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Medicine Man: Dr. Donald Prolo calls Campbell's bill "the most important thing to happen to medicine since penicillin."
Photograph by Skye Dunlap
Campbell's bill would allow physicians to call the shots
Doctors say they want the right to organize in order to improve health care
By Kara Chalmers
Representative Tom Campbell doesn't like to use the word union. Neither do the doctors who support his bill, which would allow private physicians and other health laborers the right to organize.
But Campbell's bill, which is now in the Judiciary Committee of the U.S. House of Representatives, would allow doctors to come together in groups that resemble unions, even though they technically aren't.
In order to do that, the Quality Health-Care Coalition Act would give health professionals an antitrust exemption. That would mean they would win the right to band together to negotiate contracts with HMO's and other managed care companies.
Campbell believes many doctors now are treated like employees of an HMO. So why, he wonders, shouldn't they have the right to collectively bargain?
"As it is now, managed care companies pick each one of us apart," says Dr. Donald Prolo, a neurosurgeon who grew up in Willow Glen and has practiced in the area since 1971. "Medicine is in its death throes. The Campbell bill is the most important thing to happen to medicine since penicillin.
"Allowing doctors to collectively bargain is the first step in freeing medicine from this oppressive weight of government and managed care."
Since most of the members of the House Judiciary Committee have signed on as co-sponsors, the bill could hit the House floor soon after the August recess.
The bill's supporters point out that unlike real unions, the doctors' organizations allowed by the bill would not be permitted to go on strike. Dr. Stafford Grady, a pediatric cardiologist who practices in Willow Glen, says that striking would be antithetical to the work they do.
"No one of us became a doctor to refuse to see patients," Grady says. "We take care of anyone who comes in the office."
A provision in the bill does say there would be no "collective cessation of service to patients," but according to testimony given by Robert Pitofsky, chairman of the Federal Trade Commission (of which Campbell was director of competition 1981-'83) at the bill's hearing on June 22, a collective refusal of doctors to contract with a certain health plan could be just as bad for patients. The health plan could be forced from the market, or patients may be left to pay out-of-pocket for their medical care.
Grady says one of the reasons he supports the bill is because under current conditions, he and other doctors get frustrated when insurance companies limit who they can treat.
Campbell's bill is designed to give doctors more control of those kinds of decisions. Campbell says most doctors he has spoken to say they would like to spend more time with patients. They also say they want the freedom to prescribe what they think is the best treatment for each patient.
Prolo says doctors would like to be able to determine length-of-stay in hospitals, to regain the freedom to prescribe needed medications, even if they are considered too expensive by managed care companies, and to allow people to see their physician of choice.
And although Prolo says he sees the Campbell bill benefiting the patient first and foremost, he also sees a benefit for doctors. Doctors, he says, know how much they need to charge, and they should have a say in how much they get in fees from managed care companies. But he says it's not more money he's fighting for, it's being allowed to practice as a doctor.
"There is no satisfaction anymore," Prolo says. "Doctors get into medicine because of the joy of interrelating with patients. Today they are told what to do, when to do it and how to do it, by people with a high school education."
Campbell says his bill would help both patients and doctors. He says that in his years in public life, the doctors he has met have made him believe that medical professionals get into the field because of their desire to help people, more than their desire to make money.
"The logic behind the bill is compelling," he says. "In approaching the bill, I am strongly driven by this belief."
So where do doctors' rights fit with patients' rights? Campbell and the bill's supporters insist that patients are always best served when doctors make decisions, rather than HMO executives. But he opposed the Patients' Bill of Rights Act, which would have legally required reforms that Campbell's own bill might lead to.
For example, one provision would have compelled insurers to pay for medical treatments that doctors deem necessary. But Campbell, a Republican, believes the federal government should be minimally involved in health care.
"All the difference is between having the government set the terms of contracts and allowing medical professionals to bargain to achieve the terms," he says. "I would trust bargaining more than government pronouncing what the right result of the bargain is."
Some patients rights' advocates agree.
"Doctors know better," says Doug Heller, consumer advocate for the Santa Monica-based non-partisan Consumers for Quality Care.
"We would urge an expansion of doctor's strength," Heller Says. "We also would make sure contracts would allow the care that patients need.
"HMOs dictate contracts to doctors that harm patients. It would be very beneficial to patients for doctors to be in a strong enough position to sign contracts that allow them freedom to provide medically necessary care that a patient deserves."
Managing Care: Rep. Tom Campbell, following the advice of local physicians, is seeking to allow doctors to jointly negotiate with HMOs.
Photograph courtesy of Tom Campbell
Pricey Fix
But Dr. Donald Young of the Health Insurance Association of America (HIAA), says Campbell's bill may not improve care, and may actually be detrimental to patients. Responding to doctors' complaints about extra paperwork and time on the phone with managed care officials, Young says they would likely bargain to get rid of some "quality oversight" functions of managed care, like databases that keep track of what medications patients are on. That could be dangerous, he says, because such databases can prevent patients from mixing medications, and their removal could lead to unnecessary treatments or even risks for patients.
