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According to our PCMA mission statement, our purpose is to “inform, serve, advocate and advance” high-quality medical care and to monitor the “ethical and competent” practice of medicine. (1). This general statement does not define quality or ethical practice. It is left to our organization of physicians to make that determination. Third parties are increasingly acting as proxies for patients to determine best practices, professional relationships, and compensation. The boundaries of decision making have expanded beyond individual practice. It is undeniable that payors are playing a role in who, how, where and when we treat our patients. Can our organization of physicians act to preserve the quality and ethics of medical practice in keeping with our mission? Can we continue in a meaningful way to advocate for our patients in this new environment?
Insurer and employment contracts touch on virtually every aspect of the patient-physician relationship. However, many agreements are “contracts of adhesion.”. Physicians are not usually in a position to bargain or influence these deals. (2) Recently, a “take it or leave it” contract was presented to a large physician group in our county. Management required primary care physicians take a reduction in compensation. The administration also wanted to enforce what may be considered an overly broad non-compete clause. There was no negotiation. Many physicians in that group could not accept the onerous provisions of the proposed agreement and gave notice. These recent disruptions are based on the insurer’s profitability, without apparent regard for patient choice or quality care.
In situations like these, long-term patient-physician relationships risk being disrupted and potentially lost. Long-term relationships between primary care physicians and their patients have a positive effect on patient mortality. Disrupting those relationships has a measurable, adverse effect on patient outcomes. The article from The Guardian (included in this newsletter) reports convincing, objective evidence in 2 studies from nine countries that there is a “marked link between continuity of care and lower death rates, after correcting for a range of variables.” (3).
The physician’s role as an advocate for the patient and the bearer of ethical standards is eroding. The influence of insurance companies increases through their consolidation and protection under current interpretation of the anti-trust regulations. There appears to be a severe imbalance in the healthcare market in which “dominant health insurers enjoy the benefit of largely unfettered consolidation at the cost of both consumers and providers.” This domination has resulted in higher premiums to consumers and lower compensation to physicians. Seemingly the opposite of what anti-trust is supposed to achieve. (2).
It has taken more than a decade, but our profession has arrived at the point where the majority of physicians are employed. (4) . The need for equalizing the playing field with employers and insurance companies makes collective bargaining more attractive. Due to growing physician employment, it is now increasingly available. Physicians who are hospital employees or joint employees of an organization may unionize. (5). Physicians still in training now have an enforceable right to unionize. As stated in a recent National Law Review article, doctors have “protected rights to form, join, or support labor unions, or to cooperate even in the absence of a union.” (8). The idea of unionization brings up the possibility of a strike. This action is not desirable since there are loses on both sides and it antithetical to our profession that values humanity. However, a study of well-organized physicians strikes from 1976 to 2012 showed mortality did not change, in 6 out of 7 strikes. In 2 cases it decreased! This study shows that adequately organized actions by physicians can be carried out without necessarily increasing risk to patients. (6,7).
We are an organization made up of professionals who hold diverse beliefs. Our practices are varied. Many of us work for an employer, and some still function independently. We are not a union. We need to be aware that the imbalance created by the consolidation of insurers and employers has lessened the ability for us to act individually as patient advocates and effectually promote the ethical medical practice. Our organization endeavors to promote the highest standards of quality in our community and protect its well-being. This effort must include helping prevent doctors from being forced to choose between one-sided job offers and the disruption of critical patient-physician relationships. (3). Continued advocacy and support for our medical community helps sustain its variability, creativity, integrity and professional strength. Mutual support enables us to promote our goals to maintain the high standards expected by our patients and ourselves.
By Dr. Joseph Rosen, Editor
(1). Pinellas County Medical Association. Webpage. Retrieved from: http://pinellascma.org/ (Pinellas County Medical Association, 2018).
(2) Schiff, A. H. (2009). Physician Collective Bargaining. Clinical Orthopaedics and Related Research, 467(11), 3017–3028. Physician Collective Bargaining
(3) Robinson, A. (2018, June 29) Seeing the same doctor can save your life – and AI can never replace that. The Guardian. Retrieved from: Seeing the Same Doctor Can Save Your Life
(4) Al-Agba, N. (2012, September 12). Is It time For Physicians to Unionize? Retrieved from: Is It Time for Physicians to Unionize?
(5) Can doctors form a union? (2013, August 16). Retrieved from: Can Doctors Form A Union?
(6) Metcalfe, D., Chowdhury, R. & Salim, A. (2016). What are the consequences when doctors strike? British Medical Journal. 351,1-4. Retrieved from: Mortality Uneffected by Doctors Strikes 1976-2012
(7) Hoskins, R. (2016, February 09). When doctors strike, fewer patients die. The Boston Globe. Retrieved from: When Doctors Strike, Fewer Patients Die
(8) McGahan, M & Green, D. (2015, October 29). Doctors, Unions, and Protected Activity. The National Law Review. Retrieved from: Doctors, Unions and Protected Activity