Parker Purifoy

Doctors at private hospitals are turning to unions to address the loss of autonomy and deterioration of working conditions that they believe are the result of increasing health-care mergers and acquisitions in the wake of post-pandemic economic strains on the industry.

Hundreds of physicians at the Allina Health System in Minnesota petitioned to unionize last week in what the union says is the largest group of organized doctors in the country. The new campaign marks another step for organized labor with the nation’s doctors, and unions predict a bigger push could be on the horizon.

While a unionized physician workforce could include higher medical costs, it also could improve doctor well-being and patient care, industry stakeholders say.

The group of 560 doctors, physician assistants, and nurse practitioners filed their petition to unionize with the Doctors Council, an affiliate of the Service Employees International Union, on Aug. 11. The workers are spread across 61 family and urgent care clinics in Minnesota and Wisconsin, according to union documents filed with the National Labor Relations Board.

Unionization among physicians has largely been confined to medical residents and public-sector doctors.

Organizing efforts among doctors at private institutions, however, have lagged behind other groups of employees. Organizers attribute the hesitation to physicians having been historically classified as supervisors or business owners, two groups unable to unionize in the private sector under the National Labor Relations Act.

Employer to Employee

But the number of doctors who are considered employees has ballooned in recent years largely as a result of a spike in acquisitions of physician-owned practices by hospitals or other corporate entities, such as private equity firms and insurers.

A 2022 study by health-care consulting firm Avalere Health shows that a jump in acquisitions during the Covid-19 pandemic resulted in an 84% increase in practices owned by corporations, and a 9% increase in hospital-owned practices. These acquisitions mean that over half of the nation’s roughly 1 million physicians worked for hospitals in 2022, compared to only 5.6% in 2012.

Companies are facing heavy financial pressures from the pandemic and nationwide staffing shortages, said Daniel DeBehnke, vice president and chief physician executive of health-care consulting firm Premier Inc. The pressures to return profit margins to pre-pandemic levels could be trickling down to staff, likely fueling a desire for union representation, he said.

“Health systems want to get the return on the investment they’ve put into these physician assets and that often means pressures on doctors to be more productive and efficient,” he said. “So if a physician goes from being in a small group where you get to decide your own working conditions to working for a large company that’s making those decisions for you, they will certainly feel that loss of control.”

Alia Sharif, a physician at Allina’s Mercy Hospital in Fridley, Minn., is among a group of 132 doctors to unionize with the Doctors Council earlier this year. According to Sharif, the doctors saw changes in hospital procedures over the course of the pandemic that seemed to be driven by a need for higher productivity, not better patient care.

“We saw with our own eyes that when non-clinicians make health-care decisions in boardrooms, it doesn’t always translate into what’s best for patients on the front lines,” she said.

Joe Crane, an organizer for the Doctor’s Council, has helped physicians at several Allina hospitals in Minnesota seek unionization, driven by concerns of physician autonomy. The council represents 3,300 physicians in five states.

“They’re not unionizing for traditional things like pay or benefits,” he said. “They’re reaching out because their patients are dying and they can’t do anything to stop it.”

Allina is a nonprofit system of more than 100 hospitals and clinics, making it one of the largest health-care providers in the state.

The company “abides by its statutory obligations under the National Labor Relations Act,” it said in an emailed statement. “At Allina Health, we deeply respect and value our physicians, their contributions to our organization, and the critical services they provide our community,” it said.

Nurses’ Example

The health-care industry is no stranger to union activity, with about 13% of the overall workforce belonging to a labor organization, according to a 2022 study.

But the major strategies used by unions to better members’ conditions of employment have physicians grappling with whether unionization is good for patient care, said Dan Bowling, a labor and employment law lecturer at Duke University.

“The ultimate tool for the workers and the union is a strike, and people argue that physician strikes would be bad for patient care so it’s an ethical concern for some doctors to even take steps in that direction,” Bowling said. “But it’s also unethical for them to not address the systemic issues they’re seeing.”

Doctors are seeking unionization because “their working conditions would shock the average person,” said Crane. “Most people think that workers want unions for more money or more time off but that’s not what’s driving these people. This is like their last ditch effort to save health care.”

Physicians are also seeing the impact of actions by nurses unions, which have been advocating for patient-nurse ratio policies, he said.

“Doctors are seeing very real changes happening from the nurses unions and they’re being inspired by it but also a little jealous about it,” Crane said. “They want to join and bring their voices to that table too.”

The study reported that union membership among nurses was “significantly associated” with higher wages and benefits, although unionizing doctors have different aims.

In an accompanying editorial, Duke University Law Professor Barak Richman and Stanford University Professor of Hospital Medicine Kevin Schulman wrote that physicians unions could “improve governance” of health-care systems, “bolster the input of physician-employees,” and “provide a counter-force to hospital corporatization.”

Antitrust Concerns

Unions representing physicians are also getting in on efforts to fight practice consolidations due to antitrust concerns for workers who may want to change employers.

“Years ago, if you wanted another job as a physician you could go to another hospital on the other side of the street, or other side of town but you can’t do that anymore,” Crane said. “You can’t go ‘somewhere else’ because that place is owned by the people you’re trying to leave.”

The Federal Trade Commission has challenged 20 mergers in the industry since last June. While none of those challenges were driven by labor concerns, a coalition of unions filed an antitrust complaint in May with the Justice Department against the University of Pittsburgh Medical Center, alleging its dominance in the local labor market was suppressing workers’ wages.

But Douglas Ross, an antitrust and health law professor at the University of Washington, said the mergers targeted by the FTC aren’t representative of the whole picture. Doctors and specialists likely have more options to seek other jobs than many other professions, and litigating antitrust claims would be “very difficult,” for them, he said.

“When a hospital is looking for a new cardiologist, they’re not just looking in the region, they’re looking all over the country,” Ross said. “If a physician feels like they aren’t receiving fair pay or treatment after two systems merge, they can move to a different system.”