D ANVILLE, PA — In piecemeal fashion, the doctors shuffled into Hemelright Auditorium. Most remained garbed in their lab coats; some still sported surgical caps and foot covers. Light banter was a no show; physicians wore the grim-visaged game faces of modern medicine.
These Geisinger Medical Center doctors — some 60 in number, including oncologists, nephrologists, cardiologists, radiologists and dermatologists — had not gathered on this September evening to hear about medical protocols, research findings or surgical procedures. They had assembled to hear about forming a union.
This is hardly what Abigail Geisinger could have envisioned in 1915 — nor what anyone who has ever taken the Hippocratic oath ever had in mind. Then again, Hippocrates never had to sweat the details of “downsizing” or reimbursement.
Welcome to the brave new world of managed care, where big medicine is very much big business. And that big, landmark campus on the hill — now a component partner in the merged entity known as Penn State Geisinger Health System — is hardly immune.
Sure, Geisinger, which began offering its own health-care plan to its employees in 1984 and is now the largest rural HMO in the country, is still known nationally as a near utopian sanctuary for the practice of big-time medicine in small-town America. But no less sure is that as hub of the PSGHS’s Central Region, it must deal with a current budget shortfall of $18 million. And for all its national acclaim, it is plagued by a ’90s track record of layoffs, outsourcing and flat physician compensation — amid an uneasy environment of competitive pressures and pricey technology.
Geisinger’s growing pains are largely a function of being paid less by the government as well as by insurance companies. Health plan premiums have been flat for three years — and that money represents $3 out of every $5 Geisinger takes in. And being relatively top-heavy in Medicare patients hardly helps.
Such fiscal concerns, however, are compounded, say many clinicians, by morale-sapping perceptions — from the humanistic to the strategic. Communication from the top down, for example, is often seen as arrogant and nominal. Various communication teams — strategic elements in the Geisinger 2000 master plan for change — include clinician input but are often viewed as window-dressing.
Some point to the new Women’s Center as Exhibit A for skewed priorities at a time when other services, such as the Geisinger Pain Clinic, are being pared back. Even casual observers note the juxtaposition of the Women’s Center construction to the nearby, 3-year-old Janet Weis Children’s Hospital — where one whole floor is closed and wards periodically are shut down. Then add worries about a “brain drain” and identity anxiety that Hershey, where PSU’s College of Medicine is quartered, will increasingly supplant the Danville-based Geisinger Medical Center as provider of first resort for most specialties.
It may not be paradise lost, but there is a sense of professional angst, voiced Cassandra-like by some physicians, that Geisinger could eventually become little more than a “very good community hospital” with helicopters.
<"Everyone expects some turnover, and ours may well fall within national figures," acknowledged another surgeon. "But that is just a number. What it doesn't show is the quality of people we're losing. Doctors on the high end, doctors who have started programs, built careers, who are the reason Geisinger has the reputation it does."
<"The compensation plan changes every year, " complained another physician. "We have no idea what the health plans are paying us. We don't have our own accountant. We just don't have enough information to galvanize us to fight this kind of problem."
<"We have nobody (rank-and-file physicians) on the (PSGHS) board; it's always denied," noted another doctor.
<"Morale is at an all-time low," pointed out another surgeon. "We're like sheep being prodded along with stun guns to keep us moving. We feel disenfranchised, devalued and seriously compromised."
And so it went, the rhetoric less of revolution than raw resentment. Some physicians, however, were clearly beyond venting.
“I’m at the end of my rope,” acknowledged a physician especially disturbed over a decline in available anesthesiologists. “I can’t keep working here like this. I’m very concerned about making mistakes. It’s only gotten worse.”
One “mistake” this doctor, who has been at Geisinger for more than a decade, was not about to make, however, was to “burn bridges” by allowing direct quotation.
“Look, I met my (spouse) here; we live on a farm. We have two kids. I love this area. They could make life miserable.”
