Perspective: Three Leaders Analyze Physician Unions’ Potential

Thirty years ago, when the vast majority of U.S. physicians worked in independent, often smaller-sized, medical practices, largely for fee-for-service payment, the idea of physician unions would have seemed outlandish to many people in healthcare. But the landscape has changed dramatically since then, and large numbers of physicians are now salaried by hospitals, health systems, medical groups, and health plans. So the question is no longer abstract, or strange.

And now, a team of two attorneys and one physician have authored an article published in the JAMA Network online, in which they analyze some of the elements and complexities of unionization, while making it clear that they believe that unionization may be a useful tool for certain groups of doctors.

In the article by Daniel Bowling, III, J.D., Barak D. Richman, J.D., Ph.D., and Kevin A. Schulman, M.D., entitled “The Rise and Potential of Physician Unions,” those three experts offer a nuanced view of the issues involved. Bowling is a professor at Duke University School of Law (Durham, N.C.); Richman is in the clClincial Excellence Research United in the School of Medicine at Stanford University (Stanford, California), and is also a professor at Duke University Law School; and Schulman is in both the Clinical Excellence Research Unit in the school of Medicine at Stanford, and in the graduate School of Business at Stanford University.

The three experts write that “The consolidation of hospital systems and physician practices under a single corporate umbrella has resulted in major structural changes to the practice of medicine. In 2012, 60% of practices in the US were physician-owned, 23.4% of practices had some hospital ownership, and only 5.6% of physicians were direct hospital employees.1 After a surge in acquisitions of physician practices over the decade, and in response to the COVID-19 pandemic, the fraction of physicians employed by hospitals or health systems reached 52.1% and 21.8% by other corporate entities in 2022, for a total of an estimated 74% of practicing physicians.2 Many physicians now are employed by consolidated corporate health care systems that span many different communities and increasingly are spread across multiple states.”

And, they write, “This rapid transformation has largely followed an aggressive strategy, put forward by hospital and corporate leadership, that seeks scale and exploits market power. However, it is also a strategy that is increasingly at odds with the interests of the physicians working in these organizations. The strategic differences are revealed in a variety of important policy differences, spanning from payer contracting strategies, compensation incentive structures, and service line prioritization. These differences suggest the potential for growing challenges for US medicine.”

The three experts see three key elements that physicians must consider if they’re considering forming a union. “First,” they write, “physicians need to determine whether collective bargaining is in their interest, in contrast to each physician contracting individually for their services. If collective…