Can there actually be a medical profession with physicians as only employees in an industrialized corporate or socialized system with a union representing their collective interests? Does it matter, and should it matter? Are there still alternatives?
Asking another party, specifically the government, to solve major predicaments consuming the profession is not a plan. Worse, it is a clear sign of dependency and weakness. There is no other entity that can deal with the daunting issues confronting individual physicians and the medical profession as well as they can. If only the AMA and other professional organizations would at once begin to examine the payment quagmire with its ridiculous laws (Stark), mandates, regulations, and outright scams that rig the system to the disadvantage of physicians and, at some point, patients, this could be followed by solutions for the multiplicity of physicians based on their employment and/or free market entrepreneurial interests. For physicians, a one-size-fits-all solution cannot be a solution.
Unfortunately, this is now like a David versus Goliath scenario into which the medical profession has allowed itself to be captured. No negotiation is ever possible without one party having a strong position and alternatives to deal with the other party. This present system does not just resemble but is a socialist system where physician specialties are pitted against each other and hospitals defend their indefensible bloated turf with disinformation and well-paid lobbyists. To believe that another party will fairly determine the value of medical professionals and each individual physician is fantasy. With a government that has mismanaged the country into a $38 trillion debt, simply asking for more is a nonstarter, a delusion. The same can be said for the growing corporate powers, insurance companies, and hospital systems that determine physician value and their compensation.
A call for the AMA to lead
This is an opportunity for the AMA to claim its former stature. This is now the critical issue around which the majority of its effort should take place. The system is broken, a political quagmire, an insurance debacle, and rapidly degenerating into a socialist nightmare that will destroy the profession both from without and from within. What has happened to the character of physicians that has transitioned them into malleable supplicants begging for the lesser of bad outcomes for themselves and for the profession? To celebrate a 2.5 percent decrease in reimbursement for 2025, I hate to say, is quite pathetic.
Options must be considered. Starting with the term exploitation as it applies to physicians and their profession, it is understandable that relief is being sought. Are there solutions to the present predicament in which physicians now find themselves? The answer is maybe, unfortunately. It seems there are two alternatives: One is physicians as employees or virtual employees; the other is physicians as entrepreneurs in the business of health care. That either should be directly or indirectly mandated through policies and contrived economics should not be the case. It should be a choice freely exercised by each physician as a distinct individual based on their motivation, not as part of some collective.
The risks of unionization
If unionization by joining or forming a labor union is a consideration, then engagement should be the result of prudent analysis and informed decision-making. It is remarkable how infrequently people think things through so that even intelligent people, physicians, reach untenable conclusions. At the most elementary level is why do this? What would be the purpose of unionizing? This question deserves an honest answer if any logical outcome can be anticipated. The answer then is about compensation and the ability to negotiate as a collection of employees to address this issue. Of course, then there must be an employer either in the private sector or the government. Remember, to negotiate employees must have some leverage. For physicians, what could it be? I can already see the headlines: “Greedy doctors abandoning their professionalism have now sold their souls to the almighty dollar as they abandon their ethics and the patients in need of care by threatening to strike.” If the battle around public opinion is lost, so is the war.
Consider that as union members and employees, the relationship defines your identity. There is a dependence regarding your employment, subservience to a boss, status inferior to management, both equality and equity rather than individuality. There is the corporate structure with clients rather than patients, rigidity of hierarchy and decision-making, and certainly new novel versions of the awful RVU payment methodology with its values, metrics, schemes, and scams “negotiated” into a union contract where one size fits all. How is it possible for such a system to preserve the sanctity of the patient-to-physician relationship? The answer is it cannot. And there will be another industry, labor, taking a bite of the apple.
Then ask yourselves, are hospitals with shrinking and feeble margins, archaic business models, inefficient and bloated management, and entrenched bureaucracies that have not a clue about caring for patients really able, much less willing, to cave to demands for more favorable physician compensation? If they do, which is doubtful, the outcome will be fewer doctors still employed and many more nurse practitioners and physician assistants.
Defining physician value
An interesting question is what is the value of a physician. Value is based on the essence of economics, that there is scarcity of all goods and services. Hence the concepts of supply, demand, efficiency, productivity, and the marvel of competition in open and free markets determines value, or pricing. Since physicians long ago surrendered their marketplace freedom and have allowed compensation, a measure of value, to be arbitrarily determined by others rather than the brilliant marketplace of consumers, nobody truly knows. A blatant example of such surrender is the noncompete clauses physicians so complacently sign. This shamefully mitigates their personal marketability.
Medicare is different. Public sector unions are negotiating with an entity, the federal government, that is not burdened by competition and has an unlimited supply of other peoples’ money plus ready access to money printing. However, this is the case only until it isn’t. With $38 trillion of indebtedness, ongoing inflation, and the specter of insolvency for Medicare and Social Security, it seems money is imperiled both in quantity and in value. The Inflation Reduction Act cut Medicare. The congressional single-payer bill (HR 1976) contains the key components that are destroying the British socialized health care failure. It contains similar proposals for government budgeting, bureaucratic control, central planning, and reduced pay for doctors and nurses. In 2022, 120 House Democrats co-sponsored this legislation.
It seems quite unrealistic to believe that a physician union could actually negotiate with such a political megalith acting already like a monopsony in the current largely socialized health care system.
Certainly, if there are physicians who desire such a relationship to the health care system and are desirous of labor union status, and, with full understanding of the pros and cons, then their decisions should be honored.
A final point is insight into why union membership is falling. There are reasons and they need to be understood relative to health care and physicians.
Allan Dobzyniak is an internal medicine physician.
