In a Wall Street Journal article this week, Dr. David J. Leffell, the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine wrote an Opinion column entitiled, The Doctor’s Office As Union Shop, brillantly pointed out that one outcome of the enactment of the Affordable Care Act (ACA) next year will be the trend that physicians will become employees of large hospital groups, rather than self-employed professionals that has marked the practice of medicine in the US for many years. Leffell writes that this trend, which will directly affect the quality of patient care, and could affect its cost, has gone unnoticed and unreported.
This, Leffell says, is a radical transformation of health care, in that doctors who have traditionally practiced either alone or in small groups, will become union workers. In the past, physicians have been more difficult to regulate and monitor, unlike hospitals who operate under the rubric of large regulatory agencies. Leffell believes that:
For cost control to be effective, the professional autonomy and independent clinical judgment of the physician and other providers must in some measure be sacrificed to standardization.
Leffell also writes that by reducing the reimbursement for certain office-based specialists while enhancing related payments to hospitals, the Obama Administration had, by accident or intent, created this change in the status of physicians. He believes they are compelling more and more physicians to seek employment with health systems or large physician groups.
One other factor he cites for this move towards physician as worker, is a generational shift. Doctors who are in training now, Leffell writes, are willing to forsake income for a better quality of life, and are less interested in the entrepreneurial tasks required to run a practice. They want regular hours and do not want to be responsible for patients after hours. In 2012, Leffell states, approximately half of physicians were already employed by large health care entities, and that in the next few years, these systems will employ close to 80% of all doctors.
This shift, Leffell says, is important for many reasons.
The migration of physicians into large, regulated entities is essential if the practice of medicine is going to be transformed into the corporatist-government model that is the only way health-care costs can be controlled.
This new status will provide doctors with the right to collective bargaining, something that some Republican governors have tried to restrict in recent months, especially for public service workers. What they will do with doctors working in large hospital groups, private or public is unknown at this point.
All this has not been without notice by the leaders of organized labor, Leffell points out. They see service workers with nonexportable jobs as the last best hope for their unions, whose membership has been declining for years. Leffell quite clearly states, that physicians are becoming service workers; they are well-educated, expensive to train, their decisions have significance to the lives of others, but they provide a service that cannot be outsourced to India or China, according to Leffell.
This raises the question as to whether they have a right to strike, which is the key to collective bargaining.
As we already know, some expensive or unavailable procedures are already being “outsourced” to India, Thailand, Singapore, and other medical tourism destinations. My posts on Mexico and on hospitals and clinics in Latin America and the Caribbean make this very clear. What is different here is this, if doctors in one or more hospitals go on strike, and Americans cannot get even those procedures that are not very expensive or that are available here, will medical tourism be seen as “anti-union” as scab workers are seen by striking workers in other industries? And if the trend towards unionization of doctors goes the way the unionization of workers in industrial workplaces has done, will future rising costs of unionized healthcare providers mean that as an alternative, medical tourism will be anti-union?
We cannot know for certain, because the factors that determined past unionization movements and the associated costs of labor it has engendered, does not necessarily mean that it will follow the same path. And this does not mean to imply that implementing medical tourism, for health care generally, and for workers’ compensation specifically, as I have been writing about, is in itself anti-union. On the contrary, I support unions, but am only pointing out an issue that will need to be addressed by the health care industry, physicians, unions, lawyers and politicians in the years to come.