A Hospital’s “Pilot Test Case”
The gathering was under the auspices of the Assembly of Geisinger Clinicians, the organization recognized by the administration as the collective voice of the more than 270 physicians on staff.
Adding some bite to the bark of the exasperated AGC is the restive, dues-collecting sub-group, the Geisinger Clinicians Group. The approximately 150-member GCG was formed two years ago, with each founding physician putting up $300 toward a legal fund.
At its inception in 1996, a GCG spokesman, Pediatric Surgeon Charles McGill, offered this rationale:
“…Geisinger has been a physician-led organization since its beginning. The clinicians recognize the complex nature of the decisions the business side of medicine must make to meet this challenge. The recent activities of the GCG have to do with the responsibility to be the patients’ advocates. The clinicians want to assure that significant input from the practicing physicians remain in the decision-making process at Geisinger. We feel that is essential as we seek to provide cost effective, quality care with compassion. This is what we feel our patients expect from us and what we expect of ourselves.”
To those ends, the GCG hired a Philadelphia-area law firm to help it address what it now considers its increasing sense of estrangement from, frustration with and even intimidation by the Geisinger administration.
As one key member of the GCG explained, “People are afraid to speak out, whether it’s about a ‘brain drain’ (of high-caliber, senior clinicians), lack of support staff, poor communication, compensation or whatever. People are tired of rumors and scared of reprisals, from subtle forms of harassment to being forced out…But ultimately people will have to put their money where their mouth is.”
For now, however, this surgeon does not want the words out of his mouth attached to his name — or even his speciality.
The GCG’s retained law firm, Beautyman Associates, represents doctors, medical staffs and health care providers in more than a dozen states. Recent clients include the medical staff of the Medical College of Pennsylvania (a beleaguered, Allegheny Health System constituent) and Community Hospital in Reading.
On hand to speak to the assemblage of physicians was Michael Beautyman, who had been brought in initially to either negotiate physician contracts with Geisinger or assist doctors in departing. His primary charge now was to help the physicians navigate the tricky — and possibly expensive — shoals en route to a collective bargaining unit — or CBU.
In addition, Roger Mecum, executive vice president of the Pennsylvania Medical Society, also addressed the group. The PMS, which has seen its membership, including that at Geisinger, erode in the last decade, is interested in lending support to the AGC as a quid pro quo for regaining dues-paying members. Geisinger could become a “pilot test case” for the PMS.
“We are not like we used to be,” acknowledged Mecum. “Physician needs have changed so much.”
In other words, socio-economic issues are now a priority for the PMS. Indeed, the organization even has a sub-division devoted to collec
But the PMS is hardly a rush-to-unionize proponent. Mecum used the metaphor of “guerrilla warfare,” which could entail, among other strategies, going public with physician grievances and even holding news conferences.
CBU in September?
Beautyman’s focus was the CBU and some of the legal challenges that would assuredly ensue. He also apprised his audience of results of a recent ballot that asked them to endorse the development of a CBU for Geisinger Clinicians. They were informed that 81% of those (148) responding supported the formation of a CBU and 96% of GCG members authorized legal counsel to contact the Board of Trustees.
“You are all employees of the same health care system,” pointed out Beautyman. “You fit into the parameters of the National Labor Relations Act.”
He also discussed who would be ineligible to vote — supervisors and managers — and assured all present that “No action can be taken (by the administration) for filling out a (union) authorization card.” To do otherwise, he emphasized, would be a violation of federal law.
Although Beautyman fast-tracked his audience through the CBU process up to the secret-ballot election conducted by the National Labor Relations Board, he had the less-than-favorable connotations of physician unions to contend with.Nationally, the number of physicians and dentists in unions has increased from approximately 20,000 to 44,000 in the last decade. Not coincidentally, the proportion of physicians with managed-care contracts rose from 61% in 1990 to 83% in 1995. No one thinks the numbers have gone anywhere but up in the last three years.
