and physician union in the Delaware Valley.

PND: How receptive are physicians to the prospect of unionizing?

RL: We are just about certain that this union will form on April 17. We had a meeting of five counties from Southeastern Pennsylvania and three from New Jersey. Two (Chester and Delaware County) could not attend; we understand that they are interested but they think they might use another modality to affect the physician-patient relationship. All the counties at the meeting agreed absolutely that we should proceed with the formation of the union. We will have a second meeting because we want each county medical society to have their boards wholeheartedly endorse the concept. The idea is one regional union which would represent 18,000 physicians in the area, and it’s our hope that we could at least get a third of them as a beginning. I was gratified to hear young physicians saying on our board that they are 100 percent for unionization. I think they see it as a method of maintaining professionalism in medicine rather than being a salaried employee of the hospital system that is only interested in profit.

PND: What would the union do for physicians?

RL: This union would not collectively bargain for reimbursement, because we absolutely recognize that reimbursement is a market-driven product now and physicians will get what the public can afford to pay. We will use the union so that we can regain control of the patient care, and that, we believe, can only be accomplished by having an organization lobby for us—an organization that will be listened to. Sixteen million voters are represented by the union and about 1 million by physician organizations. They influence about 1 million votes. There is no doubt the legislatures are listening. The unions have more money than do the physician organizations that are now in place. We believe that they will be the force that can have legislators take a second look at this wave of managed care that we believe is injuring the quality of care that is being provided through the HMO structures.

PND: Couldn’t the union negotiate directly with insurance companies on behalf of physicians?

RL: I don’t know how the union’s influence would be able to pressure an insurance company to change their mode of activity without injecting the employer and the legislator in the mix. I don’t see that they have too much leverage against the insurance carrier. What they have leverage against is the employer who pays the premiums to the insurance carrier. So by influencing the employer, I believe their leverage is greater.

PND: Can you give an example of how the union would work on behalf of physicians?

RL: If an employer is hesitant about some health care that he is trying to negotiate, the union could suggest that they utilize part of their constituent base—the physicians of the Philadelphia County Medical Society organization. That would make the subscriber happy, who is the employee. It would make the employer happy, because the employer sees some oversight. The cost would basically be the same because it would have to be competitive. It would make the physician organization happy because it’s being utilized. It would help the Philadelphia County Medical Society, who has sponsored this organization, and certainly help the physicians who are involved in this organization. So, there is very little negative to that whole scenario. In a case where an HMO begins to exercise their dominance by ignoring the requests of the physicians, of the employer, of the subscribers—it’s there where the union should step in and guide the HMO in a direction that would answer all the problems by indicating that we’re going to encourage in our negotiations they not use you as the insurer. That would quickly balance the sheet.

PND: Would that be a direct contract with a physician organization, or would there be some sort of an outside insurance component?

RL: For the moment, direct contracting is more of an experiment than it is a reality. We would have to work through some insurer, and it just so happens there is an insurer trying to develop in this state. When PPHP gets its HMO license it could easily incorporate into this scenario and would really work very effectively, I believe.

PND: Are there any potential antitrust problems with these sorts of relationships?

RL: I don’t see any. First of all, the organizations are regulated—they have to be competitive. The employer will not be forced by the union into negotiating with an organization that would be more costly.

PND: How will the union be structured?

RL: We would form a subsidiary medical society as the vehicle where nonmembers of the County Medical Society would be able to join the union. A lot of nonmembers who are not anxious to join the three levels of organized medicine would join a local type of group as the entree into the union. Or as I like to say it, I’d rather be president of the nonmembers. It’s a larger group. Unless you belong to the organizations, you can’t be a union member because it’s these organizations that have sponsored and financed the work to provide the union.

PND: Why not go outside of the medical society entirely and form a union that requires independent dues?

RL: There are physicians who are making that attempt. It’s easier to do it through an organized structure. It’s easier to finance the work, to make contact with the physicians. We’re aware of at least one other organization outside organized medicine that’s making the attempt, and I understand they do have 30 or 35 members. But they’re having great difficulty getting off the ground. Is it possible to form a union without that structure? It’s possible, it may even be necessary if the Philadelphia County board decides not to proceed. But it has to be easier just based on the credibility of the medical societies, who have no interest in it except to protect their physicians.

PND: How does the formation of the union change the role of the medical society?

RL: I really don’t think it changes the role. We will always need the organized medical structure. It’s been in place for 150 years for the AMA; it’s 148 years for the Philadelphia County Medical Society. It would be hard to uproot that organized structure. They would do everything the union cannot do, doesn’t want to do, and they would act as a guide for the union. It should be obvious to anyone who has dealt with union people, they do not understand the total workings of the people they represent. They have to rely on the medical society to tell them where the problems are. This is a sophisticated system today, the managed care environment. Certainly, a union could not just walk in and pick up all the intricacies of medical practice. I think this idea is going to strengthen the organization—not weaken it—because if things remain as the organization thinks they should, then it’s obvious that the organization will gradually loose membership in an exponential way. I am very concerned by what I hear from the membership that 1998 will be a catastrophic year for organized medicine.

