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The power to say no’
A physicians’ union could combat increasing frustration with managed care organizations, says Mark Bair, MD, FACEP, chair-elect of the Young Physicians Section of the American Medical Associa tion in Chicago.
"For an individual physician group to fight against a large HMO is very ineffective," he argues. "This will bring in the power of a national organization with a complete staff of legal and medical advisors, with that kind of backing and knowledge base."
For example, if an HMO contract was violating the Emergency Medical Treatment and Active Labor Act (EMTALA), the national organization could respond with federally based lawyers, says Bair. "The kind of connections they have include the ability to interact with the OIG [Office of Inspector General] and HCFA [Health Care Financing Administration], so you are bringing that power to bear with managed care."
The union will eliminate the need for ED groups to battle managed care organizations (MCOs) at the local level, notes Bair. "For instance, you may be in the middle of negotiating your contract, and the hospital is putting pressure on you to sign, and the MCO is asking you to accept inappropriate patient transfers. If you go to your ACEP [American College of Emer gency Physicians] chapter and other avenues, and their help is inadequate, you now have another alternative to turn to."
If physicians were organized, they could collectively refuse to adhere to a managed care policy that was detrimental to patient care, says Robert McNamara, MD, FAAEM, president of the American Academy of Emergency Medicine in Milwaukee and chief of emergency medicine at Temple University Hospital in Philadelphia.
"The sheer numbers would be useful," McNamara says. "For example, if the HMO said you could only use certain drugs on our formulary, the physicians could say no, we will not change our prescriptions."
Others insist that instead of unionizing, ED physicians should find alternative solutions to deal with managed care.
"Decline poor managed care contracts, fight for unpaid revenue, submit grievances routinely to keep managed care honest,’ report unethical behavior of managed care physicians or medical directors to the appropriate authorities, and [take advantage of] a number of other opportunities," urges Todd Taylor, MD, FACEP, an attending emergency physician at Good Samaritan Regional Medical Center in Phoenix. "Complaining to your colleagues is simply not enough."
It’s a mistake to assume all managed care is "bad" and needs a union to fight against it, Taylor says. Many physician groups, particularly emergency physician groups, have been able to thrive in heavily penetrated managed care environments, he says. "Under - s tand ing managed care needs and working toward common goals can be profitable. It doesn’t always have to be a fight."
Other resources can help
ED physicians may be unaware of options currently available to them to combat problems with managed care, notes Bair.
"For instance, doctors have the opportunity to bring contracts to the AMA to be legally reviewed and given feedback as to whether they should sign or not," he says. "If they have problems with the contract or it’s not appropriate, there is also some help available from the AMA legal staff." (See source box, below, for contact information.)
The theory is to use the union as a last resort when nothing else works, says Bair. "For example, if an MCO contract includes EMTALA [Emergency Medi cal Treatment and Active Labor Act] violations, the idea is to first work at the local level and look at any type of help they’d get," he explains. "If none of that is effective, the national organization would take over from there and try to help."
However, there are many issues that emergency medicine physicians have not adequately addressed that could improve their work situations, McNamara cautions. "We really need to try those avenues before going down the union pathway. We believe that emergency physicians can solve their problems in many circumstances just by using what’s already on the books, without going through a union."
(Editor’s note: In next month’s issue, two guest columnists will present a point/counterpoint on physician unions.)