Oregon Emergency Physicians Unionize
Also: Envision wins big but is still On the Rocks, EM at the VA, investing in value-based care, & decreased nursing school enrollment.
Top of the Week
Emergency physicians are facing a slew of systemic challenges, including burnout, boarding, insufficient staffing levels, decreasing reimbursement, practice consolidation, and projections of EP oversupply. One might be forgiven for asking, “Is now the time for emergency physicians to unionize?”
The emergency physicians, PAs, and nurse practitioners at Providence Medford Medical Center in southern Oregon think so. The ED’s seventeen hospital-employed emergency clinicians unanimously voted to unionize on April 26th. The group is called the Southern Oregon Providers Association (SOPA) and will partner with the Pacific Northwest Hospital Medicine Association (PNWHMA), an existing hospitalist union.
The Medford physicians cite substandard hospital patient care conditions and the lack of responsiveness from hospital administration as the main reasons for unionizing. Per David Levin, DO, “Providence management should be focusing on improving staffing and gaps in patient care, but when we repeatedly brought our concerns to their attention we have been met with silence. Unionizing helps balance the scales between us and management so we can make this a place that patients recommend first to their loved ones, and a magnet workplace for providers.”
Most emergency physicians have never been involved in a union. A Q&A primer:
Q: Why would physicians want to unionize?
A: Per the Union of American Physicians & Dentists, a California-based union, reasons for physicians to unionize:
Greater control over their earnings, benefits, and working conditions.
Improved schedules.
More respect from employers.
Job security: “Employers must show just cause for discipline or termination, and doctors have a right to bring disputes before a neutral third-party arbitrator.”
Q: Why would physicians not want to unionize?
A: Per the AMA, “Detractors of physician unions point out that collective bargaining usually results in an agreement that applies uniformly to all physicians who participate in the collective bargaining. In particular, the level of compensation may be stratified based on seniority or obtainment of certifications, and it may be difficult to write contractual language that differentiates and addresses a significant divergence among physicians in terms of experiences and skills. Proponents of physician unions respond by asserting that their contracts are analogous to those negotiated by the Major League Baseball Players Association, which of course rewards a player’s value to the team.”
Additionally, employed physicians may be putting their jobs at risk by attempting to unionize. While it is illegal to fire an employee for unionizing, employers can find another reason to let go of a physician who they do not believe is acting in their interests.
Q: What is the main reason more attending physicians are discussing unionizations now compared with prior decades?
A: The share of US physicians who are employed has rapidly increased.
Q: Which physicians cannot unionize?
A: The National Labor Relations Act specifically exempted “supervisors” from being part of an employee union, as they are deemed to represent the employer. The NLRA defines supervisors as “any individual having authority, in the interest of the employer, to hire, transfer, suspend, lay off, recall, promote, discharge, assign, reward, or discipline other employees, or responsibly to direct them, or to adjust their grievances, or effectively to recommend such action, if in connection with the foregoing the exercise of such authority is not of a merely routine or clerical nature, but requires the use of independent judgment.”
In emergency medicine, the term “supervisor” has been interpreted as applying to medical directors and assistant medical directors. Tenured and tenure-track academic physicians were also been deemed to be supervisors in a 1980 Supreme Court case. Independent practitioners and practice owners cannot unionize, as they are not considered employees.
Q: Can physicians join with PAs and nurse practitioners to unionize?
A: Yes. For a recent example, check out Piedmont Health Services v NLRB. (More in-depth article here.)
Q: Can physicians strike? If not, how do they gain leverage in negotiations?
A: Per the AMA Journal of Ethics, “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” As such, striking is often not an ethical option for physicians. However, other collective actions can be addressed during contract negotiations, such as physicians documenting patient charts in ways that reduce hospital billing while not affecting patients.
Q: How many attending physicians in the US are unionized?
A: Approximately 1.5% (100,000 physicians).
Q: What are the steps to forming a union through the National Labor Relations Board?
A: 1) Contact a union organizer or start your own union; 2) Have at least 30% of coworkers sign union authorization cards; 3) File a petition for a union election with the NLRB; 4) If the union wins 50% +1 votes, the employer must bargain in good faith over working conditions.
Q: What’s the bottom line?
A: A 2022 article in JAMA about physician unions concluded: “Over the last decade, there has been a substantial transformation in the organizational structure of physicians practice from independent medical groups to employment by large health care systems, transforming the control of medical care and altering the role of physicians within organizations. Conflicts between physicians and hospital leaders over governance, compensation, work rules, and strategy may lead to an increased likelihood of discussions of physician unions as a response. While unions offer benefits compared with individually negotiated employment agreements, they may be limited in their ability to address the higher governance concerns of the profession.”
EM Practice
Eileen Applebaum’s article about Envisions imminent bankruptcy, “Envision on the Rocks”, lit up the emergency medicine Twitterverse this week. “What will happen to the thousands of doctors, mainly ER docs and radiologists, employed by Envision? It’s unlikely that Envision will be liquidated and all of its doctors will lose their jobs. The more likely outcome is that some company will buy Envision out of bankruptcy after the bankruptcy court relieves it of most of its debts. Health insurance companies are likely bidders; insurance giant UnitedHealth Group has been actively buying up doctors’ practices. Job cuts and reductions in pay are possible, but there won’t be mass layoffs except in the unlikely case that a buyer can’t be found.”
Envision won an arbitration ruling against United Healthcare. Envision was awarded $91m to settle disputes related to underpayment by the insurance giant.
The US Acute Care Solutions Research Group published an article in Annals of EM analyzing admission rates across sites and among clinicians. We may see admission rate become part of an emergency medicine value-based care model. If so, risk adjusting by patient acuity will be key to the measure’s fairness.
By Drs. Neil Patel and Chad Kessler: “The hidden jewel of emergency medicine careers: Why it's time to explore the VA.”
House of Medicine
EMCrit’s model of physician burnout.
Pitchbook explores what investors need to know about value-based care.
Hospitology explores the business model of Privia, one the nation’s largest value-based care physician enablement platforms.
From the New Yorker: Open notes can lead to problems with physicians limiting what they include in the chart and patients seeing complex medical information without sufficient knowledge to understand its meaning.
As every emergency physician working in rural areas knows, this country has many “dental deserts”.
Hospitals & Health Systems
Florida’s hospitals have been expanding rapidly since the state changed its Certificate of Need laws in 2019.
CommonSpirit Health purchased five Utah hospitals from Steward. They will be managed by Centura Health.
Nursing & Allied Health
Per the American Association of Colleges of Nursing survey, enrollment in Bachelor of Science in Nursing (BSN) programs in the US decreased by 1.4% from 2021 to 2022.
New Jersey has 13,000 nursing job openings.
Average nurse practitioner wages by state.
AMN’s annual nurse survey.
The Dispo
Meme of the week:
