The AMA Unionizes-What Role Will the APA Have in Labor Negotiations for Psychiatrists?

To a certain extent, it didn't have a choice. As traditional unions successfully expand the ranks of organized physician employees, and as the U.S. Congress considers an antitrust exemption so that all doctors can collectively bargain, the American Medical Association decided to unionize. This means the AMA will continue to play an influential role in health care as crucial economic, workplace and patient care issues confront the medical profession. Doing nothing would have been tantamount to leaving the bargaining table even before the negotiations began.

For psychiatry, the AMA's decision to unionize could be a model for the American Psychiatric Association as it develops its own unique approach to confronting managed care as a collective bargaining unit. Even so, it is too early to tell whether the APA will seize the opportunity. Meanwhile, it has yet to debate the issue internally and to take a position on the issue of unionization.

Nevertheless, when the AMA voted in June to create a "national labor organization"-a euphemism that seemed somehow more professional than the word union-it realized the landscape of American medical practice was altered for good, although even its leadership couldn't fully predict what changes it had wrought. In five years, for instance, the AMA will lose control over the union's board, since by then the law will require that the leadership be selected by a vote of the labor organization's membership. As residents and younger doctors become more accustomed to the ways of managed care and more comfortable working with managed care, the AMA's voice and representation is likely to change as well.

Meanwhile, despite promises not to strike and to maintain "the highest [ethical] levels of professionalism," there is no guarantee that less drastic work stoppages won't affect patient care. Organized physicians could decline to accept new patients or refuse to work overtime-actions that would not violate ethical guidelines per se but would still cause disruptions in the delivery of care. And if Congress allows nonemployee physicians to collectively bargain, groups of specialists in a particular locale could simply agree not to contract with managed care organizations until their demands are met, potentially stifling access to treatment.

However, frustrated with the imbalance of economic power in the health care marketplace and weary of the infringement on physician autonomy when it comes to making decisions about medically necessary care, the AMA made its move, promising a better day. "We will follow the principles of medical ethics every step of the way. No other organization can make that promise to the patients of America-and keep it," said Randolph D. Smoak, M.D., chair of the AMA's board of trustees. "The AMA board looks forward to creating a labor organization for the profession that addresses the concerns of America's physicians and empowers them to act on behalf of our beleaguered patients and, consequently, improves the health and well-being of the citizens of America," added then AMA president Nancy W. Dickey, M.D.

Nonetheless, in an interview with PT Thomas Reardon, M.D., the AMA's current president, acknowledged that a host of details still need to be worked out, and that he couldn't foretell how the AMA's action will affect the future of medicine. "You're asking me to look into a crystal ball," said Reardon. "We hope to set this up with bylaws based on ethical principles-we won't strike, we won't withhold patient care, and we will not use this in any way to harm patients-but we know that we have no control over that in five years. So we hope to set it up in such a way that it will continue to be an ethically driven labor organization."

The other conundrum that must be considered is the potential for physician-owned groups and managed care practices getting into labor conflicts with the doctors they employ. These internecine struggles often task professional associations who strive to form umbrella organizations that cover a broad spectrum of practitioners. "We will not target physician-owned groups, unless the owner is being abusive," Reardon said, "but we will have this as an option for physicians if they need help."

How to address union issues also needs to be considered. For instance, the reaction and expectations of state associations may put a wrinkle in the AMA's plans for nationwide unionization. The Florida and Texas delegations, for example, fought hard to defeat the call for a national bargaining unit. Delegates from these states believed these issues could be better addressed on a local level.

Meanwhile, Reardon denied health insurers' claims that allowing all physicians to collectively bargain with managed care would drive up health care costs by $80 billion annually, saying the inflated figure comes from a biased study paid for by industry lobbyists. Rather, he said the AMA relies on preliminary figures developed by the Congressional Budget Office. These figures estimate increased costs ranging between $3 billion to $5 billion.

With a strong membership base and public psychiatry's historical relationship with collective bargaining (state and federally employed physicians are often represented by unions), the APA could be poised to become a major force in health care labor negotiations. Psychiatrists have been hit hard by managed care and often marginalized when it comes to allocation of health care dollars. A nationwide collective bargaining unit solely comprising psychiatrists could restore financial losses that have accrued over the years, while at the same time improving patient access to quality care.

William Glazer, M.D., president of Glazer Medical Solutions, which is based in New York and Massachusetts, is clinical professor of psychiatry at Harvard Medical School and has been involved with concerns over quality of health care since 1978. In an interview with PT, Glazer explained that unions are "a good thing" for psychiatrists. He also said the APA should consider forming a "carveout" union.

"When one looks at what's been happening and the way in which psychiatry is often left in the dust, that's a good argument for forming the APA's own union," said Glazer. "Psychiatry can empower itself and regain the authority that it deserves. This should be thought about and executed as soon as possible."

Nevertheless, Glazer questions whether the profession will successfully grasp the current opportunities. Although he acknowledges that psychiatrists are more ready now than before to collaborate, they still hesitate when it comes to taking on the system. "We are falling short when it's time to get political," he added.

There are reasons to be skeptical. When the AMA House of Delegates took on the issue, the psychiatry delegates voted their consciences in the absence of policy directives from the APA or the Section Council on Psychiatry.

"After listening to the discussion among the delegates and the alternates and the section council itself, it seemed to me that the constituencies that are represented in the APA would probably be divided on this issue," APA past-president Joseph T. English, M.D., told PT. English currently chairs the APA's Section Council. In fact, some delegates supported the measure while others opposed it, splitting the APA vote. English added that at some point "we will have a discussion of this in the APA and I'm sure there will be plenty of back and forth before we do, as an association, adopt a position."

A touchy debate could be spawned over whether the APA becomes a key player in organizing groups of psychiatrists. According to English, for instance, "Unionization means taking actions that are incompatible with the commitment of a profession-which is always to put the patients' interests first."

Even longtime managed care foe and APA past-president Harold Eist, M.D., doubted that unionization would ultimately resolve longstanding disputes with the health care industry. However, he agreed that it may "enhance physicians' ability to more effectively treat patients and get a more reasonable return for their work."

To a certain extent, the future of collective bargaining for physicians still hinges on H.R. 1304-the Quality Health-Care Coalition Act of 1999-federal legislation pending in the House that would permit nonemployee health care professionals to negotiate with health care plans. Enactment of the bill would amend antitrust laws to permit collective bargaining, an event that would mark a sea change in the balance of power between physicians and managed care organizations.

Currently, the bill is stalled in the House Judiciary Committee, even though it has the majority support of its members. The hang-up is powerful committee chair Henry J. Hyde (R-Ill.), who currently opposes the measure. Reardon said that the AMA's leadership has yet to learn the reasons Hyde objects but is working on addressing the situation.

"We will impress on him how important the issue is and explain to him that we are trying to enhance patient benefits [and] patient welfare, and give physicians back some control of the system so that patients can get the necessary and appropriate care when they need it," Reardon explained.

With about 150 co-sponsors, chances that H.R. 1304 will pass are good, said Suhail Khan, a spokesperson for Rep. Tom Campbell (R-Calif.) who introduced the measure. He told that there is also significant bipartisan support in the Senate, and that he is confident there is still time for the bill to pass this year.

Observing that the health insurance lobby was recently defeated in Texas when that state passed a measure that allowed collective bargaining, Khan added that antitrust reform could avoid the deadlock plaguing other health care reform proposals caught up in partisan debates. "Rep. Campbell is simply trying to level the playing field between health care providers and HMOs," said Khan.