Healthcare Insights: Another Historic Organizing Win for Doctors - John August

On June 27, 2024 by a secret ballot, a union representation vote conducted by the National Labor Relations Board (NLRB), doctors voted by a margin of 288-130 to form a union affiliated with Doctors Council SEIU. The attending physicians are employed by the largest health system in Delaware at four facilities: Christiana Hospital in Newark, DE; Wilmington Hospital, in Wilmington, DE; Union Hospital of Cecil County in Elkton, MD; and the Middletown Free Standing Emergency Department, in Middletown, DE.

This is the third major organizing win for Doctors Council in the past year. In 2023, 800 physicians and advanced practice professionals at Allina Health in Minnesota at Mercy/Unity Hospitals and among Primary Care Clinics voted to be represented by Doctors Council. Negotiations for a first collective bargaining agreement are underway.

The union win at Christiana Care is significant on its own and is likely to create interest among doctors across the Philadelphia and Mid-Atlantic Region. The NLRB issued its Certification of Representative on July 8, 2024 which requires that the health system recognize the union and bargain in good faith.

The unionization by private sector attending physicians is a new phenomenon. Public sector doctors have belonged to unions for many decades, but in the private sector there has been little interest or effort to organize until very recently.

In previous articles in this column I have outlined the reasons for this rapid shift in perspective: In recent years, doctors’ employment status has shifted from private practice and independent contractors to that of employee. At the same time, the healthcare industry has consolidated as never before: There are fewer and fewer large health systems which dominate local or even national markets. For profit entities and private equity have rapidly increased their footprint in healthcare.

The result is that a gigantic labor market of the nation’s physicians (900,000) have lost voice and power while the decision-making which directly impacts their profession has fallen into the hands of larger and more powerful systems. I am not sure we have ever seen such a rapid shift in loss of voice on a comparable scale, and certainly not in a labor market of some of the most highly skilled professionals that every American counts on!

There is much to learn and observe.

While there have been a number of union victories in the last few years among private sector attending physicians, the scale of growth is relatively small: several thousand at most, and spread out from Delaware to Minnesota, to Michigan to Washington State and Oregon. However, we also know that there are many organizing campaigns underway around the country with major healthcare unions receiving regular inquiries about organizing.

Over the course of many decades stretching back to the 1930’s, healthcare workers have organized unions. They organized before and after it was legal to organize. Early organizing of healthcare unions was part of broad social movements and general strikes in San Francisco, Minneapolis/St. Paul, and Seattle. Activity continued in Los Angeles and Buffalo prior to the enactment of state laws making it legal for healthcare workers to organize since they were excluded from coverage by the National Labor Relations Act (NLRA). Rapid activity continued in the 1960s and 1970s as part of the Civil Rights Movement and the passage of state laws enabling the legal right to organize in many states.

By the time of the passage of the healthcare amendments to the NLRA in 1975, 27% of healthcare workers belonged to a union.

Today, only about 13.5% of healthcare workers belong to a union. The industry has grown and the unions have not kept up their growth with the growth of the industry.

This lack of growth is due to many factors, of course: sophisticated anti-union resistance by employers, the inherent weaknesses of US labor law which limits union recognition to an employer-by-employer process with no requirement that a collective bargaining agreement be reached. This inherent adversarial and slow process makes sustained and scalable progress very difficult. Additionally, many health systems have re-engineered care delivery with efforts to engage employees in LEAN, Six Sigma, and Toyota Production System modalities, or have tried to keep pace with union wages and benefits. At least 30 different unions represent healthcare workers which only adds to the complexity to organize the industry more broadly as unions compete for members.

In my view, Kaiser Permanente and its unions stand out as a very different model than the rest of the unionized industry: After 27 years of labor-management partnership which relies on an interest-based problem-solving approach to labor relations, with an emphasis on both performance improvement and sustaining the best place to work in the industry, the unions have grown in direct proportion to the health system and have enhanced wages, benefits, and working conditions throughout this near three-decade experience. With 140,000 unionized employees in that partnership operating in an $80 billion enterprise, there is much to appreciate and learn from.

