In a move that may presage a dramatic change in the way medicine is practiced in the United States, the American Podiatric Association has announced plans to form a union. The First National Guild for Health Care Providers of the Lower Extremities will be affiliated with the AFL-CIO and part of the Office and Professional Employees International, or OPEI. Up to 10,000 of the 14,000 podiatrists in the United States will be eligible to join.
Until recently, physicians considered themselves independent contractors, not employees who needed to organize. But the explosive growth of managed-care organizations, or MCOs, has caused many of them to rethink their position. It is no coincidence, however, that podiatrists have taken the first step.
"Podiatrists are suffering the most," Louis Levine, president of the New York College of Podiatric Medicine, tells Insight. According to Levine, many MCOs have cut podiatrists out of their plans; those who belong to MCOs feel inhibited to express their grievances.
"HMOs now tell a mother or child who they can see for an ingrown toenail or a fungal problem," says Michael Wodka, president of the New York Podiatrist Association. "Often the procedure isn't even done by a podiatrist."
As they are squeezed out of MCOs, podiatrists find themselves under increasing financial pressure; some are unable to pay their mortgages or draw down the substantial debts incurred in training and setting up their offices. Unionization, in the works for a year-and-a-half, simply is "self-protection," argues Levine, who notes that podiatrists will not engage in traditional union activities such as collective bargaining. And Wodka characterizes the union as "a labor guild, not a labor union," precluding actions such as walkouts and picket lines. Rather, unionization is seen as a way of strengthening the position of podiatrists at the bargaining table and in the legislatures.
"We can go to an MCO and say, `Look, we don't like the way you're running this. If you're not doing this in our best interest, quite candidly we'll find a carrier who will,'" says Jay Porcaro, director of organization of the OPEI. "It's that collective clout that will help."
Porcaro argues that the union will prove especially effective when it comes to gag orders, or guidelines followed by a number of MCOs that forbid physicians from discussing certain topics with patients - such as recommending a specialist who is not part of the plan. While physicians may not want to speak out on their own, the union can address their concerns on their behalf (see sidebar).
The podiatrists' union is the first nationwide union for doctors but not the first of its kind. The Union of American Physicians and Dentists in Oakland, Calif., for instance, has 5,000 members (the majority of them physicians) and is growing by about 15 percent annually. Gary Robinson, the union's executive director, also says MCOs spurred the creation of the organization in 1972. "What's going on now is that the HMOs and preferred-provider organizations are moving private doctors closer to the status of being real employees," he tells Insight. "These groups are really setting the terms and conditions of employment - what procedures doctors can and can't do."
Consumers should benefit from unionization, say these physicians. HMOs originally were established to provide quality care at lower costs. "But what is happening today is just the opposite," asserts Porcaro. "What we've found is that the dollars in our packages set aside for medical insurance are not showing up in benefits. MCOs are spending millions of dollars for public relations and consultants and paying their own salaries. It isn't going to the consumers or the providers."
Acknowledging that the move is also "self-serving," Wodka says that unionization will give podiatrists access to the membership of the AFL-CIO, with 2.5 million members in New York alone. …