Physicians and Unions: Implications for Registered Nurses

Executive Summary | Discussion
Conclusion | References | Endnotes | Past Issues

EXECUTIVE SUMMARY

The American Nurses Association (ANA), along with its constituent state nurses associations, has a decades-long commitment to the right of registered nurses—the largest group of health professionals—to seek representation through organizing and bargaining collectively. It has long recognized the role that such activity can play in addressing not only wages and benefits, but the many conditions of employment that have a direct bearing on nurses' ability to practice their profession and to provide the highest quality care for their patients. Indications that many physicians are reaching similar conclusions is potentially of great interest to nursing. 

Does stepped up union activity among physicians simply mean that more physicians have come to the same conclusion as registered nurses in recognizing the role of collective bargaining in professional practice? Why should registered nurses care what physicians choose to do in this area? What relevance does the physician union movement have for registered nurses? 

There are several possible answers to these questions. Among them are the following: 

• Efforts to organize any other group of health care workers or professionals—regardless of whether they are successful—have an important impact on the climate for collective bargaining for all health care employees, including registered nurses. 

• Registered nurses have long had to contend with the argument that organizing and collective bargaining are "unprofessional" and conflict with nurses' efforts to be treated with full professional status. Organizing efforts by physicians help in many respects to undercut the argument that "true" professionals do not engage in union activities. 

• Many of the issues faced by physicians in seeking to organize are of interest and relevance to registered nurses. Among the most significant is the argument that physicians are "supervisors" and are thus ineligible for collective bargaining under federal labor law. This issue was raised in 1994 in the case of  NLRB v. Health Care & Retirement Corp. [114 Sup. Ct. 1778 (1994)], in which the Supreme Court addressed the issue of supervisory status for nurses. This precedent has been used in arguments against National Labor Relations Board (NLRB) determinations that nurses (or some subcategories, such as charge nurses) are "supervisors" and thus are outside the protection of labor law. 

• Physician organizing has raised questions about antitrust exemptions that apply to collective bargaining by employee organizations, and has helped, at least in part, to provide new impetus for longstanding attempts by organized medicine to exempt health care professionals from antitrust laws. The American Medical Association (AMA) in particular has sought for some years to allow nonemployee physicians to bargain jointly with managed care organizations (MCOs) and other payers without running afoul of these laws. ANA, along with many others, has opposed these efforts. 

• Successful organizing by physicians may on the one hand provide new forums for interprofessional collaboration, particularly in practice settings in which both nurses and physicians are unionized. On the other hand, it may provide a mechanism for physicians to seek to assert control over nursing practice. 

DISCUSSION

Managed Care as Catalyst for Organizing 
According to physician groups, the primary cause of discontent that has led to increased interest in unionization and collective bargaining among physicians is the growth of managed care and its effect on physician practice. Among the most often cited complaints that physicians report in their dealings with MCOs are loss of autonomy and infringement on physician–patient relationships, substantial reduction of fees and income, and frustrations with their professional associations' apparent inability to reverse these trends. As a result, more and more physicians are looking to unions as a vehicle to regain lost economic leverage and income and to restore their former preeminent positions in medical decision making. 

Another catalyst for organizing—also related to managed care and other broad changes in the health care system—is the shift in employment status among physicians. The traditional model for physician practice in the United States has been one of physicians as independent practitioners, operating out of individual and group practices and functioning as independent contractors in their relationships with hospitals, health systems, and insurers. In the past few years, however, increasing numbers of physicians have become employees of hospitals, health systems, and often MCOs themselves. As employees, these physicians are legally eligible to bargain collectively with their employers on wages, benefits, and other conditions of employment. At the same time, these physicians' loss of independence, along with the less fragmented, more integrated nature of their practice as employees, may also give rise to more interest in collective bargaining. 

According to data from the AMA, approximately 43 percent of the active supply of physicians is employed by group practices, medical schools and universities, hospitals, health maintenance organizations (HMOs), state and local governments, and other entities (AMA 1996, 1). This figure  represents a substantial increase from 1983, when only 24 percent of physicians were employees (Kletke et al. 1996). 

Growing dissatisfaction by many physicians with managed care, along with a change in the employment status of many physicians, has encouraged physician unions and more traditional labor organizations to step up their organizing activity. The following examples are illustrative: 

• The 150 physician employees at the Thomas–Davis Medical Centers in Tucson, Arizona, organized with the Federation of Physicians and Dentists (FPD) in February 1997. When the employer refused to bargain with the union, the NLRB sought a court injunction requiring the company to begin negotiation (Modern Healthcare 1997). 

• A group of some 260 primary care physicians employed by Medalia HealthCare of Seattle, Washington, voted recently for representation by the United Salaried Physicians and Dentists (USPD). They became the first private sector physicians in the Pacific Northwest to seek union representation in an election widely regarded as a physician backlash against managed care programs. 

• The Union of American Physicians and Dentists (UAPD), based in Oakland, California, has active organizing campaigns among physicians affiliated with a large HMO in Northern California and among physicians employed by Los Angeles County. (UAPD Makes First Move to Organize Doctors in Kaiser-Permanente of Northern California 1998; UAPD Petitions to Represent Los Angeles MDs 1998). 

Physician unions have also taken nontraditional approaches to organizing, not always limiting themselves to typical employment relationships. In October 1997, the United Food and Commercial Workers Union (UFCW) Local 56 filed a petition with the NLRB to represent several hundred New Jersey independent practice physicians who have provider contracts with AmeriHealth HMO. The union argued that the physicians were de facto employees because of the HMO's control over their incomes, patient care activities, and working conditions. The local regional director of the NLRB rejected this argument, finding the physicians (who simultaneously contract with an average of 4.66 MCOs in addition to AmeriHealth and also see Medicare patients and private-pay patients) to be independent contractors. The UFCW is appealing the NLRB decision (Modern Healthcare 1998; Labor Board Rebuffs Attempt by New Jersey Physicians to Unionize 1998). 

In Florida, the Federation of Physicians and Dentists (FPD) and the Office and Professional Employees International Union (OPEIU) had been actively working with the 17,000-member Florida Medical Association (FMA) to form a statewide physicians' union. The FMA House of Delegates chose to establish an advocacy center rather than form a physicians' guild as an FMA committee had recommended (Florida Medical Association Delegates Vote for Advocacy Center in Lieu of Unionization 1998, A-4). The California Medical Association, on the other hand, voted to explore establishing a guild to provide collective bargaining representation for house staff and for some state-employed physicians (CMA May Form a Physicians' Guild 1998, 2; California Doctors' Group Votes to Consider Union 1998). 

Background on Physician Unions 
Although the recent upswing in physician organizing is significant, physician unions are not a recent phenomenon. Unions have been actively organizing physicians—particularly interns and residents and publicly employed physicians—for decades. The largest union representing physicians is the Committee of Interns and Residents (CIR), founded in 1957 and based in New York City. CIR claims to represent 9,000 house staff—interns, residents, and fellows—employed by 50 hospitals throughout the country. The California Association of Interns and Residents (CAIR), which also represents house staff, is based in Oakland, California, and claims between 1,000 and 2,000 members (NLRB 1997, California Doctors' Group Votes to Consider Union 1998).1 

The two most established unions representing attending physicians are the UAPD and FPD. The UAPD was founded in 1972 in the San Francisco area. It claims a membership of 5,000 and represents practicing physicians, both employed (e.g., by hospitals, especially public hospitals) and self-employed (e.g., independent practitioners or members or owners of group practices). The UAPD engages in collective bargaining for its employed physician members (AMA 1997, Budrys 1997). 

The FPD, founded in 1988 and based in Tallahassee, Florida, is the largest union of private practice physicians in the United States. The FPD claims to represent some 7,500 members in 11 states and the District of Columbia. The FPD is currently in negotiations for a first contract with the Thomas–Davis Medical Centers in Tucson, Arizona. Besides collective bargaining, the FPD also provides services for its members in discussions with MCOs. These services include advising individual physicians about the terms of their managed care contracts and sharing information about the range of fees and terms offered by managed care companies in a specific market (Talks Between Medical Group, Doctors Under Way as Legal Challenges Proceed 1997, 1,199–1,200; Doctors Look to Union for Relief  1998; Valdez-Dalpena 1995). In addition, the FPD and other unions have worked with physicians to form "messenger model" independent practice associations through which physicians seek to negotiate with MCOs. 

The OPEIU claims to represent some 15,000 physicians, podiatrists, dentists, optometrists, and mental health providers through its National Guild for Medical Providers. The guild does not engage in collective bargaining for its physician members, emphasizing instead its national lobbying capabilities and influence with some union-sponsored health plans (Jaklevic 1997). In 1996, OPEIU and the American Podiatric Medical Association announced joint efforts to establish a union for podiatrists (AMA 1997). 

The USPD represents approximately 700 physicians and dentists, primarily in the New York City area. As noted earlier, the 260 physicians employed by Medalia Healthcare in Washington State recently voted for representation by the USPD, becoming the first private sector physicians in the Pacific Northwest to win union representation (Maharry 1998). 

The Doctors Council of New York, formed in 1974, represents several thousand attending physicians, most of whom are employed by various New York City agencies, hospitals, and clinics. It has recently been in discussions with several national unions regarding possible affiliation. In 1997, Massachusetts physicians employed at six health centers operated by a major insurer voted in favor of representation by the Medical West Physicians Association. (Pham 1997). 

Estimates of the number of physicians who are members of unions vary considerably. The AMA states that between 14,000 and 20,000 physicians are union members, and of that number between 6,000 and 9,000 are house staff (AMA 1997, 2). Other estimates, including those from union sources, put the number between 30,000 and 40,000 (Jaklevic 1997, Galant 1998). Thus, with a total active supply of U.S. physicians estimated to be 627,723, the percentage of union members ranges from 2.2 percent to 3.2 percent (AMA data) to 4.8 percent to 6.4 percent (union and other data sources). At present, physician unions appear to be a largely coastal phenomenon, with union activity primarily clustered in New York, Florida, and California. 

Issues 

Physician Unions and the Law 

* National Labor Relations Act 
The legislative framework regulating labor–management relations in the private sector is provided by the National Labor Relations Act (NLRA). Enacted in 1935, it provides legal protection for employees to organize and bargain collectively with their employers and gives them the right to engage in other concerted activities. Over the years the NLRA has been amended in various ways to place obligations on employees as well as employers. 

The NLRA specifically addresses the rights of private sector employees. Decisions of the NLRB and the federal courts interpreting the NLRA have helped to determine who is an "employee" within the meaning of the law. Because nonemployees are outside the protection of the NLRA, this is a critical determination. For physicians who seek to organize and bargain collectively, the threshold issue of employee status has been particularly important, as physician unions have had to argue—sometimes successfully, often not—that their members are indeed employees (as opposed to independent contractors, supervisors, or students). 

* State Labor Laws 
Because the NLRA addresses only private sector employees, individuals employed in the public sector (i.e., by state and local governments, including hospitals and health systems operated by those governments), are not covered by the NLRA. Physicians employed by state and local government-operated health care providers (state hospitals, county hospitals and public health systems, city or county clinics, district hospitals, etc.) are covered, if at all, by state laws that address the organizing, bargaining, and representation rights of state, county, municipal, and other public employees. 

* Federal Labor Relations Act 
The Federal Labor Relations Act (FLRA) spells out the rights of federal employees to join unions and to address employment-related issues. Physicians in federally operated health systems, such as Veterans Health Administration facilities, are covered by the FLRA. 

