Medical Unions and Physician Assistants

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Market changes, physician discontent, and media attention have raised the profile of unions and workplace actions in the health care industry. Unionization efforts among physicians lead to questions for physician assistants because of the unique legal supervision requirements under which they practice. This issue brief provides an overview of unions and workplace actions in medicine in the United States and outlines some critical issues for PAs who are faced with or considering unionization.

The Union Movement in Medicine

At the cusp of the 21st century the American Medical Association (AMA) made headlines for two steps it took to promote collective bargaining for physicians. First, in June 1999 the AMA House of Delegates voted to develop a national negotiating organization to represent employed physicians. Coupled with this was an AMA effort to push legislation through Congress that would relax federal antitrust laws, opening the door for self-employed physicians to organize and collectively bargain.

While this push among self-employed physicians to organize is a new phenomenon, union membership among the health care workforce has a long history. Nursing unions go back to the 1940s. The Committee of Interns and Residents was founded in 1957. Unions have represented employed physicians and PAs since at least the 1970s.

The unionization push in the 1990s arose from self-employed physicians who were dissatisfied with managed care organizations (MCOs). Physicians described loss of control over medical decision-making, longer hours, larger patient loads, lower income, and a wish for collective weight when negotiating with MCOs. A 1999 AMA report describes self-employed physicians "looking toward collective action to provide them with a counter-weight to the economic leverage of health plans." (AMA Board of Trustees Report 30, A-99)

Resident physicians expressed similar frustrations with heavier workloads, longer hours, and less supervision. Some physician assistants have noted similar discontentment over clinical decision making and work conditions. In February 2000, PAs in Colorado struck with fellow union members against Kaiser Permanente over these types of issues.

Collective Action in the Workplace

Federal and state laws protect the right of certain employees to collectively address workplace concerns with employers. Trade unions were well established in the United States by the 1830s, and their power slowly grew over the next century, though not without obstacles along the way. The passage of the National Labor Relations Act of 1935 for the first time protected the right of employees to engage in collective bargaining and other organized activities. The NLRA also established the National Labor Relations Board (NLRB), an independent federal agency that enforces federal labor laws and certifies legitimate collective bargaining units.

The NLRA governs labor relations only for private sector businesses involved in interstate commerce; several classes of employees do not fall under its protection, including employees of the U.S. government and its wholly owned corporations, states and their political subdivisions, railroads, and airlines. Other state and federal laws protect these other employee classes.

Membership in a union or collective bargaining unit is not required in order to negotiate with an employer. Decisions about how to organize and how much to organize may depend in part on the employer's organizational structure, bargaining history, and the extent of unionization already present within the organization. Employees may elect to form a collective bargaining unit if they have sufficient common interests and concerns such as similarity in skills, duties, working conditions, geographic proximity, employee desires, and integration of personnel and functions.

Employees usually choose to formally organize in a collective bargaining unit because it offers legal protections. Union membership also may offer other advantages that collective action without an identified union may not provide. For example, unions usually have expertise in negotiating agreements with employers over issues of wages, hours, benefits, conditions, and safety of employment.

Through the certifying process, the NLRB determines which professions can be in a single bargaining unit. It seems to be more common for federally employed physicians and PAs to be in the same bargaining unit than it is for those who work in the private sector and fall under the rules of the NLRB.

Key Points to Consider about Union Membership

To be a union member or member of a collective bargaining unit, one has to be a non-management employee. Most physicians are independent contractors and are not eligible to join a union. Likewise, PAs who are self-employed cannot join a union.

The Quality Health-Care Coalition Act, HR 1304, introduced by Rep. Thomas Campbell, R-Calif., in the Congressional sessions of 1999 and 2000, proposed dramatic revisions to federal antitrust laws to allow self-employed physicians to organize and collectively bargain with managed care organizations. The legislation met with major opposition from the insurance and hospital industries, the Department of Justice, and the Federal Trade Commission. The bill passed the House amidst a flurry of hostile wrangling, but no bill was ever introduced in the Senate. Similar bills have been enacted into law in some states. Their impact remains to be seen.

Are Supervising Physicians Management?

Can supervising physicians who are employees join collective bargaining units? Neither the NLRB nor the courts has provided definitive guidance on this issue. It depends on the facts in each case. The NLRB distinguishes between "authority arising from professional knowledge and authority encompassing front-line management prerogatives." In 1994, the Supreme Court disagreed with this distinction in its decision, "NLRB v. Health Care and Retirement Corp." This case involved charge nurses and the question of whether or not they were management. Despite a court ruling that found the charge nurses to be management, the NLRB continues to find that most nurses and health care professionals who direct other employees are employees and not supervisors.

