Doctors Vote to Unionize
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MARGARET WARNER: Joining me to debate yesterday’s decision are Dr. Thomas Reardon, incoming president of the American Medical Association and a general practice physician in Portland, Oregon; Dr. John Harvey, a retired internist and former professor of Medicine at Georgetown University Medical School; Chip Kahn, president of the Health Insurance Association of America, which represents the nation’s leading health insurance companies; and Ron Pollack, executive director of Families USA, a national organization for health care consumers. Welcome, gentlemen.
Dr. Reardon, why does the AMA believe that doctors now need to be able to unionize?
DR. THOMAS REARDON: Well, I think in the lead-in the answer was obvious. The physicians feel very frustrated, very disenfranchised, very helpless individually dealing with large managed care organizations and dealing with patient care issues. Now, what we need is a collective voice to begin to represent our patients. I think a good example would be our works on the Patient Bill of Rights that we’ve done in Congress. Individually, no one hears us — collectively, we get some response.
MARGARET WARNER: But give us the bottom line for the viewer out there. Does this mean — this doesn’t mean now that most of their doctors will be able to join unions. Is it going to have any practical effect on the ability of doctors to unionize right now?
DR. THOMAS REARDON: Well, I think also — let’s break this down into residents, self-employed physicians, employed physicians. This would impact the potentially employed physician but we need the Campbell bill passed to affect the self-employed physician, so that they could come with a collective voice and have an impact for their patients.
MARGARET WARNER: All right. And just one other question on the physicians already employed by a single employer, like an HMO, they’re already free to organize now, aren’t they?
DR. THOMAS REARDON: They are, except they oftentimes don’t have the ability, or they don’t have the guidance. What we would do is give them an option. We would create a collective bargaining unit, so if they ask us for help, we would give them the template, the guidance, the know-how of how to do it.
MARGARET WARNER: I see. Now, Dr. Harvey, you’re a member of the AMA, and you oppose this. Why?
DR. JOHN HARVEY: Well, I think it’s the very antithesis of what a physician has promised to do. We promise to take care of patients. A union and striking against patients, to me, would be the worst thing in the world a doctor could do. And what is collective bargaining, if it isn’t to worry about your salary? I am totally opposed to it. I think it’s a very, very sad day for American medicine. It’s absolutely antithesis of what a physician should be. His patient, her patient comes first. And we do all we can. We made a promise to the public when we graduated from medical school that we would take care of sick people who are fragmented, who are fearful, who are vulnerable, who don’t have the information we have. And what are we going to do? We’re going to talk about how much salary we get paid. That’s not for a doctor to be — not at all. I’m totally opposed to it, and I’m really upset at the AMA. I’ve always had a love/hate relationship, as many doctors have. It’s very good. It’s a good organization. It helps us a lot. It’s good in education and the activities and that kind, but I think when it gets into political organization of unionizing doctors, we’ve lost our mind.
MARGARET WARNER: I hate to say have you lost your mind, Dr. Reardon, so I’ll –
DR. JOHN HARVEY: Maybe I should say soul.
MARGARET WARNER: Have you lost your soul?
DR. THOMAS REARDON: Absolutely not. We will continue to be guided by our medical ethics, our professionalism. We will not withhold patients; we will not strike. We will put the patient first in every circumstance, and Dr. Harvey, we are attempting to put the patient first with this effort, to advocate for our patients so they get the necessary and appropriate care which they need and they deserve.
MARGARET WARNER: Let me ask you something, Dr. Reardon, because other members of the AMA have said you wouldn’t strike. Is there anything in the resolution that says that, or is that a promise from the leadership?
DR. THOMAS REARDON: No. There is — very clearly it says in the first resolve that we will follow our ethical principles and our professionalism. Our counsel in ethical judicial affairs has an opinion that it would be unethical to withhold care or strike with patients. So that is clearly — we would not do that.
MARGARET WARNER: Does that reassure you at all?
DR. JOHN HARVEY: Well, I’m not sure, because right here in Washington at George Washington Hospital the group from George Washington University went on strike one time, and weren’t allowed to cross picket lines, et cetera. You know, I think there are two points that I would like to make. There have been two transforming happenings in American medicine in the 20th century. The first was in the Depression when a group of schoolteachers got together and gave 50 cents apiece to a fund and organized what ultimately was Blue Cross/Blue Shield and then the health insurance. The other transforming — even Medicare/Medicaid was just the implementation of that. The other transforming was when the Clinton health administration bill failed and then the market forces took over and we got HMOs, PPOs and what not. At first, Blue Cross put one person in-between the doctor and the patient, and that was the payer. So no one paid any attention anymore to paying. Doctors used to be paid by chickens. One more thing and I’ll keep quiet. The second was when the market forces took over and they put a second person between the doctor and the patient, namely an insurance worker who said to the patient what the doctor’s ordered you can have but we won’t pay for it, so effectively controlled the practiced medicine. We’ve got to get rid of the HMOs, the PPOs and what not and get back to practicing medicine the right way.
MARGARET WARNER: All right. Ron Pollack, from the consumer’s point of view, is this going to be good for patient care or not good for patient care?
RON POLLACK: I think, Margaret, it’s a two-sided coin. Let me focus on one side. That is, I think there is an interest that consumers have with physicians to make sure good care is provided, and I think physicians, by and large, are driven to this process because they feel they don’t control decision making processes about clinical issues, and patients, of course, are terribly worried about that. These decisions are being made by others who never, ever get to see the patient. So I think that impulse to organize — I think that makes a great deal of sense, and from a consumer perspective, that’s good. The other side of the coin is let’s face it, there will be some negotiation about wages, and physicians are not exactly part of the downtrodden masses, and so that is going to increase costs for consumers. But I would say that, by and large, there is some sympathy about how the health care system has changed, and we want to make sure that decisions are kept in the hands of physicians and their patients.