The possibility of increased costs of medical care is another reason some oppose the bill.
If the bill passes, it would allow all doctors in a community, or all specialists, to band together and insist on being paid more by insurers, according to testimony given by Pitofsky, of the FTC, at the June 22 hearing for the bill. Pitofsky contended that this practice would raise health insurance premiums for employers, and copayments and other costs for individuals. Higher insurance costs may affect employers' decisions on whether to offer health benefits and individuals' decisions on whether to purchase coverage, he testified, concluding that the bill would ultimately increase the numbers of uninsured Americans.
If doctors do demand fee increases, Campbell says, those increases might not be passed on to consumers. Rather, they could instead come out of health plan profits. But the FTC doesn't think so. The commission's testimony says professionals' fees account for almost half of insurance payments for health care and supplies.
Heller, from Consumers for Quality Care, responds that the FTC's fears regarding higher premiums are unfounded.
"Over the last decade, HMOs have put profit ahead of patients," he says. "Any time there is any legislative move to improve patient care, HMO executives will tell you that it will raise premiums. It's a pat response."
"The bill might increase the cost of medicine," Campbell admits. "But the key is that it will improve the quality of medicine per dollar charged. I don't claim that the sun will always shine, I recognize that the cost could be higher."
The FTC says the bill would open the door for price-fixing--doctors deciding together on minimum prices for medical services.
Prolo's response is unequivocal. "Price fixing is not the goal of American medicine," he says. "It's illegal, and Congress would never pass a bill that would in any way lead to that. We just want the ability to bargain collectively with insurance carriers which are screwing us," he says. "And they're tightening the screw all the time."
If Campbell's bill becomes law, groups of health professionals would be treated the same as any labor organization, in that they would not be prosecuted for forming bargaining units in geographic areas or with members of particular specialties. Under existing antitrust laws, if even two independent doctors get together to negotiate their contracts with insurance companies, it constitutes a violation of the laws.
But in many cases physicians can already talk among themselves and with health plans about quality of care issues without violating antitrust laws, says Dr. Young of the HIAA.
"There are ample ways to let physicians get together to improve quality of care," Young says. "What they can't do today is get together for purposes of colluding to increase their incomes, and the Campbell legislation would allow them to do that."
According to the FTC, collective bargaining rights are designed to raise the incomes and improve the working conditions of union members.
Dues and Don'ts
Unionizing is the best way to fight powerful interests that are increasingly controlling medicine, says Dr. Robert Weinmann, a neurologist who has a practice in San Jose. He is the president of the Union of American Physicians and Dentists (UAPD), headquartered in Oakland. The current right to unionize applies only to about 16 percent of physicians nationwide, who are salaried employees of a hospital, according to a spokesman for the California Medical Association. It does not protect combinations of private health professionals like Prolo.
The UAPD has about 5,000 members, 90 percent of them from California. Any licensed physician, osteopath or dentist can join, according to Weinmann, who notes that only about 60 percent of his members are salaried employees of a hospital or of the government. He feels that anyone who wants to practice medicine needs to belong in a union.
"I first realized that government wanted to take over medicine," Weinmann says. "A few years later, it was clear that profiteering companies wanted to. With such capable, powerful and greedy entities wanting this, it became clear that we would need to have an organization that could fight. The best answer for fighting this machine was a union--so we made one."
The UAPD has not yet had a strike, although they have voted twice to have one. Both times, their terms were met before they actually had to run for the picket signs, Weinmann says.
"[The Campbell bill] is not necessarily a pro-union bill," says Weinmann, who also spoke in favor of the bill at the June 22 hearing. "It allows other organizations like medical associations or any doctors' group to have the privilege of collective bargaining without really being a union, but I supported it strongly."
Doctors who want to concentrate on the practice of medicine need to leave the negotiating to others, says Weinmann.
"It is also dangerous to let hospitals and managed care companies represent doctors' interests, because they will represent their own interests first," he says. "They'll leave the doctors and patients with scraps from the table.
"If doctors want to practice medicine, they'll need an organization that is willing and able to take on the pirates who run managed care and the flunkies who read computer screens instead of talking to patients."
"We're willing to allow the bill because we're confident we'll show we negotiate better and more professionally than other groups," says Weinmann. "We'll force them to become real unions."
For Tom Campbell, the bill is a way to improve the quality of health care in some way, however small; no matter what other bigger decisions are made on health care for the country.
"I feel that the patient suffers, the way things stand now," Campbell says. "My bill is only one small part of a solution. It is my contribution, and hopefully a good one, for the country. There is a bigger mosaic, of which this is one tile."
Robert Weinmann sounds another note: "The Campbell bill is a step in the right direction," he says, "for doctors to be introduced gently to the concepts of unionism."
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Willow Glen, California Since 1992