* Qualification for Legal Protection 
Do physicians qualify for legal protection under existing labor law to form unions and bargain collectively? The answer is a qualified "yes"—provided the physicians are considered employees under the NLRA (or other relevant laws). Three main arguments have emerged in challenges to physicians' rights to union representation: 

• The physicians involved are independent contractors, not employees; 
• The physicians involved are students, not employees (a principal issue pertaining to union activity among house staff); 
• The physicians involved are supervisors, not employees. 

* Independent Contractors 
Independent physicians (i.e., those who do not work for a wage or a salary from an employing hospital, clinic, practice, health system, or HMO) have traditionally been viewed as independent contractors rather than employees. The general issue of distinguishing independent contractors from employees has occupied much of the attention of the NLRB and the federal courts. The tests involved in making this distinction have focused on such factors as the amount of control the alleged employer exercises over the individual's work, whether payment is for services rendered or for a specific time period, whether the work involved is usually done by employees or self-employed individuals, and whether the alleged employer provides the place of work and the instruments or equipment needed for the work (AMA 1997, 7–8). 

Whereas some unions have thus far restricted their organizing activities to physicians in traditional employment relationships—whose growing numbers provide a large pool of potential members—others have focused on private practice physicians who contract with MCOs. The most prominent example, previously discussed in this article, is that of the UFCW's attempts to organize physicians who contract with AmeriHealth HMO in New Jersey. The outcome of the UFCW's appeal to the NLRB of the regional director's finding that the physicians are independent contractors will, of course, have important implications for organizing efforts among physicians. 

In some instances, physicians officially hold the status of independent contractors rather than employees because of the continued existence in many states of laws defining the "corporate practice of medicine." The "corporate practice of medicine doctrine" refers to state laws, originating in the early 1930s, that "ban[ ] unlicensed individuals and companies from engaging in the practice of medicine, and thus controlling patient care, by employing licensed professionals such as doctors or dentists. Its intent was to assure that only persons with medical licenses could actually deliver medical care and that lay persons would not influence professional decisions regarding treatment" (NHLA/AAHA 1997, 5). 

Most states currently do not have such statutes; those that have them may interpret their specific applications differently. The existence of these statutes has prevented (and often continues to prevent) hospitals and other nonphysician employers in some states from directly employing physicians (NHLA/AAHA 1997). In those states, physicians who appear to function as employees of hospitals, health systems, and HMOs may be considered "independent contractors" largely to avoid violation of the state's ban on the corporate practice of medicine. 

* Student Status 
The NLRB has long held that house staff are students, not employees, and are thus ineligible for collective bargaining. This position stands in contrast to findings of state labor boards and courts in applying state laws governing public employees. In many states, house staff in public hospitals, including medical centers operated by state universities, have been successfully organized and represented. Similarly, the Federal Labor Relations Authority (which administers the FLRA) has found house staff in federal systems to be employees rather than students. 

The latest challenge to the NLRB policy has taken place at Boston Medical Center, which was formed in 1996 as a result of a merger between Boston City Hospital—where house staff had been represented for collective bargaining by the CIR—and Boston University Hospital, a private sector facility. The resulting merged facility has refused to recognize the CIR; the NLRB's rejection of CIR's challenge is currently being appealed. ANA and the American Federation of Labor–Congress of Industrial Organizations (AFL–CIO) jointly filed an amicus curiae brief in support of CIR's contention that their members are employees and thus are covered by the NLRA. A successful challenge by the union in this case would vastly expand the numbers of house staff who could potentially be organized (SEIU Hopes to Organize Thousands if NLRB Decides Doctors in Training Are Employees. 1997). 

* Supervisory Status 
Supervisors as defined by the NLRA are not considered "employees" and thus are excluded from coverage by federal labor law. ANA has worked with many state nurses associations to assert that registered nurses who direct the work of others as part of their professional responsibilities fall within the protections of the NLRA. The issue was brought to the fore most clearly following the Supreme Court's 1994 decision in NLRB v. Health Care & Retirement Corp. [114 Sup. Ct. 1778 (1994)] rejecting the previous long-standing rationale used by the NLRB to find that nurses are not "supervisors." Although the Court did not hold that registered nurses—or categories of registered nurses, such as those who function as charge nurses as part of their work assignment—must be considered supervisors, its decision has led to a number of challenges by employers to organizing and bargaining activity by nurses. The issue continues to be addressed by the NLRB and by federal courts. 

