Labor relations

Making History

Allina Mercy Hospital physicians vote to unionize

BY Quy Ton, MD, MPH, Katie Esse, MD, Jessica Boland, MD and Tomas Murdych, MD

These changes sap the morale and health of physicians and negatively impact the physician-patient relationship. Indeed, health care is unlike any other industry because of the previously sacrosanct physician-patient relationship that is at the heart of medicine and health care. The physician-patient relationship is unique as physicians have an ethical and fiduciary responsibility to first do no harm and to act only in the best interest of each individual patient. Physician autonomy allows doctors to advocate for their patients even on nonmedical matters. In contrast, corporate executives, by definition, prioritize the financial solvency and overall “health” of the corporation they lead. Many patients also recognize that third parties (i.e., insurance and pharmaceutical companies, administrators and policymakers/politicians) have been intruding on the physician-patient relationship. These intrusions can negatively impact patient care, increase moral injuries physicians face and result in sub-optimal and morally ambiguous care.

Many employees do not voice their opinions for fear of futility or reprisals.

The corporatization of health care prioritizes and increases hours of bureaucratic tasks such as documenting visits, reviewing charts, completing paperwork, attending required trainings, and responding to billing/coding/insurance disputes. A 2016 study in the Annals of Internal Medicine found that doctors spend two hours on desk work for every one hour with patients. This increase in documenting care rather than providing it combined with a loss of control over their profession have led to escalating moral injuries that have taken their toll on physicians. According to the 2023 Medscape burnout and depression survey, 53 percent of physicians (up by 26 percent since 2018) reported that they are burned out and 23 percent reported feeling clinically depressed. Over 75 percent of doctors indicated burnout had at least a moderate impact on their life and 43 percent reported that it has a severe impact. The highest levels of burnout are among emergency medicine and hospitalist physicians. Every year, women and minority physicians consistently report higher levels of burnout and depression. Another survey reported that one in ten physicians reported suicidal ideation over the past year.

Unions as a Counterbalance

The moral injuries incurred in this new health care climate were further exacerbated during the COVID-19 pandemic. At Mercy Hospital, physicians were the only front-line workers to initially not have their COVID-19 sick pay covered even though Minnesota law required it. Physicians were the only group to receive a pay cut during the pandemic when a retirement benefit was unilaterally removed from them while executives maintained it. For some physicians, these top-down actions imposed on them in the midst of the pandemic were the final straws that convinced them of the need to unionize.

Few doctors are unionized across the country, a function of doctors historically owning their own practices. In recent years, health care consolidation has squeezed out small private practices and more hospitals have chosen to employ doctors directly. Within Allina and other large health corporations, few physician-owned specialty groups remain as most private specialty groups are being forced out in favor of corporation-employed specialty groups. Cost-savings are cited as justifications for the subsequent disruptions in patient care and physician careers.

When physicians owned their group practices, they did not need unions. Their practices were largely autonomous, and they could negotiate directly with hospitals and maintain clinical independence. As employees of corporations, physicians do not have final decision-making capacity over decisions affecting their working conditions and how they care for patients. At Allina, even physician leaders who have worked there for decades have tried to advocate for positive changes within the corporate structure and yet, were powerless to do so. Non-unionized individual employees do not have a collective voice and, more importantly, a collective process to negotiate and maintain autonomy and clinical independence. Executives implement their priorities and specific policies, which can have negatives impacts on employees and patients.

In a corporate structure, many employees do not voice their opinions for fear of futility or reprisals, especially when most have at-will employment contracts. Most physician employees (including at Allina) can be terminated for any reason or no reason. One of the first changes unions typically negotiate for (and usually win) is to change at-will employment to just-cause employment, which requires adequate justification for termination. This single change allows physician employees to advocate for themselves and their patients without the insecurity inherent in at-will employment contracts.

At Mercy Hospital, physicians began a unionization movement at great personal risk when they took steps to explore the process of creating a physician union. Some have been intimidated by administrators and are justifiably concerned they can be removed from their jobs and blacklisted. After filing for unionization, risk of termination has decreased as national labor laws can provide some protections against retaliation. However, fear of retaliation remains.