As attending physicians have begun a new trajectory of unionization, it is critical to keep all this history in mind. Can attending physicians find new ways to organize on a large and rapid scale? Based on a wide literature of news articles, opinion pieces, and medical journal reports, a consensus has developed which identifies two related themes driving unionization efforts:

1. Loss of control over the essence of their profession: the patient-physician relationship
2. Moral injury: that profound psychological state at the root of burnout and demoralization. Please watch this brief video on the definition of moral injury

These are complex, deep-seeded dynamics at the heart of what it is to be a doctor. U.S. Labor Law tends to limit collective bargaining to narrow issues of wages, hours, working conditions, and conditions of employment. Traditional collective bargaining rarely solves the root-causes of conflict.

I suggest that without new and dynamic approaches to organizing and collective bargaining it is not likely that the organization of physicians will meet the expectations that are burgeoning across the nation among doctors.

I asked doctors from Christiana Care to answer two questions:

1. What motivated you to organize?
2. What do you hope to achieve through this effort?

Here are answers to these questions. Their perspective sheds light on the challenge and opportunity for collective bargaining to evolve to be able to solve the underlying motivations for doctors to organize:

NOTE: I have not attributed these quotes to the writers. It seems that in the early stages of collective bargaining, it is unnecessary to create potential conflict by identifying specifics.

“There has been a steady transition in physician practice structures over the past few years. According to a recent article in the New England Journal of Medicine, 52% of physicians were hospital-employed with another 22% of physicians being employed by some other corporate entity as of January 2022. Consequently, the physician-patient relationship is suffering as these institutions appear to place more emphasis on meeting metrics instead of delivering quality patient care.

Physicians are experiencing burnout and low morale due to a lack of involvement in the way we deliver healthcare. We have lost sight of what it means to care for our communities and instead are more focused on meeting corporate-mandated benchmarks.

It's no surprise that there is a new trend of physician unionization across the country. This is the only way we can push back against the rise of corporatization and private equity to truly deliver optimal healthcare to our community.”

Source:

Schulman, K., & Richman, B. (2024). Hospital consolidation and physician unionization. New England Journal of Medicine/The New England Journal of Medicine. https://doi.org/10.1056/nejmp2400463

“I was motivated to organize due to the shift in valuing profit in healthcare over the actual health of patients. This emphasis has led to me feeling more and more like a factory worker whose only value is in how many widgets one produces rather than valuing the vital care I provide to my patients. I fear that the continued push by my hospital, without any boundaries, will lead to decimation of physicians and my profession through exploitative means.

I am hoping that through a collective voice, boundaries can be set and this will protect the fundamentals of what physicians do, which is take care of people's lives.”

“The frustrations of working at a hospital that had once been committed to patients and physicians, but which lost its way in the widespread transition to corporate medicine. The inability to approach or speak with literally anyone in our service line who is actually a decision maker.

The daily frustrations we face in the struggle to continue to prioritize and provide safe and high-quality patient care in a system that withholds resources and now seems to care little about its employees or customers.

Lack of responsiveness to serious patient care issues: lack of techs, lack of nurses, aging equipment, anesthesia staff shortages (precipitated by the hospital's attempted takeover of the anesthesia group).

The energy, courage and selfless motivation of the core members of the organizing committee, who are really incredible people and physicians, and are in this this for all the right reasons.

I hope we can achieve better and more frequent and direct communication with administration on important issues regarding patient care and physician well-being, ultimately leading to tangible goals and action items.

More of the necessary resources including nursing, techs and equipment that will allow us to provide the best patient care in a stable and predictable fashion.

Creating an environment that will once again attract the most qualified and capable physicians.

A decrease in the number of middle level administrators who don't seem to have a clear role.”

“Last summer, out of left field, the CMO of the medical group had a town hall meeting and announced to everyone that they were going to re-write everyone’s employment contracts in order to make it more standard to the marketplace and incentivize people to be more productive.

They provided no details on how this would occur and gave no timeline. They announced some will do better, some will see no change and others will have a pay cut.

The irony of this is my employment contract for the first 5 years of my employment had bonuses based on productivity.