Conversely, while a few courts have held that physicians are not supervisors, the majority of courts and the NLRB generally see them as supervisors. However, there are a few cases in which the NLRB has recognized physician bargaining units and considered only department heads to be management. In some cases, physicians who clinically supervise PAs might be considered non-management if they did not exercise control over the PA hours, hiring, firing, salaries, and performance evaluations.

Pros and Cons of Union Membership

Union membership and collective bargaining offer some advantages for attaining more favorable wages, hours, benefits, and job security. Unionization of workers could give a health care organization a more stable work force; rewarding seniority with higher wages and preferential leave might entice more employees to stay. Union representation could also help health care workers to more effectively address patient safety issues, including adequate staffing, resources, and equipment. In addition, unions usually negotiate a legally binding contract between employer and collective bargaining unit preventing arbitrary decisions on employment issues by the employer, and typically unions provide structured employee grievance processes.

Depending on which union or bargaining unit the various members of the health care team join, the collegial nature of the work place may suffer by pitting one group against another. One profession's concerns may be overridden by a more vocal profession within the same bargaining unit or union. For example, PAs, often small in number relative to other types of professionals, may find their professional concerns taking a back seat to concerns of the majority in a mixed bargaining unit.

The union model generally rewards seniority, but does not recognize differences in specialization or skill level. This could affect compensation and does not conform to the medical model, which typically offers greater compensation for individuals with specialized training.

Rigid job classifications imposed during union contract negotiation may give management less flexibility when trying to cover patient care needs. The process of negotiation will require that union representatives be educated on the clinical ramifications of labor decisions.

Work Place Actions by Union Members

For most health care providers, strike potential raises the most difficult dilemma that occurs as part of union membership. Strike is the ultimate weapon in attaining concessions from management, and the federal government protects the right of union members to strike. However, the risk of jeopardizing patients presents ethical predicaments. If a strike is considered, care must be taken to safeguard patients. In 1974 amendments to the NLRA, Congress added provisions that apply only to health care employers and employees. There can be no strike, picketing, or work stoppage by any union against any health care employer without providing at least 10 days written notice to the employer and the Federal Mediation and Conciliation Service. [NLRA, Sections 8(g) and 9(b), 29 USC Sections 158(g)]

Some negotiated contracts contain a "no strike" clause. Federal and state union members may be prohibited from striking if their work is considered essential for public safety. Short of strike, other workplace actions - including informational picketing, non-disruptive public demonstrations, lobbying, and publicity campaigns - could draw attention to the workers' plight.

A strike could also create a dilemma for patients who are union members. Such patients may face a personal conflict between needing health care and crossing a picket line.

A physician work stoppage could create a dilemma for PAs because of the legal requirements for supervision, though the history of physician collective action seems to indicate that strikes occur rarely. The AMA's national negotiating organization for physicians specifically states that physicians they represent will not strike.

AAPA Policy on Strikes

The AAPA has specific policy on strikes, which states, "The AAPA recognizes the role of organized labor in society but condemns any action in the workplace that has an adverse effect on patient care." Guidelines for Ethical Conduct for the Physician Assistant Profession, also policy of the AAPA, emphasizes patient care above monetary gain and contains a section on strikes. Those guidelines state, "It is unethical to abandon a patient. PAs may face a difficult personal decision to withhold medical services when strikes occur if patients may potentially be harmed. The potential harm should be carefully weighed against the potential good that can be accomplished through strikes and other workplace actions that endeavor to improve working conditions and, ultimately, patient care. In general, PAs should individually and collectively work to find alternatives to strikes in addressing workplace and organizational concerns."

Conclusion

PAs and other health care employees have belonged to unions for many years. As physicians see managed health plans eroding their ability to make autonomous patient care decisions and diminishing control over their workplace and income, their interest in unionization has increased. These physicians and some other health care workers perceive collective action as one avenue to advocate for change and regain control.

While collective bargaining offers advantages, it also creates ethical dilemmas. Before organizing, providers should consider how a union could affect relationships with patients and with colleagues. Will unionizing favorably or adversely affect patient safety and quality of care? Will it affect the cost of care? Will their union status put them at odds with colleagues? Would they ever strike? If so, under what circumstances?

Which union and which collective bargaining unit a PA joins depends in part upon the work setting in which they practice. Rules governing organizing and workplace actions vary among private sector, state, and federal government settings. More information is available from union representatives and regional offices of the National Labor Relations Board. Additional resources include the National Right to Work Legal Defense Foundation and the U.S. Labor Department. Some AAPA constituent chapters may know of unionized PAs in their states or PAs who have been involved in recent organizing efforts who may be able to provide some insights.

Lexicon

Bargaining Unit A group of two or more employees joined together to assert their organizational rights or to collectively bargain. The NLRB's basic test for an appropriate unit is whether the employees share a "community of interests." Under this test, the Board considers five factors: (1) similarity of duties, skills, interests, and working conditions of the employees, (2) organizational structure of the employer, (3) desires of the employees, (4) extent and type of union organization of the employees, and (5) bargaining history in the industry.