PND: How would the different county societies work with the new regional society?

RL: We eventually are going to have to form regional groups rather than county groups. I do not believe that the Pennsylvania Medical Society adequately represents all the physicians in the state. They are necessary to sift what is of statewide importance, but they can’t resolve, for example, a specific hospital issue. With hospital systems coming into place, hospital systems are going to dictate how some medicine is being practiced in the area. The whole scenario of medicine is changing to the point where everything is going to be regional, and so the society should think that way.

PND: How would physicians enter the union?

RL: As I understand it, there are two ways. One is by acceptance by the Board of Directors of the County Society, and then membership applications are sent out. The other way is to send out an application form to each and every physician in the area and have them sign up. We felt that the first would be the simpler way to go and feel confident that a large number of physicians will quickly join.

PND: Must at least one-third join in order for the union to be initiated?

RL: To my knowledge, there is no specific number required because we are not collectively bargaining. So I don’t think that percentage is necessary.

PND: What do you expect the union dues to cost?

RL: We understand the podiatrists pay $83.00 per year. I see no reason why it should be higher. I anticipate it might even be lower if our numbers are bigger.

PND: Is this union going to be part of a larger national union?

RL: The OPEIU, the union that the podiatrists have affiliated with, is the union that we believe best fits our need. There has been consideration of the AFSCME union—which here is 1199—but we felt that the 1199 represents a lot of health care workers at lower levels primarily, and it probably wouldn’t be consistent with us, who are at the higher levels of the medical chain, and it would perhaps be unfair to them.

PND: Will the OPEIU refer employers that they are negotiating with to physician organizations affiliated with the physician union?

RL: I think when we sign up with the union, this is the one thing that we would lay in place. As long as they have that understanding that they can best do it, we would expect it from the union. It could work.

PND: What leads you to believe that you will have the level of influence within the union to have them adopt your agenda?

RL: I believe that the union is excited by the fact that they are now being asked to represent a profession—the number one respected profession in the country—and allow the physicians to influence the union. Physicians are not entering this as a profession, they are entering this to protect the relationship of the member of the union with his physician. And I don’t know anyone in the country who is very happy with the physician-patient relationship being torn apart, except the profit-making HMO’s.

PND: Is of collective bargaining a possibility in the future for this union?

RL: We were informed at our February 6th meeting anyone can join a union. The difficulty would be if they would start to negotiate reimbursement schedules. That would cause an antitrust investigation, and I’m not sure it would fit in the National Labor Relations Act. But this would not be formed for that reason, so we are not forming what most people know to be a union, but an organization that will represent the physicians as a unified body. It may very well end up as a guild. There are some who want us to call it a federation. Whatever you want to call it, that’s alright with me. Union seems to have tickled everyone so we continue to use that term. Most physicians are interested in the physician-patient relationship. That is the immediate problem. Once that relationship is resolved, then we would move to the next level: that physicians have to be considered employees. It will take a long time, I assume, but 65 percent of physicians now practicing less than 5 years are employed anyhow.

PND: Do employed physicians have to fear repercussions from their employers if they join the union?

RL: I would warn physicians to study their contract carefully so they are able to join the union as a salaried employee. Once they are placed in supervisory roles, they can’t join a union that would be able to collective bargaining for them. Eventually the union is going to divide itself into those who are salaried and those who are not salaried so that it can have a better relationship with those physicians who want more forceful negotiations. One of the things we are considering is to have the union attempt to get legislation to make all physicians who sign managed care contracts be considered employees of that HMO, so everyone will be able to collectively bargain.

PND: How did this physician union idea begin?

RL: In 1972 there was a movement towards unionism that originated in California, the Union of American Physicians and Dentists. In 1973, I attempted to start a union in this area along with other physicians—one was a Philadelphia County medical officer. That was not successful. I understand that in the early 1980’s Dr. Greco, our PMS president, was advocating for a union, and that did not take off. And in 1991 the records state that Dr. Gordon MacLeod, past president of PMS, advocated the formation of a union and it did not take off. I think today, with our advocacy and the success of the podiatric union, that it has a better chance of total success. There are more physician frustrations than ever, so the environment is much better for success than it ever was. During the period between the 70’s and the 90’s, physicians did rather well as a benefit of the Medicare Act, which now is probably the basis for all the problems we are facing. Physicians now begin to see that it was economically great, but a disaster to the physician-patient relationship. Now in place are physicians who finally reached offices in organizations that can better express themselves; the activists have gotten into power and are changing the way medicine handles things. That’s not true through the entire medical structure. It’s certainly true in Southeastern Pennsylvania. I certainly hope that activism remains in the forefront of the Philadelphia County Medical Society. If I have anything to do about it, it will.