In a radical departure from policy, the AMA's House of Delegates rejected the advice of its own executive branch and voted on June 23rd to create a "national labor organization" to help qualified physicians collectively bargain with managed care organizations.
The decision marks a dramatic shift in thinking for the AMA and reflects the shifting demographics of - and perhaps a new revenue stream for - the association, which has seen its integrity compromised by botched marketing deals, a shrinking membership base and the increasing restraints of managed care.
The vote came during the AMA's recent annual meeting in Chicago. The association's Board of Trustees had previously opposed a national union, twice rejecting requests from delegates to consider the idea. In a report this April, the Board stated that a union could damage the AMA's professional reputation and fail to achieve its ultimate goal.
But the Board's stance met with increasing opposition from delegates across the nation. A special panel of seven physicians was convened during the meeting and surprised many by recommending the formation of a labor arm for doctors. With that recommendation, the subject was brought to the House for discussion on June 23rd.
Several delegates remained opposed to unionization. Dr. Troy M. Tippett II, a Pensacola, Florida neurosurgeon, introduced an anti-union resolution by saying, "I didn't think I would be here when the AMA shifts over to the dark side, when it would shift to pickets and pay from ethics and patients." Tippett and others made a strong case, but the majority of delegates disagreed with their views. When the votes were cast, the Florida resolution was defeated by just over 40 votes.
The delegates next considered an amendment that would make their labor organization rather unique. If passed, it would have required physicians to not withhold services from patients, to not strike, and to not honor picket lines from other unions.
Curiously, this amendment was also voted down, meaning that AMA union members would be able - theoretically - to go on strike, if necessary, for their negotiating demands to be met. (This position has since been vigorously denounced by AMA officials.)
The delegation then faced its most important issue of the day. Avoiding the word "union," they voted in favor of a resolution to "immediately implement a national labor organization under the National Labor Relations Act to support the development and operation of local negotiating units as an option for employed."
Who Is Affected?
The AMA's decision does not affect every doctor in the U.S. Under current federal laws, only physicians who are "employees" - those who work full-time for HMOs, hospitals or government agencies - can join a union. Approximately 17% of the nation's physicians fall into the "employee" category, with a much higher percentage of medical students taking such positions out of school.
Independent practitioners, meanwhile, are prohibited from unionizing under current antitrust laws, but those laws may not be in effect much longer. Texas recently became the first state in the nation to allow all physicians to collectively bargain with managed care groups. In addition, pending legislation in Congress would give all doctors nationwide the right to collectively bargain with managed care companies. (The AMA supports this legislation.)
Reaction to Unionization
Many doctor groups and existing doctor unions have applauded the AMA's pro-union stance. They see the decision as a long-overdue step toward reclaiming a doctor's right to care for patients as they see fit.
"The truth is, doctors are no longer being treated as professionals, and [they] want to regain some control over their environment," said Dr. Edmond R. Donoghue, a delegate from the National Association of Medical Examiners.
Consumer groups, employers and federal regulators, however, see otherwise. Some liken the fight between doctors and HMOs to a battle between the rich and the even richer.
"This is a debate between those earning six figures (doctors) and those earning seven figures (health insurance companies)," said Ron Pollack, executive director of the Washington, D.C.-based consumer group Families USA. "If doctors' salaries escalate, consumers will end up paying a price for that."
And the trend wouldn't stop with medical physicians. Some experts (including FTC chair Robert Pitofsky, who called the plan "bad medicine for consumers") predict price-fixing and boycotts by pharmacists and dentists as well.
What about Striking?
For most unions, the ability to strike is their biggest weapon, their "ace in the hole." But AMA members are prohibited from striking, not just for ethical reasons but by the Hippocratic Oath, which states in part that a doctor "will go for the benefit of the sick and will abstain from every voluntary act of mischief or corruption and further from the seduction of any patient."
