With historic numbers of U.S. doctors now employed by hospitals, health systems and other corporate entities, a growing number of physicians are exploring the potential for collective bargaining and unionization to pose a counterweight in the increasingly consolidated health care industry.
A webinar produced by the AMA Academic Physicians Section featured a presentation by Barak Richman, PhD. He is a professor at Duke University School of Law and professor of business administration at Duke Fuqua School of Business and discussed the potential for physician unions to help preserve and restore physician autonomy.
To illustrate his points, Richman pointed to a labor union that many outside of the medical profession are already well aware of: the National Football League (NFL) Players Association.
Major shift toward physician employment
“American law, American policy, the entire industrial structure of the health care sector is really premised on the presumption that physicians are independent,” Richman said. “We presume physician autonomy. We have all sorts of rules and ethical codes and funding mechanisms that not only rely on physician autonomy but are really designed to preserve it.”
But that autonomy can be threatened in an employment situation, he noted, and employment is becoming the predominant physician practice setting, with more than half of physicians delivering patient care now employed.
“This is as dramatic a sea change as I think we've seen in American medicine in the last hundred years, and it's something that has not been fully appreciated,” said Richman.
Learn more by reading the JAMA editorial “Restoring Physician Authority in an Era of Hospital Dominance,” co-written by Richman.
How unions can be effective
"I view the rise of physician organizing activity as, first of all, a very logical consequence of the dominance of hospitals and the loss of physician autonomy,” Richman said.
Unionization is one response to the increasing consolidation within health care, drawing an analogy to how the NFL Players Association represents football pros in a tightly limited market. There are only 32 teams, after all.
“If it weren't for the NFL Players Association—the union that represents professional footballers—we would not see market wages” in pro football, Richman said.
“The other thing that unions do is they allow employees to negotiate for nonwage considerations,” he added, pointing to how NFL players have negotiated changes affecting player safety and the use of name, image and likeness.
“If the problem with the health sector is a problem of governance, if the wrong people are in charge, or the people who are in charge have the wrong incentives,” unions can help rewire the system.
The webinar also included other presentations on physician unionization by:
- Jay Hochsztein, MD, attending radiologist at Jacobi Medical Center and second vice president at Doctor’s Council, a physician union in the New York City area.
- Anna Yap, MD, an AMA member and assistant professor of emergency medicine at the University of California, Davis, School of Medicine. She led the creation of a resident and fellow union while a resident at University of California, Los Angeles, Health.
The AMA has assembled a variety of resources to help physicians flourish in the employment setting.
- The AMA Advocacy Resource Center’s issue brief on collective bargaining for physicians and physicians-in-training.
- These Annotated Model Physician-Group Practice Employment Agreement (PDF).
- The AMA Physicians’ Guide to Hospital Employment Contracts (PDF), free for AMA members.
The AMA supports the right of physicians to engage in collective bargaining, and it is AMA policy to work for expansion of the numbers of physicians eligible for that right under federal law.
AMA union-related policies contain several caveats. First, physicians should not form workplace alliances with those who do not share physician ethical priorities. Second, physicians should refrain from the use of the strike as a bargaining tactic, although in rare circumstances, individual or grassroots actions, such as brief limitations of personal availability, may be appropriate as a means of calling attention to needed changes in patient care.
Learn more with the AMA about understanding physician employment contracts.
