- January 29, 2013, 7:04 p.m. ET
The Doctor’s Office as Union Shop
As new health-care laws turn physicians into service workers, why wouldn’t they organize?
As the country moves toward the effective start date of the Affordable Care Act in 2014, the operational and economic elements of this vast legislation are becoming clearer. Yet one likely outcome of the act that will directly affect the quality of patient care, and could affect its cost, has gone virtually unnoticed and unreported: the increasing trend for physicians to become employees, rather than self-employed. This development represents a potentially radical factor in the transformation of health care—the doctor as union worker.
Physicians have historically practiced either in small groups or alone. Unlike hospitals, which operate under the rubric of large regulatory agencies, physicians have been much more difficult to regulate and monitor. 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. This can’t be accomplished by overseeing thousands of doctors in thousands of offices and medical complexes, each conducting its own symphony.
The Obama administration, by intent or accident, has effectively driven a major change in the status of physicians. By reducing the reimbursement for certain office-based specialists while enhancing related payment to hospitals, the administration is compelling more and more physicians—many of them with an any-port-in-a-storm fatalism—to seek employment with health systems or large physician groups.
Another factor lubricating the path to physician employment is generational: Doctors now in training appear willing to forsake income for a better quality of life and are less interested in the entrepreneurship required to run a private practice. They prefer regular hours and don’t necessarily want to be responsible for patients after hours. The net effect is that in 2012 approximately half of physicians already were employed by large health-care entities. Some industry observers estimate that, over the next few years, health systems will employ close to 80% of all doctors.
The shift will be 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. The number of failed cost-control experiments in this country—remember the HMO experiment?—is dizzying. None has worked.
The change in the nature of physician employment will have effects never before experienced in America. As the effects of the Affordable Care Act come into focus, it becomes clear that when the majority of physicians are no longer self-employed—and barring any legislation to the contrary—their new employed status will provide doctors with the right to collective bargaining.
Leaders of the organized-labor movement already view service workers with nonexportable jobs as the last best hope of labor unions whose membership is at an all-time low. The truth is that physicians are now becoming service workers. They are well-educated and expensive to train, and their decisions have substantial significance in the lives of others. But doctors essentially provide a service, one that cannot be outsourced to India or China.
If doctors unionize, that raises an immediate question about their right to strike—the key lever in collective bargaining. That’s a question for another day. For now, it’s enough to contemplate what will occur when the practice of medicine becomes detached from its past as a profession—when doctors may in time come to see themselves not solely as healers but as workers, units of labor, in a system that is committed to delivering care to the greatest number.
When doctors occupy a service niche like the chambermaid in Las Vegas or the school teacher in Chicago, the expectations and compensation of the physician-worker will be defined in ways that may make the benefits of collective bargaining appear very attractive.
Americans don’t expect the quality of their care or access to it to decline as health-care costs drop. But quality of care and access will require significant attention in a reformed medical system. As has happened in other countries that have charted the course we are now on, a new reason for lack of access may at times be: “Office closed, doctors on strike.”
Dr. Leffell, a practicing physician, is the former CEO of the Yale Medical Group and a professor at the Yale School of Medicine.
A version of this article appeared January 30, 2013, on page A11 in the U.S. edition of The Wall Street Journal, with the headline: The Doctor’s Office as Union Shop.
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