Closed Shop An establishment employing only members of a labor union. Just after passage of the National Labor Relations Act in 1935, federal courts tended to uphold the legality of the closed shop. Many states, however, by legislation or court decision, banned the closed shop. In 1947, the Taft-Hartley Labor Act declared the closed shop illegal and union shops were prohibited unless authorized by a majority of the workers in a secret poll. It was amended in 1951 to allow union shops without a vote of the majority of workers. After that amendment, there came a push for states to adopt so-called "right to work" laws that declare union shops illegal. More than one-third of all states have adopted "right to work laws."

Collective Bargaining The process by which the employer and representatives of the employees negotiate in good faith the terms and conditions of employment, any question arising from those negotiations, and the completion of a written contract. The law does not compel either party to agree to a proposal or require concessions.

Labor Organization As defined in the National Labor Relations Act, a "labor organization" is an organization of any kind or any agency or employer representation committee or plan in which employees participate and which exists in whole or in part to deal with employers concerning grievances, labor disputes, wages, rates of pay, hours of employment, or conditions of work.

National Labor Relations Act (NLRA) Also known as the Wagner Act, this 1935 law established an exemption to antitrust laws for labor organizations acting on behalf of employees to collectively bargain and created the National Labor Relations Board to interpret labor laws.

National Labor Relations Board (NLRB) An independent federal agency of the executive branch. It has five members, who are appointed by the president to interpret national labor laws.

Open Shop An employer that does not restrict its employees to union members.

Picketing Posting of one or more union members at the site of a strike or boycott in order to interfere with particular employer's business or to influence the public against patronizing the employer. Picketing usually involves carrying and displaying signs, placards, or banners.

Slowdown Strike A deliberate lessening of work effort for a definite purpose and time. In motive, it is similar to a strike, differing from the latter only in the degree of work stoppage involved.

Strike A concerted refusal of employees to perform work that they have been assigned, in order to force the employer to grant concessions that the employees have demanded.

Union Any registered group or association of employees that exists in whole or in part for the purpose of collective bargaining or dealing with employers concerning terms and condition of employment. The National Labor Relations Act does not specifically define "union."

Union Shop The term "union shop," closely allied with the term "closed shop" indicates a company where employees do not have to belong to a labor union but are required to join within a specified period of time in order to keep their jobs.

Resources

AFL-CIO

The American Federation of Labor-Congress of Industrial Organizations (AFL-CIO) is a federation of 68 unions representing more than 13 million workers. There are 51 AFL-CIO-chartered state federations.

Education - UCLEA Links
State-by-state resources for information on labor issues, via the AFL-CIO web site.

Federal Mediation and Conciliation Service
Created by Congress in 1947 as an independent federal agency to promote the development of sound and stable labor-management relationships. The Service meets its responsibilities through a variety of services, including dispute mediation in collective bargaining contract negotiations, preventive mediation services, arbitration, and the provision of grants to foster innovative joint labor-management committees.

National Institute for Labor Relations Research (NILRR)

Research for the general public, scholars, and students, providing the "supplementary analysis and research necessary to expose the inequities of compulsory unionism." NILRR conducts analysis, and publishes monographs, brochures, and briefing papers.

National Labor Relations Board
An independent federal agency created by Congress in 1935 to administer the National Labor Relations Act. The NLRB has two principal functions: (1) to determine, through secret ballot elections the free democratic choice by employees whether they wish to be represented by a union in dealing with their employers and if so, by which union; and (2) to prevent and remedy unlawful acts, called unfair labor practices, by either employers or unions.

National Right to Work Committee
http://www.right-to-work.org/ or http://www.nrtwc.org/
A coalition of 2.2 million American citizens united by the belief that "[n]o one should be forced to pay tribute to a union to get or keep a job." Its members believe that federal labor law should not promote coercive union power, and they support state Right to Work laws.

National Right to Work Legal Defense Foundation
A non-profit organization providing free legal aid nationwide to employees who believe their civil rights have been violated by compulsory unionism.

U.S. Department of Labor
A federal agency charged with ensuring the adequacy of America's workplaces. It is responsible for the administration and enforcement of federal laws and regulations, including protecting workers' wages, health and safety, employment, and pension rights; promoting equal employment opportunity; administering job training, unemployment insurance, and workers' compensation programs; strengthening free collective bargaining; and collecting, analyzing, and publishing labor and economic statistics.

LMRDA
Information through the Labor Department about the requirements of the Labor-Management Reporting and Disclosure Act of 1959. The reporting requirements apply to labor organizations, except state or local central bodies and unions representing public employees.
 
 
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