Perspective: Three leaders analyze the potential of physician unions

Thirty years ago, when the vast majority of American physicians worked in independent, often smaller, fee-for-service practices, the idea of ​​physician unions seemed strange to many people in health care. But the landscape has changed dramatically since then, and a large number of doctors are now paid by hospitals, health systems, medical groups and health plans. So the question is no longer so abstract or weird.

Now, a team of lawyers and a doctor has authored an article that was published in gamma network Online, where they analyze some of the elements and intricacies of union formation, making clear that they believe union may be a useful tool for certain groups of physicians.

In an article by Daniel Pauling, III, J.D., Barak D. “The Rise and Potential of Physician Unions,” These three experts provide a nuanced look at the issues at hand. Bowling Professor at Duke University School of Law (Durham, NC); Richman is a member of the Cross-Country Excellence Research Consortium at Stanford University School of Medicine (Stanford, CA), and is also a professor at Duke University School of Law; Schulman is in both the Clinical Excellence Research Unit at Stanford Medical School and at the Graduate School of Business at Stanford University.

The three experts write that “the consolidation of hospital systems and physician practices under one corporate umbrella has led to significant structural changes in the practice of medicine. In 2012, 60% of practices in the United States were physician-owned, and 23.4% of clinics owned some hospital ownership, And only 5.6% of physicians were direct hospital employees.In response to the COVID-19 pandemic, the number of physicians working in hospitals or health systems reached 52.1% and 21.8% by other institutional entities in 2022, for a total of 74% of practicing physicians. Unified corporate healthcare systems that cover many different communities and are increasingly spread across multiple states.”

They wrote, “This rapid transformation has largely followed a bold strategy, put forward by hospital and corporate leadership, that seeks to expand and exploit market power. However, it is also a strategy that is increasingly at odds with the interests of clinicians working in these organizations. Strategic differences are revealed. in a variety of important policy differences, spanning from payer contracting strategies, compensation incentive structures, and service line prioritization. These differences point to the potential for growing challenges facing American medicine.”

The three experts see three basic elements that physicians must consider if they are considering forming a union. They write: “First, clinicians need to determine whether collective bargaining is in their best interest, as opposed to each physician contracting individually for his services. If collective bargaining is to be seen as beneficial, clinicians need to determine who represents the union: all physicians within The system or only those in a particular hospital? All physicians across specialties or only specific departments? This latter concern reflects the potential challenge when different physicians have different governance and compensation interests within a single institution.”

Next, clinicians need to consider whether collective bargaining over salary makes sense. What if primary care physicians and specialists join the same union to negotiate with a hospital on a fee-for-service payment model, but then decide to develop a separate strategy when operating under a surrender payment model? The potential complications may be many.

Meanwhile, they wrote, “Third, and most important, clinicians should consider the benefits of collective mobilization to shape hospital policies. Collective bargaining can help address strategic issues of critical importance to staff, as in 2022 when nurses strike at Sutter Health about staff shortages and access to adequate personal protective equipment. Consider through collective bargaining. Physicians and hospital administrators may differ on patient discharge policies, documentation standards, quality improvement programs, and requirements for post-visit services.”

Most importantly, they wrote, “unions are not a panacea. They are a tool available to some physician staff and can be sought as a response to the growing tensions within large hospital systems. However, they may not provide as much leverage for inclusion in strategy as physician-led organizational structures such as physician-owned practices or other professional corporate models.” They note, however, that “while there are some concerns that unionization may harm patient care by interfering with the patient-physician relationship, it is important to recognize that many of the business strategies of standardized health care systems may also be harmful to patients, and that the formation of The unions may act as a lever that clinicians can use to fend off those potential harms.”

Thus, in the end, experts believe, the working conditions that develop forward in health systems, will inevitably bring the union discussion back to the fore again and again. They concluded that “disagreements between physicians and hospital leaders over governance, compensation, business rules, and strategy are likely to increase the likelihood of physician unions discussing in response.” “While unions offer advantages over individually negotiated labor agreements, they may be limited in their ability to address the concerns of the profession’s top management.”