Seeking Clout in HMO Era, AMA Votes for Union

The American Medical Assn., saying that doctors are frustrated in their efforts to deliver high-quality care, took an extraordinary step Wednesday toward forming a labor union to give more power to physicians in their dealings with managed care companies.

For the AMA, with a long history as one of America’s most conservative institutions, the vote signaled an angry outcry by doctors who believe that they are losing autonomy in today’s health care system.

“When we negotiate as individuals, we do not have any clout,” Dr. Nancy Dickey, the AMA president, said in a conference call with reporters from around the country. The HMOs and other managed care companies “have become so large and aggressive” that they do not let doctors “practice the best medicine,” she said from the AMA meeting in Chicago, where the medical group’s House of Delegates voted to create the labor organization.

The new union never will go on strike, she said. But it will use other tactics, such as “educational campaigns,” to enlist public support for doctors in disputes with managed care companies, she said. Organized doctors also could retaliate against unreasonable employers by “being a little slow in completing some of the paperwork” demanded by managed care companies, she said.

About 15% of the nation’s physicians are employed by managed care or other companies and would be eligible for membership in the new union.

The AMA’s national labor organization will help groups of doctors in communities to organize and negotiate contracts with hospitals, medical schools and HMOs and other managed care companies with salaried doctors on their payrolls. “It’s a local option. We’re here to provide the tools for local doctors,” said Dr. Randolph Smoak, the AMA’s president-elect.

The California Assn. of Health Plans has not taken a position on the issue of physicians forming labor unions, Cory Black, a spokesman for the HMO trade group, said in a telephone interview. In California, most health plans negotiate contracts with medical groups--organizations of doctors--rather than with individual doctors, he noted.

“We support the physicians’ ability and their right to form associations or organizations to negotiate the best contracts in their interest,” Black said.

Doctors employed by Los Angeles County voted last month to join the Union of American Physicians and Dentists, which is affiliated with the American Federation of State, County and Municipal Employees. The 800 doctors who will be covered by the union contract work for the county Department of Health Services, which runs the trauma centers and provides care for uninsured county residents.

The AMA and most of its members traditionally have been fierce opponents of unions. The profession has emphasized the long years of schooling and the talents and judgments of doctors. These experiences contribute to an entrepreneurial, individualistic attitude toward life that is very different from the solidarity and collective attitude of workers who become union members.

At Wednesday’s news conference, the discomfort was evident: Smoak and Dickey carefully avoided calling their group a doctors’ union. Smoak referred to it as “an organization,” a “national umbrella” or a “collective bargaining unit,” while Dickey spoke of an “additional tool for doctors” or a “legally constituted entity” that can negotiate on behalf of physicians.

But when the two AMA leaders spoke of the doctors’ grievances, the complaints could have come from a speech by CIO organizers in the historic labor battles of the 1930s: Doctors are being “hammered” by health plans, said Smoak, adding that physicians are little Davids in battle with the HMO Goliaths.

Managed care organizations treat doctors as “little more than ditch diggers churning through patients,” complained AMA President Dickey. The formation of local unions can give doctors a “much bigger voice” in changing working conditions, she said.

Doctors’ basic complaint is that managed care does not permit them to use their training and best judgment on behalf of their patients, she said.

The nature of medical practice has changed dramatically in the last decade. The majority of patients were treated under a fee-for-service system, with doctors deciding on treatment and health insurance companies acting as passive payers of bills.

When medical cost inflation hit double-digit rates in the late 1980s and early 1990s, corporations, which provide health insurance to most Americans, rebelled and demanded change. The health insurance industry responded with HMOs and other systems to control costs. Payments to doctors and hospitals have been reduced, and many medical procedures and treatments must be approved in advance. Patients often must go to gatekeeper doctors before being allowed to see specialists.

Mergers and acquisitions in the health care system have produced a small group of major firms providing health care for millions of people. These companies say that they are efficient at delivering care. Doctors argue that much of the money going to administrative costs and corporate profits comes at the expense of patients.

“More money should be directed back toward patient care,” said Smoak. Organized doctors would have more power to negotiate with health care firms over how money is spent and decisions on care are made, said Dickey.

The vast majority of physicians are self-employed, and it has been illegal under federal antitrust laws for them to do what a union does: organize, bargain and establish fees. The AMA is also working hard to persuade Congress to change federal law to allow private-practice physicians to negotiate collectively with managed care firms.