However, to many Geisinger physicians — a nationally respected group that is arguably as idealistic about medicine as it is naive about business– “First do no harm” is antithetical to the withholding of any service as bargaining leverage. And that could include a slowdown of paperwork as well as a halt in elective surgery.
“I don’t think collective bargaining will occur here,” flatly stated one physician familiar with speaking in the first person plural. “I don’t think there’s a fire in the belly.”
Perhaps, then, that fire is more like heartburn when doctors size up their perplexing situation on the Danville campus. For most, unions still conjure images of Jimmy Hoffa — not Albert Schweitzer.
Witness the following exchange:
First Doctor: “What is the difference between a union and a collective bargaining unit?”
Attorney Beautyman: “None.”
First Doctor: “Oh.”
Attorney Beautyman: “But one is more palatable. On campus you can call yourself anything you want.”
First Doctor: “I see.”
Second Doctor: “How about consortium?”
Attorney Beautyman: “Yes, consortium is fine.”
Among the myriad physicians uncomfortable with unionization is Danville-based Robert Haddad, M.D., senior vice president clinical operations/Central Region.
Haddad, who still stays active in the practice of internal medicine, said he is “disappointed that a group has elected to pursue that (course). Unions have no place in medicine. It’s not compatible with this culture.”
Echoing those sentiments is Stuart Heydt, M.D., CEO of PSGHS, who began as a Geisinger clinician 25 years ago. Heydt, who last year relocated to Hershey and recently sold his Danville home, termed physician unions “incongruous organizationally and professionally. It’s not constructive to head to a bargaining unit. There’s ample opportunity for those in the system to express their point of view.
“The idea that you can create a bargaining unit that will hunker down and set certain unequivocal demands in order to provide service is antithetical to what we’re about,” stressed Heydt. “I understand that people say they have a perspective and it’s not being heard. But people can influence decision-making if they go about it in an honest and constructive way. They also need to understand we’re at a time when we have to be creative and responsive to the fact that our resources are not infinite.”
Nor, apparently, is the supply of patience.
Whether it results in a CBU or not, the organizing process, which could conceivably include complementary roles for both Beautyman and the PMS, is moving apace. Beautyman has been authorized to send a letter to the PSGHS board putting it on official notice that Geisinger clinicians are heading, maybe inexorably, toward forming a more perfect union if their concerns are not addressed.
That letter, which reportedly was akin to a heat-seeking epistle in its initial draft, will still be packed with anecdotal reports that will not reflect well on administrative deportment or ethics.
There are accounts of physicians verbally agreeing to compensation compromises in order to retain support personnel, only to see those key staffers laid off six months later. Examples of errant communication skills feature the likes of a private E-Mail query responded to with an insulting, intimidating letter — copied to others.
“The tragic flaw here is hubris,” Beautyman said. “You’ve got to know when to compromise. Things haven’t gone well with the HMO. They need to reduce costs. There’s always unhappiness with downsizing.”
His characterization of the PSGHS’s overall manner of operations is that of a “Harvard Business School case study of how not to do it. You should be bringing people into the fold, the malcontents, if you will. But they’re not flexible; they stay in denial.”
Keeping It Personal
According to a number of physicians, there’s no denying that the dynamics at Geisinger have become entirely too personal.
Some overall, negative fallout was inevitable given the onset of managed care restraints that were already apparent when Heydt took over as CEO in 1991. But Heydt’s predecessor, neurosurgeon Henry Hood, was country-doctor friendly, charismatic and a veritable guardian angel of the Abigail Geisinger legacy. Indeed, he would begin all his formal meetings with a brief reflection on the Geisinger mission and a solemn reiteration that headquarters would never leave Danville.
Now, neither Hood nor headquarters are where they used to be. Hood is retired and relegated to nostalgic icon status, and headquarters — along with Heydt — is in Hershey.