The issue of supervisory status is a critical one for physicians as well as for nurses. Like nurses, physicians may also direct the work of other employees incident to their overall patient care responsibilities. Thus, organizing efforts by physician unions have also had to contend with the argument that their members are supervisors, and not physicians. For instance, Thomas–Davis Medical Center sought to challenge their physician-employees' bid to be represented by the FPD on this basis. Nurses and physicians clearly share a common interest in the resolution of the issue of when health care professional employees may be considered "supervisors." 

Antitrust Laws 
Antitrust laws are intended to protect the consumer by promoting competition in the marketplace. These laws generally prohibit "combinations" and "conspiracies" that restrain trade or stifle competition—activities that harm the consumer by allowing for artificially increased prices and reduced quality. 

When originally enacted in 1890, antitrust laws were intended to prevent big businesses from combining to unfairly restrain trade and competition. In the early part of this century, courts interpreted the law to outlaw collective action among workers as well. However, beginning in 1914 Congress intervened to specifically exempt labor organizations from the antitrust laws and since then has spelled out in additional statutes the meaning of the term "labor organization" and the kinds of activities the law defines as "protected" or exempt from antitrust prosecution. Collective bargaining activities conducted by labor organizations are exempted from the antitrust laws both as a result of Section 20 of the Clayton Act (one of three principal federal antitrust laws) and the Norris–LaGuardia Act. The Clayton Act provision immunizes "dispute[s] concerning terms or conditions of employment." However, this protection does not automatically extend to any and all activities conducted by labor organizations (Klien 1997). Among other things, a "dispute concerning the terms or conditions of employment" generally has to involve employees—as opposed to individuals who are not considered employees for purposes of the NLRA, such as independent contractors. Activities on behalf of independent contractor members of a union may not be immunized from the antitrust laws. Organizing independent contractors or having them as members does not in and of itself violate antitrust laws, and even some activities—such as fixing fees—may still be immune if the fees charged by independent contractors have a direct bearing on the wages (or other conditions of employment) of union members who are employees (Klien 1997, 3). However, a union may be subject to antitrust laws for activities on behalf of independent contractor members that do not affect the wages of employee union members (Klien 1997). 

Some guidance for providers in determining what kinds of joint activities may be allowed under the antitrust laws has been provided by joint statements on antitrust enforcement issues by the Department of Justice and the Federal Trade Commission (DOJ and FTC 1996). The statements were originally issued in 1993 and were revised in 1994 and 1996. The 1996 version provides some guidance on the use of the "messenger model" for communication between providers and payers. As one commentator explains, "The object of the messenger model is to allow a simple [physician] network to operate without the existence of a new agreement among the participating physicians. . . The messenger model allows the physicians to appoint a ‘messenger' who facilitates the development of a fee schedule between payers and each physician in the network" (Hirshfeld 1997, 28). Notably, one physician union's activities in using the "messenger model" of assisting physicians in their negotiations with insurers have been the subject of investigation by the Antitrust Division of the Department of Justice (Klein 1998). Recently, the Department of Justice filed a complaint against a Delaware local of the FPD, claiming that its activities constitute illegal price fixing (Hallam 1998). 

AMA Policy 
The growing interest in unions among physicians has posed some special challenges for the AMA. Its constituents are vitally concerned with how changes in the health care system—including the growing influence of managed care, as well as a shift toward employee status for physicians—have affected their practices and incomes. AMA has long supported the right of physicians to bargain jointly with MCOs and other payers. Its focus, however, has primarily been on pushing for changes in federal antitrust laws to allow such activities to occur outside the context of collective bargaining through a labor organization. Changes in the antitrust laws would affect a broader range of AMA's members than would successful union organizing (i.e., such changes would not be limited to employed physicians). Organizing among employed physicians is also a continual reminder of the rapid trend toward physicians functioning as employees—something with which the AMA has traditionally been uncomfortable and which, through its historic support for laws banning the "corporate practice of medicine," the AMA and its state medical societies have often opposed outright. 

