Steeped in corporate profits, liable to be fired without due process, lacking transparency in billing, and beset by rising working hours and falling wages, emergency physicians are increasingly wondering whether unions and collective bargaining could be promising for them.
They would like to, at the very least, wrest control of their practices from corporations and private equity. But unions won’t unilaterally change workplace health care issues, said Stuart Bussey, MD, JD, president of the California-based Union of American Physicians and Dentists. (https://www.uapd.com/.) “Doctors are commodities,” he said. “Medicines are on sale. It has always been so. No one pushes back. »
Joe Crane, national director of the Doctors Council organization, the nation’s oldest and largest doctors’ union (https://doctorscouncil.org), said at the TakeEMBack virtual summit in September that unionizing is a step in the right direction, but physicians need to determine if unionizing is possible, by first asking themselves why they want to unionize. “We can only legally organize the emergency services group,” Mr Crane said. “We have to examine every doctor employed in your establishment. Do the issues affecting you have an impact on other physicians? How is the company formatted and who reports to whom?
He said 30% of doctors would have to sign on to want a union to start the legal process of triggering a vote to unionize. This petition is forwarded to the National Labor Relations Board, which calls an election. “We need the votes of 50% plus one to organize ourselves,” he continued. “At this point we’re looking at around 70-75% of the workforce, an overwhelming majority, so we can come in with a warrant. During this time, the employer cannot make unilateral changes to labor policies.
When negotiating safety and working conditions, doctors should not be afraid to speak up. Federal law guarantees the right to organize and an employer cannot retaliate because of these efforts. Mr. Crane estimated that it could take 18 months to two years to secure a first collective agreement. “[S]I fight now,” he said. “Honestly, I don’t know where things are or how things will get worse, but they will. We organized a small hospital that was part of a larger system, but it took almost three years to get that first contract. At every step of the process, the company’s response was, “This is going to impact every other physician in our system.”
Overcome the obstacles
Emergency physicians face an unusual problem because many of them are independent contractors who cannot form unions under current laws. The standard response for people who are independent contractors and file a 1099 with the IRS is that they cannot unionize because they are not employees, Crane said, but he added “If you’re a W-2 employee and you have someone to report to who can get you fired, you most likely have the right to unionize. The bigger question is going to be, ‘Are you actually correctly ranked as 1099?’
Dr Bussey said legislation could be passed allowing doctors to bargain collectively, although this method has been tried and failed in Congress. “We have the power to strike,” he said. “We don’t use it. We have the power to picket and we use it. The employer does not like the spotlight to be shone on its poor practices. After we picketed, they settled the contract.
Dr Bussey said he understood and sympathized with doctors who are scared. “They keep cutting their money and increasing their hours,” he said. “Like the frog in boiling water, you better jump while you can. Nurses get paid more. Physician assistants and nurse practitioners get more money. Doctors have to do something because their industry is shrinking.
The American Medical Association’s 2020 Biennial Analysis of Physician Practice Arrangements shows that most American physicians work outside offices. (American Medical Association. May 5, 2021; https://bit.ly/3iI9DTk.) It is estimated that more than 50% of emergency physicians are employed by contract management groups, and a recent workforce study by the American College of Emergency Physicians predicted an oversupply of emergency physicians by 2030. (Ann Emergency Med. 2021;S0196; https://bit.ly/3lVrGYu.)
The need for unions became clearer during the pandemic when institutions were reluctant to provide the resources and staff needed to care for patients, said Brian Fox, DO, a family physician who practiced at Indigo Urgent Care in the USA. Washington State. “It’s a great time to unionize right now,” he said. “A bit of pressure has eased. We couldn’t think of organizing ourselves in the middle of a pandemic.
“We discovered that Washington State had a stockpile of N95s,” he continued. “The organization we were working with did not ask the state for them. They didn’t want to present a scary image to people entering. It’s not acceptable. You play with the lives of providers and patients for optics. The bottom line is that we are workers, not professionals, now.
Hitting initially seemed anathema to doctors, but they found they could do it surgically. First they picketed to bring their concerns to light, then they went on strike for two days. “Eventually there was some movement on some issues, but a lot of providers got so fed up they left,” Dr Fox added. “The new suppliers didn’t know what the problems were. The final contract was slightly better than the work contract we had individually.
Robert McNamara, MD, past president of the American Academy of Emergency Medicine, said now is a good time for emergency physicians to work collaboratively to improve their working conditions. It might be questionable to consider contractor emergency physicians because they have little say over their schedules, must give 90 days notice before leaving a position, and can be fired without due process.
A rock and a hard place
Dr McNamara said his primary concern is the practice of corporate medicine, which can find emergency doctors under the thumb of contract management groups and the private equity firms that own them. He said current labor market issues, including the looming oversupply of emergency doctors, made the prospect of unions acceptable. The AAEM has a policy that supports members who unionize, but advises EPs to seek practice ownership through existing regulations that prohibit fee sharing and corporate medicine practice. (May 16, 2004; https://bit.ly/3iIwLAX.) CAPE policy does not mention the term union and indicates that EPs can participate in collective bargaining units, and mentions four times that they must ensure the timely provision of emergency care. (October 2020; https://bit.ly/3mAxfdu.)
“There is no reason why a small group of emergency physicians working for one of the corporate entities cannot organize themselves into one or two emergency departments in a system. It would be possible and a good test,” Dr. McNamara said. “It could spread like wildfire if it happened.” He said he hoped CAPE would recognize the need to start fighting the corporate practice of medicine.
The TakeEMBack group may provide an outlet for collaboration for those concerned about their lack of independence and protection as physicians. (https://www.takemedicineback.org.) The future could be complicated, however, as insurers begin to acquire contract management companies. The $2.2 billion acquisition of Sound Inpatient Physicians Holdings by OptumHealth (owned by UnitedHealth Group, a healthcare and insurance company) and investment firm Summit Partners raises the specter of the acquisition doctors’ contracts by health insurers. (Fierce Healthcare. June 7, 2018; https://bit.ly/3mvddRD.)
“We are between the proverbial rock and the anvil,” said Dr. McNamara. “My personal belief is that aligning with private equity to fight insurers [who want to acquire groups] has diminished the specialty in the eyes of the public and legislators. It was an unholy alliance, and we are paying the price.
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Ms. SoRellehas been a medical and science writer for over 40 years, formerly at the University of Texas MD Anderson Cancer Center, The Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She contributed to REM For more than 20 years.