Doctors’ Journey: From HMOs to Unions?

Like many doctors, Byron Thomashow, a pulmonary specialist, is fed up with managed care. He’s tired of justifying the need for clinical procedures to ill-informed HMO personnel. He’s weary of fighting endless battles in order to treat his patients. He’s frustrated by the loss of autonomy he once enjoyed in making medical decisions.

But unlike many of his colleagues, he’s fighting back. In fact, he’s given up on managed care altogether, electing to withdraw from the web of HMOs and health insurers that have come to dominate the U.S. health-care system. “I just couldn’t stand it,” he explains. “The thought of being put on hold by people who don’t know a quarter of what you are doing to get permission for patients to go to the bathroom” was too much to take.

Barney Softness, a New York pediatrician, is another rebel. When his health maintenance organization suggested he fire his registered nurses to reduce costs, he did something few doctors have dared to do: He fired his HMO. He says he just wants “to give the kind of care that I think people deserve.”

These two mutinous physicians are not alone. Across America, state insurance commissioners are reporting a veritable revolt by doctors against their HMOs, and medical-society officials say more and more practitioners are severing ties with managed care altogether. A recent headline in the New York Times heralded this trend, citing a growing rebellion by doctors.

Much of the dispute revolves around the reduced fees insurers are paying physicians for their services. Nonetheless, despite a glut of physicians in many specialties, doctors’ incomes have continued to rise, unencumbered by the laws of supply and demand. For this reason, some critics have described the controversy as much ado about money. But it is also about something more fundamental: the sudden encroachment of “outsiders” into the practice of medicine.

For the first time in history, insurers are telling physicians how to practice their profession, and the medical community is up in arms. As an early participant in managed care, I am no stranger to this phenomenon, and I’ve seen what it is like to lose your autonomy as a doctor. It is not a pretty sight.

As a salaried physician at an HMO, I experienced firsthand the sense of helplessness and outrage that can result when a third party comes between you and your patients, preventing you from caring for them the way you were trained. Indeed, after years of advanced training and education, I felt something I’d never felt before in my life as a doctor: the inability to have my medical decisions carried out.

As any doctor can tell you, this is a dreadful feeling. It goes to the very heart of medical practice. Moreover, it challenges some of the basic assumptions about what it means to be a physician. From the outset of their training, doctors are taught that they alone bear ultimate responsibility for the fate of their patients, and, therefore, they alone must have the final say--in conjunction with their patients--on clinical decisions. They may consult with other health professionals before reaching a conclusion, but, in the end, they must make the final call.

This may seem a bit autocratic to some, but because lives are at stake, it’s a necessarily authoritarian regime. When dealing with life-and-death decisions, you can’t have a committee bickering over strategy.

On the other hand, medicine cannot afford to operate in a vacuum. When dealing with one-seventh of the U.S. economy, you just can’t leave the decision to physicians alone. This is how we arrived at the current economic crisis in the first place. The medical community, unconstrained by managed care, continued to inflate medical spending until it consumed a whopping 14% of the nation’s economic output.

This voracious appetite for dollars obviously couldn’t be sustained, and the need to control runaway costs set the stage for managed care. The result was the current revolution in health care, in which laws of economics finally held sway over the canons of medicine. Economic pressures chipped away at the hegemony of the medical profession, and managed care did what no other force had ever done: It turned doctors into “employees” on a massive scale.

Now, the revolution has led to another first: Physicians are clamoring to join unions as never before. Courted by everyone from the American Federation of Teachers to the International Assn. of Machinists, doctors are beginning to unionize across the country. They are being welcomed with open arms. The Service Employees International Union, the nation’s fastest-growing union, pledged in March to spend $1 million this year to organize the nation’s 600,000 doctors. Even the United Food and Commercial Workers union has gotten into the act, seeking to expand its base by enrolling doctors disaffected with managed care. This could lead to some intriguing alliances: Doctors could find themselves walking the picket lines alongside supermarket workers in New Jersey.

Though there is some precedent for the concept of a physicians’ guild, unionization still raises some troubling ethical questions for the healing profession. Perhaps the most important issue involves organized labor’s right to strike. Could doctors go on strike, denying care to their patients? If so, who would treat their patients while they walked the picket line? How would they reconcile withholding care with the obligations of the Hippocratic oath?

These are difficult questions, but they’ll have to be addressed as we move into the next phase of the managed-care revolution. In the meantime, one thing is certain: The revolution will continue. As insurers press on with their onslaught, doctors will persist in the struggle, fighting a rear-guard action in the hope of regaining some control over their fate in the new health-care economy.*