Reprinted from the May 14, 1999 issue by permission of the Daily Herald, Arlington Heights, Illinois. All rights reserved.
The 52-year old woman looked five months pregnant.
Her abdomen, though, was not swollen with life, but the life-threatening fibroid tumors.
There was no question in Dr. Paul Rosenberg’s mind the growths had to come out, but before he operated earlier this month, the medical director of the woman’s insurance company urged him to delay the surgery. Maybe the tumors would shrink during menopause, he said.
"I said no way. She’s walking around with a bowling ball in her abdomen." Said Rosenberg, the founder of Female Healthcare Associates Ltd., which has offices in Naperville, Bloomindale and Elk Grove Village.
The company ultimately approved the surgery, but Rosenberg expects to wait several weeks for reimbursement.
The story is emblematic, Rosenberg says, of way over a 15-year career as an obstetrician and gynecologist he has changed from someone who knew or cared little bout unions or collective bargaining to one who favors that kind of blue-collar representation for his blue blood profession.
"We have to be allowed to get to the bargaining table to talk to the managed care providers and to negotiate contracts," said Rosenberg, a board member of the DuPage County Medical Society.
The rise of managed care with its emphasis on containing health care costs has led doctors across the nation to consider banding together in ways they once thought anathema to their once self-reliant profession.
Roughly 6 percent of the nation’s 756,000 physicians belong to unions, according American Medical News. Virtually all of them are salaried doctors who work for hospitals, health plans or clinics, because antitrust laws bar solo practitioners from organizing.
It’s still a small number, but one that will grow, those in the labor movement say, as more doctors go to work for someone else instead of themselves after their residencies.
About 36 percent of all doctors draw a salary no instead of run or belong to a practice, says the American Medically Association.
In the last five years, however, as much as 80 percent of new doctors have taken salaried positions, according to Dr. Barry Liebowitz, president of the National Doctors Alliance, which was formed by the Service Employees International Union this year to organize physicians.
Perceived and real hardships have encouraged independent physicians to take a closer look at unions. Once regarded as Marcus Welby-like bastions of strength and independence, some doctors now portray themselves as powerless sheep who need protection from managed care companies.
Managed care providers, doctors contend, drag out reimbursements and infringe on their freedom to decide how to treat patients by imposing gag rules, requiring referrals and denying coverage.
"This is really infringing on their professional authority," said Grace Budrys, a DePaul University sociology professor and author of the book "When Doctors Join Unions."
Most large health maintenance organizations, hospitals and managed care companies have not taken a formal stance on doctors and collective bargaining.
Chris Hamrick, spokesman for the Illinois Association of HMOs, contends while managed care does not cover every procedure and medicine, it does pay for what it covers a majority of the time.
He also said doctors–who earned a median annual income of $164,000 in 1997, according to the American Medical Association–may have more than independence and altruism on their minds.
"Sometimes the line between patient protection and physician income protection gets blurred," Hamrick said.
With varying levels of success, physicians have explored collective bargaining or tried to join unions in New Jersey, Delaware, Connecticut, Ohio, Florida, Arizona, Washington, Massachusetts, New York and even nearby Rockford, according to the journal Medical Economics.
The American Medical Association itself has been studying the possibility of forming a union and will debate the issue up again at its June House of Delegates meeting in Chicago.
Most recently, the Illinois State Medical Society house of delegates last month decided to form a collective bargaining unit that would negotiate on behalf of independent doctors but not strike.
"We really are serious about needing to be heard and about needing to be able to make the right choices for our patients," said Dr. Clair Callan, a Lake Forest anesthesiologist and president of the 15,000 member society.
It’s not clear now the society will go bout setting up its bargaining unit, or what it will look like.
It probably will require state or federal legislation though, because anti-trust laws bar independent physicians from unionizing or bargaining together to guard against price fixing. Currently only salaried doctors can organize, but employers sometimes succeed in convincing the National Labor Relations Board that those physicians are supervisors.
A federal bill sponsored by Republican Rep. Tom Campbell of California would allow doctors to bargain with insurance companies without fear of breaking antitrust laws. So far, however, other health care issues, like the proposed patients bill of rights and the uninsured have eclipsed it, said Bill Pierce, a spokesman for the Blue Cross Blue Shield Association. "This is not part of that debate," he said. No measure has appeared this lawmaking session in Springfield.
"Clearly the issue has a lot of hurdles in front of it," Pierce said.
Doctors who favor organizing have a long list of grievances. They resent having their decisions second guessed and overridden by non-medical bureaucrats, being bullied into signing contracts, and seeing their reimbursements slashed and dragged out.
Rosenberg says it takes one large insurer an average of 125 days to send him checks that are 10 to 20 percent lower than a decade ago. Callan adds managed care companies owe some physician groups in Illinois $500,000.
"These physicians are having to take out personal loans in order to cover their payrolls," she said.
All this is occurring as doctors face more liability. Rosenberg’s practice pays $60,000 in annual malpractice insurance premiums per doctor, he said. "Insurance companies want to tell physicians and hospitals how to practice medicine, but they don’t want any of the liability that goes with making decisions," said Lanny Wilson, a Hinsdale gynecologist and obstetrician.
Physicians are like sheep now, says Wilson, president-elect of the DuPage County Medical Society. Collective bargaining, however, could embolden them and invigorate the state medical society, which lost 25 percent of its membership last year, partly because doctors consider it powerless, he said.
"If we can rally around a cause like this it could energize us and it could bring a lot more people into the society," Wilson said.
The society and other medical groups have competition.
Traditional labor unions have smelled doctors angst and moved in to augment their own dwindling ranks. The SEIU’s National Doctors Alliance has vowed to spend $1 million per year organizing physicians and the International Brotherhood of Teamsters, the International Association of Machinists and Aerospace workers, and the United Food and Commercial Workers have targeted doctors.
Unions that already represent salaried doctors, such as the Union of American Physicians and Dentists, and the Federation of Physicians and Dentist, also argue they are better suited to handle physician labor relations than traditional groups like the AMA and the state medical societies, which now are limited to promulgating standards, education and lobbying.
"Doctors right now are desperate to look to anyone who has been successful in negotiating contracts," said Rosenberg, who favors letting the local societies do the talking. "They are desperate for anyone who can protect them."
Most people in the health industry agree doctors’ relationship with insurers and with patients will be much different in five years.
It’s unclear if unions or collective bargaining units will be part of the mix.
"Definitely something will happen. How it will happen is not clear," said Budrys.
Something needs to happen soon, Rosenberg said. He knows of physicians who have quit to become stock brokers, car salesmen, and Internet entrepreneurs.
"You are seeing practices close. Doctors are going out of business. Good doctors are retiring early," Rosenberg said. "I feel we are on a downward spiral. Either we stop it now or the private practice will be a thing of the past."