When physicians choose representation by unions, particularly by larger, national labor organizations, they are implicitly—and in some cases explicitly—saying that their professional associations have not adequately represented them or asserted their rights in the workplace. The AMA and state medical societies have, in many cases, displayed some degree of antipathy toward traditional national unions. The AMA has particularly sought to distance itself from the potential use of strikes by physicians, and thus to attack physicians' affiliation with traditional unions—which generally do not pledge to give up the strike as a potential weapon—as "unprofessional." 

While continuing to support in principle the right of physicians to organize, the AMA has sought to provide alternative means of representation. It argues that state medical societies and the AMA itself, through its newly created Division of Representation (now called the Division of Physician and Patient Advocacy) are better suited and more competent to guide physicians in these efforts than are traditional labor unions (AMA 1997, 3). 

The AMA has also provided support for the Rockford Physicians Council (RPC), a group of physicians employed by the Rockford (Illinois) Health Systems, which sought representation through organizing and filing with the NLRB for an election. The RPC is a local, independent organization without ties to any national unions. The RPC also pledged not to strike or to undertake "other job actions that might interfere with patient care to resolve disputes with employers" (Larkin 1997). Based on that pledge and a request from the Winnebago County Medical Society, AMA's Division of Representation agreed to subsidize the services of two labor attorneys to provide legal representation to the RPC; the AMA also indicated that it would consider "supporting other organizing efforts that comply with AMA policy on protecting access to services" when those requests come through state or local medical societies (Larkin 1997). 

In May of this year, the RPC dropped its petition for an NLRB election after the physicians' employer agreed to a number of changes providing for greater autonomy and participation in management decisions (Rockford Doctors Drop NLRB Plea 1998). The AMA pointed to this "bargaining success" as evidence of "the superiority of organized medicine's approach to collective negotiations by physicians" (AMA 1998a). 

A major focus of the AMA's efforts on physician bargaining remains on support for creating new exemptions to the antitrust laws to allow physicians to negotiate jointly with insurers and payers without fear of violating federal law. In fact, the AMA has suggested that such antitrust exemptions could provide an alternative to physician organizing. In his testimony on H.R. 4277, The Quality Health-Care Coalition Act, introduced by Rep. Tom Campbell (R-CA), AMA Trustee Donald J. Palmisano, MD, JD, stated, "Most physicians don't want to be part of a trade union, but they do want to be able to engage in joint negotiations with big health plans"—which efforts to modify the antitrust laws, such as the Campbell bill, would seek to provide (AMA 1998b). 

Analysis 

Efforts to organize physicians into unions pose a number of significant issues, many of them of direct interest to nurses. 

For some physicians, interest in union organizing may represent a recognition of their changed status in the health care system and a realization that collective bargaining represents a legitimate, tested means for health care professionals to obtain power and leverage in dealing with their employers. 

Physicians who have traditionally been the subject of union organizing efforts—including not only house staff and publicly employed physicians, but also physicians employed by private hospitals, health systems, and staff-model HMOs—are those already accustomed to working in organized settings, practicing in settings that impose some limits on their autonomy, and dealing with a single employing entity that controls their wages, benefits, and working conditions. The kinds of settings in which these physicians practice may also require them to work most directly, perhaps even collegially, with other professional employees, such as registered nurses. 

For nursing, with a commitment to collective bargaining that spans more than five decades, supporting the right of physicians to organize is arguably not only an act of collegiality, but of self-interest. Physicians encounter many of the same issues in organizing and bargaining as do RNs—for example, confronting the argument that both professional groups, or significant sectors thereof, are "supervisors" and thus outside the protections of labor laws. ANA has publicly supported the collective bargaining rights of house staff in particular for more than 20 years, contending that these physicians are employees, subject to the coverage of federal and state labor laws, rather than students outside the reach of those laws (AFL–CIO and ANA 1997). 