Deny and Delay

Over a century of unionization in other industries and increasing corporate interest in fighting unions have spawned a $340 million per year cottage industry of law firms that specialize in anti-union campaigns. Anti-union law firms deploy well-orchestrated and precisely timed campaigns to discredit and defeat union efforts by employing a wide range of coercive and subversive tactics to achieve their goal of preventing or breaking up unions by any means possible. Besides direct intimidation of union leaders, they have used other subversive methods to identify potential union organizers. The methods include posing as fellow employees to infiltrate pro-union meetings, conducting surveys under the guise of Diversity, Equity and Inclusion (DEI) and establishing advisory councils to decrease the perceived need to unionize.

Many corporations fighting unionization efforts claim to want open dialogue and debate over unionization. However, these claims of wanting to educate employees do not hold up to scrutiny. Corporations hire large law firms that specialize in anti-union campaigns with the singular goal of defeating unionizing efforts. Meanwhile, corporations supported by dozens of anti-union lawyers maintain full control of all forms of communication, including company emails, direct mail and all forms of oral communication. They do not allow access to physical spaces or work time for union supporters to speak uninterrupted nor allow union organizers to set foot on corporate property.

In February, Allina physicians at Mercy Hospital, in compliance with federal regulations, filed a petition with the National Labor Relations Board (NLRB) for corporate leadership to recognize their union. Despite signatures supporting the union from about 70 percent of the bargaining unit (which far surpassed the NLRB 30 percent minimum requirement to hold an election), corporate executives decided to require a union election. The petition to unionize is a rare organizing push by physicians but is not uncommon among other health care workers, including nurses, pharmacists and food service and maintenance staff. The 150 Allina doctors are organizing to create the first physician union in the state and only the second private-sector union in Minnesota to include physicians. The new union would represent Allina-employed physicians at Mercy Hospital’s two campuses in Coon Rapids and Fridley.

“yes” votes won, authorizing a new union with 64 percent support.

A Look at the Future

It appears inevitable that physician unions will become widespread across the country as a means to recover the professional autonomy and clinical independence physicians lost when most became employees of health corporations. The continued decline of physician autonomy and the progressive erosion of the physician-patient relationship are not sustainable. Structural changes, including unionization, are needed to help reverse these prevailing forces in health corporations and the American health care system.

Per the AMA, “Unions are not a panacea. They are tools available to certain physician employees and can be sought as a response to growing tensions within large hospital systems … The large health care systems currently gaining traction can lack avenues for physician advocacy and meaningful participation in organizational governance. As a result, a new trend is likely to emerge: the pursuit of physician unions ... union-organizing attempts are on the rise in the health care industry … Since January 2022, the NLRB has received 153 petitions for representation to initiate the unionization process in the health care industry overall.” Physician-trainees are leading unionizing efforts among physicians, with an estimated 15 percent of U.S. medical residents already organized under the Committee of Interns and Residents in recent years.

Unionization among physicians would lead to a leveling of power and allow for a more natural balance between the priorities of health corporation leaders and the rights and responsibilities of physicians and their patients. An appropriate balance within health care corporations is needed—one that is similar to the balance between public health officials, who prioritize the health of populations, and physicians, who prioritize the health of individual patients. Physician unions can help flatten the current top-down hierarchy of health corporations. Unions introduce an important structural change that can elevate physicians and patients by enabling shared decision-making responsibilities. Increasing physician agency can help address the feelings of moral ambiguity and powerlessness that many physicians and patients feel in the current corporatized health care system. Physician unions can and will serve as necessary counterweights that balance corporatized health care.

Hopefully there will be swift recognition of the new union so that time and resources are directed toward addressing issues important to delivering the best possible patient care. The election results at Mercy Hospital demonstrate a clear mandate to create a physician union and to begin good faith negotiations for a new contract that addresses what motivated physicians to come together to advocate for themselves and their patients. The time has come to usher in a new era of health care by deciding to be innovative and boldly recognize this new physician union. The time has come to demonstrate the true value and benefits that a more equal partnership between physicians/patients and executives/administrators can bring to patients, employees and health care delivery as a whole. Only with a more equal decision-making structure and actual access to the room where things happen and final decisions are made, will conditions exist that genuinely empower all sides to engage in truly fair and fruitful discussions. Only as equal partners working together to make decisions can patient care be optimized and delivered as the function of the organization for the health of the communities it serves.

Quy Ton, MD, MPH, is a hospitalist at Mercy Hospital.

Katie Esse, MD, is a neurohospitalist at Mercy Hospital.

Jessica Boland, MD, is a intensivist at Mercy Hospital.

Tomas Murdych, MD, is a hospitalist at Mercy Hospital.

Written on behalf of the Coordinating Committee of the Mercy Physician Union / Doctors Council SEIU.