“Stu Heydt is making unpopular moves and has the personality of a parson’s table,” assessed Ollie Bates, M.D., a recently retired Geisinger nephrologist. “But the administration has done nothing illegal. Personality, I think, is a major stumbling block. Dr. Hood was a profoundly charismatic individual.”
Heydt, a hard-driving executive given to “tough love” approaches with employees, is mindful — and even understanding — of the perception of administrative arrogance. He underscored “perception.”
“We’re not arrogant,” explained Heydt. “We are sensitive to needs. But it doesn’t surprise me a bit. It’s a translation from, ‘Hey, I’m frightened and anxious and need reassurance, and you don’t seem to be listening to me. You’re not accessible. I want you to look me in the eye and tell me I have job security and all the resources I want.’ When that doesn’t happen, you’re perceived as uppity, arrogant, standoff-ish…But I don’t believe for a minute that any member of our management team is aloof or uncaring.”
Perception, of course, is its own reality. And at Geisinger, reality now means serious talk about the National Labor Relations Act.
“The personal factor may be the biggest factor,” summarized Bates, the former Geisinger clinician. “And that’s a shame. Central Pennsylvania must have a Geisinger.”
Will Union Suit Docs’ Needs?
As Geisinger clinicians plot strategies to buttress their negotiation leverage, they have plenty to ponder regarding the ultimate move — the formation of a union. Since physicians who are employees of hospitals, clinics or HMOs are free to form unions, this is, indeed, a viable option for the Geisinger clinicians.
The American Medical Association estimates that between 14,000 and 20,000 physicians are members of a
union. While this is more than at any time since such unions came into existence in the 1930s, it still only represents an estimated 3% of physicians — and most of these are interns and residents. Among the unions (and their founding years) representing physicians are: The Committee of Interns and Residents, 1957; The Union of American Physicians and Dentists, 1972; and The Federation of Physicians and Dentists, 1981.
Always among the issues is the question of whether a given physician or group of physicians are “managers” or “supervisors.” Only “employees” qualify for an anti-trust exemption and the right to bargain collectively under the NLRA.
These are some other questions — and answers — regarding the CBU process that were presented to the Geisinger clinicians.
Q: Why do we need to form a CBU?
A: A CBU will provide us with the legal ability to require Geisinger management to engage in collective bargaining.
Q: Why is a CBU any different than the AGC or the GCG?
A: The AGC and the GCG are only informal associations that do not receive any protections from the federal government, whereas a CBU is legally recognized to engage in negotiations with management.
Q: What protections or advantages does a CBU have?
A: When properly formed, a CBU enjoys the protections enunciated under the National Labor Relations Act, which requires employers to negotiate in “good faith” with a CBU. Management is under no such obligation to negotiate with the Assembly of Geisinger Clinicians or the Geisinger Clinicians Group.
Q: Can Geisinger take any punitive measures against us?
A: No. The NLRA specifically prohibits management from singling out CBU organizers for termination. Any actions taken in violation of such a prohibition are punishable by law.
Q: How will the CBU be structured?
A: The CBU can be structured in several ways. The CBU could consist of all physicians on staff, or it may be broken down by smaller groups. For example, we may form a CBU for each Geisinger campus.
Q: Who would lead the CBU?
A: The leadership of any CBU is decided by a vote of its constituency. After the CBU is formed, its members would then elect the officers.
Q: How do we form a CBU?
A: Have at least 30% of all eligible employees sign authorization cards or a petition; an election petition is then filed; management can then challenge the petition; an election campaign is commenced; an election is held; certification of CBU if the majority of those voting approves.
Q: What actions can a CBU take?
A: A CBU is authorized to negotiate on behalf of its constituency as to terms of employment.
Q: What is the cost of a CBU?
A: Costs inherent with organizing a CBU depend upon management’s response. The process can be lengthy and involve numerous legal challenges. Therefore, your commitment to the process is required. Once formed, it is the decision of the CBU leadership to determine what annual dues its members will pay.
Q: Could Geisinger management choose to negotiate physician contracts with the GCG and without a CBU?