Organizing among employed physicians has, of course, taken on greater significance as increasing numbers and percentages of physicians have moved from independent contractor to physician status. This change in status makes these physicians more clearly eligible for collective bargaining. Arguably, in changing their relationship to hospitals, health systems, HMOs, and other providers, it has also helped—and will continue to help—a greater awareness of their roles as part of a broader group with common interests and concerns not only as professionals, but as employees of a common employer. In other words, the difference between physician as independent entrepreneur and physician as employee may be more than just a legal technicality. 

This is not to suggest that self-employed physicians do not face legitimate issues, or that union activity among these physicians is any less significant a development than organizing among employed physicians. It is a phenomenon that bears careful watching. The challenge posed by some physician unions to traditional distinctions between independent contractors and employees may have significant implications for all professionals who work in an increasingly integrated health care system. Of course, a determination that physicians who contract with multiple MCOs may be considered employees of one or more of those entities would greatly expand the potential for organizing among physicians. It could also affect some nurses who have traditionally been viewed as independent contractors, including self-employed advanced practice nurses and some nurses who work through staffing agencies. 

Union activity among physicians may provide new areas for nurses and physicians to work together to address problems and concerns of mutual interest—such as unsafe staffing, whistle-blower protections, and use of nonclinical administrative personnel to override clinical decision making by health care professionals. It may present important new opportunities to work with physician organizations on legislative and other policy issues that affect patient care quality and access. 

Of course, in other areas, physicians' objections to a perceived loss of autonomy may prove a source of conflict with nurses. Some physicians cite increased use of advanced practice nurses as an example of physicians' loss of autonomy and control. Will successful organizing provide some physicians with a means to push for limits on the use of advanced practice nurses?2 There is, of course, no guarantee that physicians will always use the leverage of collective bargaining over terms and conditions of employment in the most constructive or collegial ways. (Similarly, of course, no such guarantee exists regarding organizing by other health care workers.) 

Concern over how physicians may seek to use increased leverage in bargaining with MCOs has been a chief reason for nursing's opposition to efforts by organized medicine to win broad antitrust exemptions that would allow physicians to bargain with MCOs. Aside from concern about the effects of independent, competing sellers combining to set their fees, ANA has also voiced concern that many physicians might use the leverage an antitrust exemption would afford them to exclude advanced practice nurses from participating in managed care plans, limiting their reimbursement, or placing anticompetitive restrictions on them, such as requiring physician supervision (ANA 1996; ANA 1997, 32). Antitrust laws already include a broad exemption for labor organizations involved in collective bargaining activities. The law allows physician employees—like all other employees—to avail themselves of this exemption. 

 CONCLUSION

However, attempts by physician groups to win antitrust exemptions bear continued watching, as do efforts to use union organizing as a means to resist change, such as increased use of advanced practice nurses. The physician union movement will not make existing areas of disagreement or conflict between nurses and physicians disappear. It may, however, provide additional means for these professionals to address their differences and to identify areas of mutual agreement and possible collaboration, particularly in health care settings in which both groups are organized. 

REFERENCES

AMA. 1998a. AMA Applauds Bargaining Success of Rockford Physicians, May 5. 

AMA. 1998b. AMA Supports Campbell Antitrust Bill. News release. June 29. 

AMA. 1997. Physician Involvement with Collective Bargaining, Report of the Board of Trustees, Report 28-i-97, pp. 3–6. 

AMA 1996. Collective Bargaining. Board of Trustees Report 16-i-96. 

ANA. 1997. Legislative and Regulatory Initiatives for the 105th Congress. Washington, DC: American Nurses Association. 

ANA. 1996. Statement on the Antitrust Health Care Advancement Act of 1996 (HR 2925). September 5. 