So what good is it to be able to go on strike legally, when you are forbidden to do so morally and ethically? And how much effect can you have at the bargaining table when you only represent an average of 1/3 of the nation's physicians?
Dr. Randolph Smoak Jr., the AMA's president-elect, has denied the possibility of union members hitting the picket lines. "Your doctors will not strike or endanger patient care," Smoak said in a prepared statement. "We will follow the principles of medical ethics every step of the way."
Dr. Robert M. Tenery Jr., chair of the AMA's Council on Ethical Judicial Affairs, added that the council had no specific ruling on strikes. Instead of forming a picket line, Temery said, "Our opinion holds that physicians may not ethically withhold essential medical services." (emphasis added)
The AMA's Ulterior Motive?
An underlying reason for the AMA to unionize - and one that has not received much attention from the national media - could be that the association is looking for ways to increase its flagging membership base. According to an association report, only 34 percent of all U.S. physicians and medical students belong to the AMA, down from 45% just a decade ago and nearly 75% in the 1960s.
However, the number of doctors who have joined a union is on the rise. An estimated seven percent of the nation's doctors (about 40,000) already belong to unions nationwide, up from 25,000 just two years ago.
For the AMA, creating a union would be a way to reel in young doctors who had decided not to join the association while in medical school. An increased membership base, compounded with a new revenue stream from union dues, would mean greater financial reserves for the association. That extra revenue could in turn be used to strengthen the AMA's lobbying factions on Capitol Hill, thus ensuring the association's continued (and medically biased) influence in the health care arena.
Consequences for Chiropractic
Now that the medical profession's largest association has given its blessing to doctors unionizing, a number of questions spring to mind:
What does this mean for chiropractic?
How will the profession, which has fought for more than a century to earn its share of the health care market, react to the AMA's resolution?
Should chiropractors form a union of their own?
While all of the above issues would apply to chiropractic's decision, the chiropractic profession must examine the issue from its own unique perspective. Blindly following the AMA is not necessarily the way to go.
The new AMA union will likely present both challenges and opportunities. Depending on the course we choose, MDs could become union "brothers" and "sisters," or DCs could work strategically as "scabs" who take positions formally offered to MDs before negotiations broke down. Health plans may look for qualified non-union (DC) replacements to provide patient care. In areas such as orthopedics, nutrition, diet, wellness and sports medicine, chiropractors could be a logical substitute for medical doctors.
The question of whether or not chiropractors should form a union of their own is one that could fill an entire issue of Dynamic Chiropractic. The reality of this action would likely be severely impacted by the same problems the AMA has, specifically lack of solidarity. (Editor's note: The August 11, 1997 issue of DC featured a pair of front-page articles - one written by AFL-CIO president John Sweeney, the other by Louisiana chiropractor Donald E. Marx discussing the issue of chiropractors and unionization.
But the benefits could justify the additional union dues. For one, it could mean higher reimbursement rates. As it now stands, when an independent practitioner contracts with a health plan, they only have so much clout. Union negotiations could mean that all doctors would get reimbursed at the same rate, and all have equal access to the same plans.
These are other questions that must be considered:
Because most DCs are still practicing as independent doctors, they would not qualify for traditional unionization under current labor laws. But should Congress pass new legislation, collective bargaining, especially on a local and regional level, could quickly become a reality. The very core structure of our state and national organizations could be substantially altered as "member benefits" reflect a more union flavor.
The issues are many and complex. A "wait and see" position will undoubtedly yield much greater insight. Whatever the profession does decide, one thing is certain: the era of the independent health practitioner may be coming to an end as more and more doctors begin to unionize.
Your Comments Wanted
If the opportunity presented itself, would you join a chiropractic union? If so, why; if not, why not? Dynamic Chiropractic wants to know your feelings on the subject. If you have an opinion on the subject, visit www.ChiroWeb.com/unionand make yourself heard. Your comments will be collected and published in a future issue of DC.
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