MARGARET WARNER: From the insurance industry perspective, do you see this as a way for doctors to get more control over the health care decisions, or just a fee?
CHIP KAHN: Well, in terms of quality there’s nothing stopping doctors from joining together and going to health plans and insurers and making their points and getting them to change whatever they want, but in terms of payment, this will increase costs, premiums by as much as 11 percent, and over time it could increase cost to the health care system $85 billion a year. The fact is particularly if there are changes that they want, independent practicing doctors can join together and collectively bargain — they’re going to be a 600-pound gorilla, and they’re going to dictate to the consumer and the taxpayer, and it’s going to cost all of us more money. We’ve made a lot of progress in the last few years in keeping health care costs down. This will not help that.
MARGARET WARNER: Dr. Reardon, will it increase costs?
DR. THOMAS REARDON: I don’t think it will increase costs, and let me explain why. But first I’d like to respond to Dr. Harvey, and that is Dr. Harvey, we are going to create an option so those physicians at George Washington don’t have to join a union that will strike. We will have a no-strike clause, and we’ll put the patient first. In response to the cost, that’s a smokescreen and a facade that the insurance companies always throw up. They did it on the Patient Bill of Rights before Congress, and yet the Congressional Budget Office said it would be pennies per month to give patients’ rights and protections of this health care system. This will not drive costs up the way Chip Kahn says.
CHIP KAHN: Let me just say that the antitrust laws are there to protect the consumer, and there’s a reason why this kind of unprecedented move has never been allowed before for professionals who are independent business people to gather together to, in a sense, dominate the market.
MARGARET WARNER: How do you feel about this, if private physicians also — essentially most doctors in the country got this power?
RON POLLACK: Well, I agree in part and I disagree in part. Where I agree is the core concern, I think, for physicians is making sure that there’s high quality care provided and that they and the patient make these decisions. I think moving in that direction is not going to be costly. Now, if, on the other hand, the negotiations focus on salaries and compensation, then it could be costly. So I think on the patients’ rights side of that, that’s not where the significant costs are going to be. Potentially, there could be costs when we deal with salaries.
MARGARET WARNER: Do you think, Dr. Harvey, that it’s possible that — at least on the patient care side — it could be helpful for physicians to have an intermediary? I know you don’t like intermediaries.
DR. JOHN HARVEY: I don’t like intermediaries. That’s what I was explaining. When you put people between the doctor and the patient, things bad happen. I want to bring up another point. Is it moral to make money out of health care. I don’t believe it is. And 30 to 40 percent of the costs now are the overhead of the HMOs, the insurers, the owners of the insurance companies, the stockholders in the various corporations. Let’s get rid of that and get the doctor and the patient back together again.
CHIP KAHN: First, let met just say it isn’t 35 percent. And, second, there are costs, most of the costs there are just the costs of administering insurance. We have a private health insurance system in this country for most Americans. And most Americans, despite whatever concerns they have with managed care, like their insurance. Survey after survey shows that.
DR. JOHN HARVEY: Forty million people are uninsured. That’s not most Americans.
RON POLLACK: I must say I’m a little amused by this because this is a dispute on the one hand of those who have six-figure incomes and those who have seven-figure incomes.
MARGARET WARNER: The doctors are the six figures.
RON POLLACK: The doctors have the six figures and the insurance executives have seven-figure incomes. But I think if the core of the focus turns to be on what a patient needs and making sure there’s quality of care, and things like doctors not being penalized for taking more time with a patient, not being penalized when they advocate on behalf of a patient, either in a hearing or some other process, or they are not told you’re seeing too many sick patients and it’s driving costs up, then I think everyone is going to be winners. If on the other hand, the focus is going to be all on compensation, we’re all going to be losers.
CHIP KAHN: These issues could be dealt with already so it has got to be compensation.
MARGARET WARNER: Then why aren’t they dealt with now?
CHIP KAHN: I argue they are dealt with now.
MARGARET WARNER: All right.
DR. THOMAS REARDON: Let me respond to that Margaret, if I may, because an individual physician calls an insurance company to advocate for their patient. They say thank you, Doctor and they hang up. But when an organization or a collective voice of physicians calls that insurance company or that managed care organization, they respond, just as they responded in Congress to the Patient Bill of Rights issue. We are having that battle on who should make medical necessity determinations. The insurance companies would like to have that final rule. I as an individual physician can have no impact on that insurance company. But collectively if a group of physicians come forward and say we think that the medical necessity determination should be made by physicians and there should be an appeals process to protect the patient; that’s what we’re after.
MARGARET WARNER: All right. And what about Dr. Harvey’s idea, what we really need is to get rid of all the intermediaries, including the HMOs?
DR. THOMAS REARDON: I think we all agree with that but I’m not sure we’re going to turn the clock back.
DR. JOHN HARVEY: Well, what we need is a national health program. We’re the only first world country that doesn’t have one and we need to have one.
MARGARET WARNER: All right. We’re just about out of time.
CHIP KAHN: Let me add that the Federal Trade Commission and the Justice Department says that doctors can join together collectively to work with insurance companies and health plans regarding quality. That’s not the issue. The issue here is compensation.
DR. THOMAS REARDON: The issue — you won’t listen to us if we don’t do it collectively.
MARGARET WARNER: All right. Gentlemen, we have to leave it there. But, thank you all four very much.
DR. THOMAS REARDON: Thank you.
RON POLLACK: Thank you.