Physicians should consider ‘collective empowerment’ to tackle problems in U.S. health care: ACP

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Using unity and strength in numbers may be a way for physicians to counterbalance the burdens dragging down American health care, according to the American College of Physicians (ACP).

“Empowering Physicians Through Collective Action: A Position Paper From the American College of Physicians” outlines the current workplace and economic conditions contributing to doctors’ frustrations with health care. It also explores options for physicians to improve those through advocacy, organizing and collective bargaining.

“In recent years physicians have shifted away from independent practice and towards employment, while at the same time physician burnout has increased dramatically,” ACP President Jason M. Goldman, MD, FACP, said in a news release about the paper. “There is substantial labor organization activity in the health care sector, and interest in unionization is growing among physicians, particularly among physicians in training.”

Authors Ryan Crowley, BSJ, David Hilden, MD, MPH, and Jenny R. Silberger, MD, wrote the paper for ACP’s Health and Public Policy Committee, with input from ACP’s leadership and other committees. Sources include peer-reviewed studies, reports and surveys, along with government sources such as the National Labor Relations Board. They made eight policy recommendations and updated terminology about how doctors should approach employers and insurers.

Protests planned?

ACP is not calling for physicians to walk off their jobs in protest. The paper noted any steps involving refusals to work only after all other negotiating tactics have been exhausted and all parties involved can sure safe patient care.

But “physicians are increasingly frustrated with the nation’s health care system,” the paper said. In 2001, ACP-American Society of Internal Medicine proposed “joint negotiations” among doctors over “collective bargaining” that could imply an adversarial relationship between employers and unions.

“However, it is necessary to reassess this position to reflect the consolidated, corporatized health care environment, the current realities of physician employment, and the diminished clinical influence of physicians,” the paper said.

Since then, more doctors have become employed by hospitals, health systems or other corporate organizations. As they have lost independence, health care has become less and less affordable for patients, there are not enough physicians and other clinicians, and burnout levels are alarming.

The period 2023-2024 had 33 petition filings for bargaining units with doctors, compared with 44 for the time 2000-2022. There were 46,689 physicians in unions 2014, growing to 67,673 in 2019, or 7.2% of the physician workforce, according to figures from the American Medical Association.

With all those factors in play, it may be a new era with new actions for doctors.

“We use the term ‘collective empowerment’ throughout the paper to describe actions that physicians may take, including advocacy, engaging the organized medical staff, and collective bargaining, to achieve better patient care, physician well-being, and other goals,” the ACP paper said.

Policy recommendations

ACP made eight policy recommendations for physicians considering collective action.

• Safe, affordable, high-quality care for patients is primary and ACP supports collective empowerment actions to improve that, and to bolster the patient-physician relationship and physician well-being.
• Practicing physicians must be included among executives with voting privileges on hospital and health system governing boards.
• Doctors have the right to engage in protected, concerted activity, including organized protests, to amplify concerns about health and safety, working conditions, or other issues, without retaliation by an employer.
• Physicians should be permitted to join a labor union or not, and those organizing should prioritize bargaining units with other health care professionals dedicated to patient care.
• ACP supports legislative and other efforts to narrow the definition of “supervisor” for the purpose of collective bargaining.
• Stepwise actions, such as refusal to perform administrative or billing duties, should be considered only after all other negotiating tactics are exhausted and safe patient care is ensured.
• ACP supports innovative approaches to amplifying physician voices, such as labor-management partnerships.
• Independently practicing doctors should have the right to negotiate jointly with health insurance plans on issues including payment and administrative policies that affect access and quality of care for patients.

“Despite the trend toward hospital ownership, independent, small physician-owned practices should be supported and encouraged,” the ACP paper said. “Physician-owned practices have lower preventable admissions and may make less specialty referrals than practices owned by hospitals,” and there is evidence that clinician-owned practices have less burnout.

The ACP paper included a summary of recent history of collective bargaining efforts in American health care, including the 2023 strike by nonphysician workers of Kaiser Permanente. That was the largest health care strike in U.S. history.