Will Union Give Relief to Doctors?

Fresh from medical school, Angela Wang forsook the stratospheric salaries of the private sector for a still-comfortable living as a radiologist at a Los Angeles County hospital, UCLA-Rancho Los Amigos in Downey.

Her county job gave her stability and time to lecture, write papers and mentor students. All that is gone now, replaced with the constant specter of layoffs, budget-cutting and 12-hour workdays.

Now the bloated health department’s cost-cutting has made Wang, 50, one of the latest recruits in the struggle to unionize Los Angeles County’s nearly 800 physicians, the largest campaign to organize public sector doctors in U.S. history.

“We don’t even feel like physicians anymore, we feel like an assembly line,” Wang said, anticipating a union election scheduled for next month. “You really have to have a mission, and if you deviate from that mission, what is there?”

The drive is one of the nation’s most striking examples of growing unionization among doctors as part of the nationwide backlash against managed care and its public-sector guises. It also speaks volumes about the stumbling attempts to transform a local agency that serves millions annually and whose financial woes nearly knocked Los Angeles County into bankruptcy only a few years ago.

A three-year cost-cutting campaign has ended in failure and the county hospitals’ doors are kept open only through a federal bailout. But there has been change--although many differ over the value and extent--in a hospital system that one administrator jokingly compares to a complex of feudal states.

Disciplinary actions against doctors are up, medical services are being contracted out to the profit-hungry private sector, and cost-cutting moves, such as consolidating laboratories, have sparked an uproar over possible harm to patient care.

“What has been most compelling so far” to the county’s doctors, said Dr. Dan Lawlor, the union official spearheading the drive, “is the fact that they haven’t been able to fix these problems themselves. The fact that a high-powered internist or resident was not able to pick up the phone and stop it.”

Dr. Donald Thomas, the associate director of the Department of Health Services and the official who oversees physicians, believes that is a good thing.

“The system you’re talking about used to be a political process that had very little to do with quality of care,” Thomas said. “There’s a lot more of a tendency on the [county] supervisors’ [part] to ask us [administration] and utilize our opinions than just take some angry call” from a doctor.

Lawlor said that if the county’s physicians vote in the May election to unionize, they would become the largest pool of public doctors ever to join a union. Observers say it will be an uphill battle to organize physicians in the far-flung county system, but note that unionization among medical professionals is soaring nationwide.

Doctors’ memberships have quadrupled in the last five years in the American Federation of State, County and Municipal Employees. The other major national union for public sector workers, the Service Employees International Union, recently announced a $1-million nationwide campaign to organize doctors.

The Los Angeles campaign shows how even public-sector health care is driven by the bottom line, union officials say.

“Cost and efficiency is the buzzword now,” said Joe Bader, director of the local office of the Union of American Physicians and Dentists, the group seeking to represent the county doctors. “There’s costs and impacts on focusing on that rather than on other issues.”

Mark Finucane, the director of the Los Angeles County Health Department, denies his administration is obsessed with cutting costs and says he has tried to include doctors in management by hiring both Thomas and another physician to run the mammoth public health program.

“I don’t think doctors historically have had as much of a say in the department,” said Finucane, who happened to go to high school with Bader. “I think they have had a greater say now.”

The doctors in the county’s health department have a wide array of responsibilities, but most spend their time treating the working poor.

The county’s six hospitals and many community clinics primarily serve the uninsured, almost always working families whose jobs neither provide health insurance nor pay enough for employees to buy their own.

“None of us have stayed at the county to get rich,” said Dr. Janice Nelson, director of the blood bank at County-USC Medical Center. “It’s the intellectual challenge, it’s the patient mix, it’s having all types of excitement every day, and taking care of groups of people who wouldn’t get taken care of otherwise.”

Almost all of the county hospitals are affiliated with universities, making them teaching institutions as well as the county’s only trauma centers that take critically injured patients without regard to their insurance status.

Those hospitals swelled over the years as county supervisors exercised political power to secure plum contracts or jobs at hospitals in their districts.

