Provider Unionization Is Growing—But It’s Not Inevitable

The recent news about nearly 300 primary care physicians at Mass General Brigham filing a petition to create a union has once again sparked discussions about collective bargaining within healthcare. Unionization of health workers is not new, but physician unions are still somewhat novel and are a by-product of the larger trend toward direct physician employment. Each time a group of physicians decides to unionize—especially at large, well-known systems—it spurs other physicians to explore this option if they feel their concerns are not being seriously considered by their system partners.

Recent years have seen physicians unionizing at other large systems, such as Kaiser Permanente and Cedars Sinai, and residents unionizing at Penn Medicine and Stanford Medicine. The most recent national study, published in 2022, showed that 6% of physicians currently belong to a union and over 8% are eligible—numbers that have certainly grown in the years since.

ECG takes a neutral stance on collective bargaining. However, we seek to explore the root causes of union formation and how health systems can proactively assuage the push for unionization by:

Why Unions Form

The most frequently cited reasons among physicians for unionizing are career sustainability and work/life balance. As with so many professions, technical advances and greater connectivity have caused the job to bleed outside of historically defined parameters, with patient communications, administrative roles, EHR documentation demands, and call burden commonly cited.

However, these growing job expectations are nearly universal among physicians, and it is only when they also feel their compensation has been allowed to lag behind market benchmarks, or that any professional effort that doesn’t result in the generation of RVUs is categorically undervalued by health system leaders, that these negative feelings fester into actionable levels of resentment.

Physicians recognize their evolving role in healthcare and clearly understand how shifting care to lower-cost and higher-efficiency outpatient settings, coordinating care across specialties to treat complex patients and improve outcomes, and achieving improved patient access are necessary for the long-term viability of the health system. But when providers don’t feel they are given a personal financial stake in these initiatives, disillusionment arises.

It is dangerous to view compensation alone as the root cause of unions, because so many factors can contribute to physician dissatisfaction. But compensation plans are the clearest feedback loop from the system regarding which activities are valued above others. And since most physicians receive substantial funding through RVU generation, even concepts such as evolving care team models and the increasing autonomy of advanced practitioners can threaten physician compensation.

Finally, some amount of job dissatisfaction or disengagement is natural and tends to cycle over the course of a career. But with so many forums for communication among employees, grievances can echo and crescendo more easily. If physicians collectively feel like they aren’t being heard and engaged by system or medical group leaders, seeds of discontent can easily take root.

How Systems Can Stem the Tide

The groundswell around unionization can only be expected to intensify as conceptual awareness grows. What practical steps can medical group and health system leaders take to ensure physicians feel engaged and valued?

First and foremost, give your physicians avenues for meaningful feedback and engagement. Many of these structures currently exist, but they can sometimes become superficial boxes to check (for all participants). Instead, ensure your provider committees have representation among all cohorts and a reporting structure to system leadership that provides a regular cadence and targeted outlet for their feedback. If physicians feel stymied, they will seek other structures wherein their voice can be heard.
Ensure there are mechanisms in your compensation plan that reference current market benchmarks in a systematic and timely manner while also tying back to the financial performance of the group and your payer and value-based strategies. Physicians understand they function within a broader financial ecosystem and generally appreciate being looped into those discussions at the appropriate level. This will help make compensation levels feel objective and transparent.
Review the incentive structure within your compensation plans annually. Too often, value-based incentive components become participation trophies and lose any salience for changing physician behaviors and driving meaningful improvements. Physicians recognize this. But crafting reach goals that represent moon shots for the system and passing along the benefits of real access and margin improvements to the physicians can drive higher engagement and satisfaction.
Physician leadership time has long been a challenge for systems to manage. For many physicians, momentum can wane during their midcareer years, and opportunities for leadership roles can offset that. But these roles come at a cost to the system in terms of lost clinical effort and/or stipends, so they must be managed carefully. Incorporate clear responsibilities and annual, measurable goals into these role descriptions.
At academic medical centers, where a greater portion of funding is needed to recognize clinical effort to avoid defections to competing systems, medical groups must find ways to ensure that growing redirection of funds does not result in the perception that the other elements of the tripartite mission are less valuable. This is among the greatest challenges in academic medicine today, but there are ways to dedicate funding to traditional academic activities such as start-up research funding and above-and-beyond teaching effort.

The consistent theme with many of these tactics is turning what feels like a concession to the physicians into opportunities for heightened engagement and accountability that drive the system to achieve its financial and strategic imperatives. But that takes a concerted effort among system and physician leaders.

Takeaways

The process of unionization can turn provider focus away from patient care and foster an adversarial stance across parties. It can be disruptive among the medical staff and set dangerous precedents across the system. And most important, it can result in protracted negotiations that establish unrealistic expectations for change among union members, because they are still subject to the compliance and financial parameters that inform all employed physician compensation.

And this is the true takeaway: if physicians trust they are held to fair and market-based clinical expectations and compensation plans, they are far less likely to unionize. But only heightened degrees of transparency will engender the requisite trust.

The good news is that in almost all cases, the sentiments that drive unionization take a long time to gain roots, so systems can prevent their formation—not by stifling their clinicians but by empowering them through proactive engagement and active listening.

In this case, an ounce of prevention could be worth a pound of cure for physicians, systems, and the communities they serve.