Budrys, G. 1997. When Doctors Join Unions. Ithaca, NY: Cornell University Press. 

California Doctors' Group Votes to Consider Union. 1998. The New York Times, February 22, Section 1:13(1). 

CIR. 1998. Web site. <www.cirdocs.org> Accessed August 17. 

CMA May Form a Physicians' Guild. 1998. American Medical News, March 9, 2. 

DOJ and FTC. 1996. Statements of Antitrust Enforcement Policy in Health Care. Washington, DC. 

Doctors Look to Union for Relief. 1998.  St. Petersburg Times, January 5. 

Florida Medical Association Delegates Vote for Advocacy Center in Lieu of Unionization. 1998. Daily Labor Report, May 19, A-4. 

Galant, D. 1998. Organized Medicine. The New York Times, January 25, 14NJ, 4 (1). 

Hallam, K. 1998. Feds Sue Doc Union Over Price-Fixing. Modern Healthcare, August 17, 3. 

Hirshfeld, E. 1997. Interpreting the 1996 Federal Antitrust Guidelines for Physician Joint Venture Networks. Annals of Health Law 6(1). 

Jaklevic, M. C. 1997. Physicians Find Power in Unions. Modern Healthcare, October 6, 104. 

Klein, S. A. 1998. Physicians' Union Feels Antitrust Scrutiny.  American Medical News, March 9, 3. 

Kletke, P. R., D. W. Emmons, and K. D. Gillis. 1996. Current Trends in Physicians' Practice Arrangements: from Owners to Employees. Journal of the American Medical Association, August 21. 

Klien, A. S. 1997. Annotation: Union Activities Violating the Federal Antitrust Laws—Federal Laws, 20 L.Ed. 2d 1528. 

Labor Board Rebuffs Attempt by New Jersey Physicians to Unionize. 1998. Daily Labor Report, January 12, A-10. 

Larkin, H. 1997. Illinois Doctors Organize to Protect Care; AMA Backs It. American Medical News, November 3. 

Maharry, M. 1998. Medalia's Doctors Vote for Union. The News Tribune (Tacoma, WA), June 3, A1. 

Modern Healthcare. 1998. February 23, 53. 

Modern Healthcare. 1997. September 8. 

NHLA/AAHA. 1997. Patient Care and Personal Responsibility: Impact of the Corporate Practice of Medicine Doctrine and Related Laws and Regulations. Washington, DC: National Health Lawyers Association/American Academy of Hospital Attorneys. 

NLRB. 1997. Boston Medical Center Corporation and House Officers' Association/Committee of Interns and Residents, Petitioner, NLRB Case 1-RC-20574,  p. 2 

Pham, A. 1997. 84 Blue Cross Doctors Want Union at 6 Centers. The Boston Globe, May 1, D7. 

Rockford Doctors Drop NLRB Plea. 1998. American Medical News, May 18. 

SEIU Hopes to Organize Thousands if NLRB Decides Doctors in Training Are Employees. 1997. Daily Labor Report, June 9, C-1. 

Talks Between Medical Group, Doctors Under Way as Legal Challenges Proceed. 1997. Labor Relations Week, November 19, 1,199–1,200. 

UAPD Petitions to Represent Los Angeles MDs. 1998. Daily Labor Report, June 23, A-10. 

UAPD Makes First Move to Organize Doctors in Kaiser-Permanente of Northern California. 1998. Daily Labor Report, May 12, A-6. 

Valdez-Dalpena, P. 1995. Doctors with Union Cards. Business Week, January 23, 101. 

ENDNOTES

2. Notably, among the issues cited by the California Medical Association in voting to consider establishing a subsidiary guild is the "pressure" felt by state-employed psychiatrists (one of the physician groups the CMA subsidiary would presumably seek to represent) "to add psychologists to their medical staffs." (CMA May Form a Physicians' Guild 1998). 
 

 Return to the Nursing Trends & Issues Index

 Return to the Reading Room