Yet over time the national transformation of the medical field ate away at the county system’s financial foundations. Private hospitals and medical plans poached Medi-Cal patients to grab the state funds that came with them. The ranks of the uninsured rose dramatically as paying patients went elsewhere, leaving the public hospitals with more patients--and less revenue--than ever before.

In the early 1990s, the county tottered on the edge of bankruptcy as the cost of its hospitals grew and grew. Every year supervisors snagged some new money to close the gap, but in 1995 their luck ran out.

For the first time in county history, doctors were laid off. Only a bailout from the Clinton administration--then in full reelection mode--saved hospitals from closing.

As the dust cleared, Finucane arrived. Leaving his job as head of Contra Costa County’s health department, he took on the massive task of restructuring Los Angeles County’s $2-billion health department in a more cost-effective manner oriented toward cheaper, preventive outpatient care.

One of the first changes came in a letter sent to physicians at the emergency room at Martin Luther King Jr.-Drew Medical Center from a private medical group. The company said it was about to win a contract to run the emergency room and that it would take over employing the doctors.

Finucane disavowed the letter and halted the contracting effort, but doctors were put on guard.

Someone called the Union of American Physicians and Dentists.

“People who had been there a long time saw a shift in management and saw us as physicians having less of a say in how hospitals are run,” one King-Drew doctor said. “We realized we had a group of people who are not looking out for our patients . . . telling us what to do.”

Indeed, though the emergency room remains operated by salaried county doctors, four other departments at King-Drew Medical Center now are operated by private contractors. Dozens of private health clinics have secured county contracts. And the union’s ranks have grown to more than 200 as doctors join individually, although there is as yet no official representation or contract.

A recent proposal to make it easier for the health department to contract out services has raised new alarms. Union leaders fired off a letter to county attorneys, warning that such a step could be construed as interference with their organizing effort.

“We see what’s happening in the private sector,” Bader said. “These medical groups . . . that are poorly run, and the doctors are hired and fired at will and patients are stranded.”

None of that, Finucane said, will happen at the county. He said the proposal on contracting out is mostly a technical way to renegotiate agreements with universities, which pay for some of the county doctors’ salaries.

“It’s an illustration of this hypersensitive atmosphere that this is looked at as some effort to bust up unions,” he said.

Adding to the anxiety has been the health department’s ill-fated “re-engineering” process, an ambitious effort to restructure, save money and avert future layoffs. After nearly three years, the initiative is falling as much as $212 million short of its goal, and supervisors have criticized it for merely slashing costs and not addressing structural issues.

Baby-faced management consultants rankled doctors by telling them how to organize their services. And a novel labor-management partnership meant that all other health department staff--clerks, nurses, even interns and residents--were represented at high-level health department meetings because they were unionized.

“The other people don’t have to run around making things more efficient,” said one county doctor. “But they [management] can just tell us, ‘You will do this.’ . . . They’re going after the physicians because we’re not unionized.”

Physicians’ complaints coalesced around proposals to centralize pathology labs. Currently, each hospital runs its own laboratory to analyze test samples. But administrators say that is a symbol of the expensive lack of coordination among hospitals, and last year they proposed to save $6 million by consolidating labs at King-Drew and UCLA-Olive View Medical Center in Pacoima.

The proposal, Thomas said, has been around for years and is modeled on a successful arrangement at Kaiser-Permanente hospitals. But when administrators tried to move forward with it, physicians--especially pathologists who depend on swift lab results to tell them if a patient has meningitis, cancer or hepatitis--hit the roof.

They warned of delays between the arrival of samples at labs and the reporting of results, delays that could make a significant difference to patients awaiting critical care.

“There are a lot of things we do that can’t wait a day,” said one doctor, citing emergency cancer surgeries or meningitis diagnoses. “Doctors are outraged by this.”

Health department administrators have agreed to reconsider the consolidation in their labor-management committee. But Thomas, the administrator in charge of physician issues, sees the reaction as largely a turf issue.

When the department cut pathologists’ control of clerical staff, Thomas said, doctors were also in an uproar. “It was like taking their toys,” he said.

“Outside of priests,” Thomas said, “physicians are the most resistant to change.”