-Caveat Lector- New Unionist August 1999 "Doctors unite!" by Joel Albers Growing control over medical care by HMOs and insurance companies pushes once reluctant AMA to adopt unionizing. The American Medical Association (AMAS) long an opponent of forming physicians' unions, recently voted to establish a physicians' labor union. In recent years, the playing field has been tilted heavily in favor of corporate HMOs, which have unilaterally set contract terms with doctors. These involve placing financial pressures on physicians to limit referrals to specialists, to see more patients per day, and to limit what patients are told about more costly procedures. HMOs also include a contract clause allowing the firing of any physician without cause at any time. Financial pressures to contain costs induce some physicians to actually avoid sick patients. While the financial incentives to limit care allow the HMOs to survive, surveys of physicians and other studies indicate the quality of patient care is compromised as a result. Establishing a union will allow physicians to negotiate contract terms, which according to the National Labor Relations Act, the basic labor law of the United States, concern "grievances, labor disputes, wages, rates of pay, hours of employmen or conditions of work." It is this last term, "conditions of work," which will allow physicians to negotiate on behalf of patients as well as on reversing recent pay cuts. Although physicians are among the highest paid occupations, pay means little without adequate job security or control over working conditions, which a union can protect. So far the AMA decision to unionize applies only to the 108,000 physicians (including all residents) who are direct employees of HMOs, hospitals and other institutions. The remaining 512,800 in private practice, whom HMO contracts define as "independent contractors," are barred from organizing as unions by the National Labor Relations Act. Certified unions are exempt from, and independent contractors are subject to, Sherman Antitrust laws. According to the Federal Trade Commission, if just two private practice physicians discuss patient charges with each other they can be fined and jailed. Their conservation constitutes price fixing, restraint of trade and monopolistic practices under the Sherman Antitrust laws. Antitrust regulation over medicine is predicated on the market model, which in theory, promotes competition among individual private practitioners, resulting in lower prices and greater choice, all in the name of consumer protection. The FTC's assumption of physicians as indpendent competitors, is, however, pure fantasy. The reality is that physicians' prices are largely fixed by HMOs and other insurance companies, and that therefore they cannot compete by lowering prices. This is the case in Minnesota where 80 percent of the populationa re enrolled in only four large HMOs. The dilemma of HMO-controlled pricing is similar for pharmacists. Because HMO reimbursements for pharmacists are fixed at or below their costs, pharmacists are forced to increase rather than decrease prices for uninsured cash-paying patients if they expect to survive in the marketplace. As it is, hundreds of independent pharmacies have closed in recent years. On the other hand, the McCarran Ferguson Act, and in Minnesota, the Minnesota Care Act of 1992, with help from the FTC exempt insurance industry consolidation from antitrust laws and permit HMOs to engage in monopolistic practices without interference. The AMA is finally promoting a bill drafted by Rep. Thomas Campbell (R-Ca) and John Conyers (D-Mi), recently introduced into Congress, which would permit widespread antitrust law exemption for self-employed health care professionals. The Quality Health Care Coalition Act of 1999 would allow health care professionals to COLLECTIVELY NEGOTIATE with HMOs and other third party payors in developing the terms of their contracts. All other strategies of physicians, pharmacists and others to gain more control over their clinical practices from HMOs have largely failed. ---- Physicians in most other industrialized countries (and many less developed ones) engage in collective bargaining. Physicians in all of the Canadian provinces engage in direct negotiations with their respective provincial governments over fees and work conditions. Physicians of Britain, Germany, Sweden, Denmark, Finland, Norway and Israel are unionized. Swedish doctors are represented by a single association that operates within the framework of alarger labor union. The British Medical Association became a union in 1974, and had been functioning in that capacity for far longer. State health professional associations in the US should debate all the options for surviving in today's health care market dominated by HMOs, including the union option. The AMA labor union approach is advantageous because it can eliminate financial incentives to limit care and avoids having to compete with HMOs on their terms and investing huge sums of capital which most health professionals cannot afford. --- In the end, however, the contradiction between the goal of making quality health care available to every individual and the need to make a profit in the competitive marketplace cannot be reconciled. Health care must be freed from its status as a commodity for sale to hose who can afford it, while health care practitioners mutst be freed from their status as exploited wage workers who lack control over the terms and conditions of their work. Unionizing will in itself not overcome the contradiction. But unionization of health care professionals is an essential step toward the eventual organization of the entire working class, the one force that can change our economic system and society. Joel Albers is a pharmacist in Minneapolis. DECLARATION & DISCLAIMER ========== CTRL is a discussion and informational exchange list. Proselyzting propagandic screeds are not allowed. Substance—not soapboxing! These are sordid matters and 'conspiracy theory', with its many half-truths, misdirections and outright frauds is used politically by different groups with major and minor effects spread throughout the spectrum of time and thought. That being said, CTRL gives no endorsement to the validity of posts, and always suggests to readers; be wary of what you read. CTRL gives no credeence to Holocaust denial and nazi's need not apply. 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