They were removed based on the current CEO’s vision of healthcare in the US. Approximately 10 years ago It was announced that the fee for service insurance payment systems were fading away so at CC we will take RVU incentives out of everyone’s contract and replace it with quality metrics. The medical group was to develop these metrics.

The CEO wanted to position CC to be the leader in how (in her view) the health care insurance system is going to change. Over time the medical group could never figure out quality metrics so they ended up just giving us our bonuses year after year.

Over the past year of “The Compensation Redesign” the medical director devised an incredibly complicated employment contract that provided CC the ability to change all aspects of my compensation at any time of their choosing. During the year there were no good faith negotiations and all of the terms were dictated by them.

We feel we have earned the respect from our employer and not be treated like an interchangeable cog. We feel terms should be negotiated and not dictated. We were looking forward to incentivizing us on productivity but wanted it to be fair. We felt none of this was happening.

In unionizing I hope to never be placed in a situation like this again. I hope that as CC succeeds so too will the doctors that provide the care. I hope that management understands they do not have free rein to void contracts and change terms of employment whenever they choose to.”

“I was motivated to organize because of the unilateral decisions being made by our hospital system without our input. They redesigned our entire compensation plan without even speaking to someone from our specialty. They eliminated our PTO as previously structured

When we requested a meeting to discuss the changes, they delayed and then cancelled the meetings and then threatened to fire us if we did not sign the new contract. We hope to achieve a fair process in negotiations that will result in mutually beneficial outcomes.”

“Organizing was the solution to the constant helplessness I felt towards the persistent unilateral changes occurring at work, sometimes as often as weekly.

There were talks about our compensation being “redesigned” for the past two years; however the hasty and haphazard manner in which it was rolled out signaled to me that administration’s priority was to roll out something unfinished, even at the risk of doctors leaving.

Within our group, when we asked details about how the new plan would work, we were met with “we’ll get back to you on that,” and no one ever did.

I don’t think a lot of my colleagues felt comfortable leading the organizing effort as Christiana Care is basically a monopoly in the area, and they have homes and families here, so I felt it was necessary to spearhead the effort and give others the courage to join along the way.

I am proud to say that we won with a resounding success, and it’s thanks to all of our teamwork. Unionizing, counter to what our employer has been saying, has actually brought nearly 500 doctors closer together than ever before in the history of this organization.”

“First and foremost, I want to improve patient care. Though there is no magic recipe to do that, it can start with proper staffing, pay, and workload for physicians and other employees in the hospital. I also hope to inspire others in the hospital, such as nurses and physician assistants, to stand up for their rights and not be afraid to organize their departments. And finally, I want to inspire others that think they can’t achieve something like this at their workplace to know that I felt the same way when we started too, and although it’s not easy, we got there one step at a time with a great team of colleagues and organizers.”

It is interesting that in this expressed mix over major concerns about the ability to practice medicine with independence and support that is lacking for such care, there are also central issues about compensation. We should keep in mind that compensation systems for doctors are very complex in today’s healthcare setting: contributing factors to this complexity include a shift toward value-based payments (VBP).

Most agree, as do I that this shift is an essential system change toward improved care, and reduced cost. However, without physician voice in how such a shift should take place, VBP systems will continue the trajectory they have been on: little scalable improvement in quality outcomes or reduced cost. Such dynamics add to the state of moral injury at the heart of physician experience.

We will be watching the bargaining for a first contract at Christiana Care carefully.

Doctors at Christiana Care have told me that they wish to avoid adversarialism and get at root causes of obstacles to their ability to practice medicine according to the highest standards. To accomplish this will require a very different approach to bargaining, one more suited to interest-based problem solving and shared purpose.

In my view, such an approach will be necessary to accelerate physician organizing. It is my fervent hope that physicians will use their tremendous power inherent in their fundamental purpose as scientists and healers to set new standards for collective bargaining. They have an opportunity to bargain far outside the constraints of the NLRA. In doing so, they also have an opportunity to organize outside those constraints as well.

Finally, building the conditions for deep engagement by doctors in the manner in which healthcare is delivered is central to the improvement of care and the future of the profession. It is not likely that health and healthcare quality will improve without the collective voice of doctors.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.