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David J. Leffell | The Doctor’s Office as Union Shop





As the country moves toward the effective start date of the Affordable Care Act in 2014, the operational and economic elements of this vast legislation are becoming clearer. Yet one likely outcome of the act that will directly affect the quality of patient care, and could affect its cost, has gone virtually unnoticed and unreported: the increasing trend for physicians to become employees, rather than self-employed. This development represents a potentially radical factor in the transformation of health care—the doctor as union worker.

Physicians have historically practiced either in small groups or alone. Unlike hospitals, which operate under the rubric of large regulatory agencies, physicians have been much more difficult to regulate and monitor. For cost control to be effective, the professional autonomy and independent clinical judgment of the physician and other providers must in some measure be sacrificed to standardization. This can’t be accomplished by overseeing thousands of doctors in thousands of offices and medical complexes, each conducting its own symphony.

The Obama administration, by intent or accident, has effectively driven a major change in the status of physicians. By reducing the reimbursement for certain office-based specialists while enhancing related payment to hospitals, the administration is compelling more and more physicians—many of them with an any-port-in-a-storm fatalism—to seek employment with health systems or large physician groups.

Another factor lubricating the path to physician employment is generational: Doctors now in training appear willing to forsake income for a better quality of life and are less interested in the entrepreneurship required to run a private practice. They prefer regular hours and don’t necessarily want to be responsible for patients after hours. The net effect is that in 2012 approximately half of physicians already were employed by large health-care entities. Some industry observers estimate that, over the next few years, health systems will employ close to 80% of all doctors.

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