By Christopher Guadagnino, Ph.D.

Published May 1998

OTHER COVERAGE OF PHYSICIAN UNIONS

• Physician unions take root in Pa.

• Physicians seek antitrust waiver

• Surgeons fight Blue Cross rate cuts

• 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

• Prospect of physician unions in Pa.

• React to this article in the Discussion Forum.

PND: What are you doing to pursue your main priorities as president of the medical society?

DZ: I have set out to initiate and investigate three goals this year. The first is looking at the development of a regional western Pennsylvania medical society that would enable the local societies to have a larger voice in meeting the needs of their membership. The second is to address a growing concern that physicians are losing their autonomy regarding their ability to deliver quality care unimpeded by external forces that are both economic in the form of health insurance companies and political in the form of vertically and horizontally integrated health systems. We are looking at the issue of unionization and guild formation. And third, all clinicians want the freedom to deliver quality care in the most cost-effective manner at the right time. Something that we think is vitally important because it buts the clinician right back where he needs to be in the care paradigm—setting the pattern of care and carrying it out—is informatics and process improvement.

PND: What was the impetus to consider regionalizing the medical society?

DZ: These insurance and health systems reach across hospital and county borders. A decision made at corporate headquarters will affect individual and group physicians way out into the various communities and have impact as far as Erie, into Bradford, Altoona, Johnstown, Washington. In the past, before there was this integration, the physicians, through the body of their medical staff as well as through their involvement in hospital board governance, were able to affect the decision-making process for the patient as well as for the profession. With the amalgamation that’s occurring, the voice of single physician groups and even whole medical staffs have become completely immaterial in the final decision that is rolled out. And hence, there is a need to create a regional voice that will try to address physicians’ concern on a greater scale than a single county society. We have had an initial discussion phase with our colleagues from the six surrounding counties—Beaver, Butler, Erie, Lawrence, Washington and Westmoreland. Whether we will form a completely new corporate structure or not, I’m not certain. There was a consensus of representatives of each individual society present that we do need to develop a more uniform group of medical societies. There are a number of options. We could elect to just meet every quarter with a formal agenda. Another would be to consider a direct formal merger and consolidation of the county medical societies and their administrative staff and governance structures, producing a new regional entity. Another plan may be to recognize that, since the Allegheny County Medical Society is the largest, that some of the outlying county societies could affiliate directly with it. This has the some benefits in that it is the least legally difficult process. It does not necessarily preclude continuation of local activities; the local county medical societies could in essence become part of our board of governance here. The other plan was to look at forming a completely new Southwestern Pennsylvania Medical Association and then formally integrate the entire membership forming a new representative body.

PND: What real power would a regional medical society have in dealing with insurance companies and hospital networks?

DZ: Right now, we do not have a single authority that carries with it either a major political or economic clout. By organizing the southwestern region, I think it brings a greater clout for us in the state society and it enables us to communicate far more effectively with our major insurer and, hopefully, the two systems that are developing. We do have regular bi-monthly meetings with executives from Highmark to address mutual concerns and we have received some favorable results that have resulted in some alteration of some of their products, as well as correction of some of their initiatives.

My hope is that, by having a larger number of physicians represented, when that collective voice of our leadership goes to meet with a Highmark, we would have greater clout in representing our membership. Will we be able to say to Highmark, "Well, if you don’t do this, we’re going to tell them not to accept your product." I’m not so sure that we can be successful in doing that at this point in time. On the other hand, I think that large collective voice does have greater resources to go to the public forum of the media than in the single specialty organizations as before. The society could go directly, not only just to physician membership, but directly to the public. I meet with a number of employers, and I think they truly want the best care for their dollar. If the regional society feels that a product that’s being put out is not in the best interest of the employees, I think the employers will listen.

PND: How do physician guilds or unions fit into this picture?

DZ: There’s a fair number of physicians, especially our younger members, who are experiencing significant dissatisfaction with the intrusion by businesses and health plans into the direct delivery of care and are very anxious also over the continued employment of physicians across the region. Hence, they’ve raised that issue with the leadership that the physicians need a different venue for addressing these concerns. One of the subjects that was raised was a physician guild, the other was a physician union that would be affiliated with major labor organizations. In order to address whether there’s validity to it or whether this is just a passing fancy, the county Medical Society has its Spring meeting devoted to the subject of physician unionism and whether there is a role for that in our medical structure. We are undergoing a due diligence investigation as to whether that’s feasible. I’m hesitant to say whether this will happen or not because I do not know yet whether it is a vehicle that is legally appropriate. It is appropriate for those physicians who are employed. As their fringes and benefits, as well as their incomes are further controlled in a negative manner, then I think you will see a greater impetus toward that for them. The bigger question that I need advice on, also to see what the membership feels, is, whether that vehicle would be appropriate for the greater number of non-aligned physicians, who really constitute the majority of the physicians in these various societies. I see that the older members probably do not think that a union is an appropriate alternative, while the younger members tend to have a more open view regarding these issues.

PND: What is your view regarding physician unions?

DZ: I don’t have a solid position regarding the role of unionization among physicians at this point in time. I do think it’s an area that needs to be studied in terms of its legal limitations and as to whether a process can be developed in concert with other labor organizations that allows some sort of political clout to be developed. The biggest question is, Can truly a union be developed that would give the profession the bargaining that it needs? I don’t mean bargaining relative to pure economics, but to assure that the right medicine is able to be delivered at the right time in the most cost-effective manner.

PND: To that end, what is the role of informatics and process improvement initiative that you mentioned earlier?

DZ: The county Medical Society is in discussions with Highmark and with our respective institutions through the membership regarding a system that puts physicians in the direct role of making the proper decisions for the delivery of care. It is a process of defining what constitutes the mechanism of care. Not necessarily looking at a disease and developing guidelines for, say, congestive heart failure and where the intervention needs to occur, but integral within all of the various diseases are disease processes such as pulmonary ventilation management, pre- and postoperative care of diabetes, any one of a myriad of areas that occur in intensive care or even in surgical services. The treatment of the complex patient as well as the noncomplex patient breaks down into a series of steps dependent upon what occurs. For example, take the management of an intensive care patient who has multisystem difficulties such as heart failure associated with renal failure associated with pulmonary dependency and, to boot, they develop superimposed insulin-dependent diabetes associated with their illness. Each one of those is a disease process wherein care guidelines or maps can be instituted and the clinicians can buy off on them. At the same time, you don’t just initiate a care guideline, you develop it in concert with your expertise and the patient status that is present so that you produce the best process available. Since the clinicians are developing them, they buy off on it and accept the reducibility of variance in care management. We’re looking at actual care issues—how best to address tube dependency, or how to get a uniform process for management of diabetes, whether its in surgical patients or not. We’re not looking at the steps of the care or where the intervention occurs, as in critical pathways, we’re looking at the actual overall diagnosis and treatment to reduce variability of care that is delivered.