Storm winds are blowing across medicine in Minnesota, and they are stirring up more than late-winter snow and cold. In response, many physicians are facing difficult choices – some old and some new – to retire, to merge their practice with another group, to sell their practice, to seek corporate investment, to pursue non-patient care work, to unionize. Each decision is, of course, personal, but the root causes driving such choices are familiar to us all.
Over the past few years, medicine and healthcare, broadly, have experienced a storm like no other with the COVID-19 pandemic and its aftermath. And the blows keep coming. Despite the fact that the pandemic persists, it has been largely forgotten by the public; the healthcare workforce is tired and diminished; relentless administrative burdens consume our time and patience; the de-professionalization of medicine demoralizes us (it was medical school, not provider school, after all); optimal patient care is threatened as care capacity is maxed out at multiple levels (ED, urgent care, TCU, LTC...); practice and hospital finances are increasingly fragile (remember that New Year’s “gift” from Medicare in the form of a 2% cut to physician services?); and more.
The nature of how and where physicians practice also continues to change. According to an April 2022 study from the Physicians Advocacy Institute, nearly three out of every four U.S. physicians are now employed by hospitals or health systems (52%) or by other corporate entities, such as private equity firms or health insurers (22%). Between 2019-2021, the percentage of employed U.S. physicians grew by a dramatic 19%. From a geographic perspective, the Midwest region, which includes Minnesota, leads the nation in terms of the proportion of physicians employed by hospitals or health systems (63%), although it is the region with the lowest proportion of physicians employed by other corporate entities (~16%). A 2019 report from the Minnesota Department of Health, based on 2018 survey data (notably pre-pandemic), reported similar information, with only 15% of physicians reporting that they are owners or co-owners of their medical practice.
Recently, a group of staff physicians at Allina’s Mercy and Unity campuses announced that they had filed a petition with the National Labor Relations Board for a union representation election with Doctors Council SEIU. Should the involved physicians vote to unionize, it would represent (to the best of our knowledge) the largest Minnesota physician unionizing effort to date, and the first since a group of Duluth physicians joined the United Steelworkers in 2016. We have heard of similar discussions across the state.
Are physician unions the best response to current pressures and forces that are overwhelming many of us? That is a question that each physician will need to make for themselves, considering their own circumstances. Importantly, the MMA is a professional association, not a labor organization. As such, the MMA will not – and cannot – comment on specific unionization efforts or assist in efforts to collectively bargain. The MMA does, however, recognize the right of physicians and physicians-in-training to have their voices heard, including engaging in collective bargaining, consistent with state and/or federal law.
These are turbulent times. Regardless of which path you choose for yourself, let’s work together to support each other and our beloved profession amid these headwinds. In fact, that is what MMA has helped physicians do for 170 years. With your membership support, the MMA will continue its work to support the medical profession and advocate for change to make Minnesota the best place to practice. Together, we can eliminate the use of restrictive covenants in physician employment agreements, that lessen competition, disrupt continuity of care, and limit access to care; we can advocate for changes in health plan practices, including non-sensical prior authorization requirements and formulary hassles; we can advocate for medicine in the courts to protect good medical care; and more.
Change is a constant in medicine, but you are not alone. Help MMA help medicine.
Will Nicholson, MD
Edwin Bogonko, MD, MBA
Chair, Board of Trustees
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Thank you for your thoughtful letter about the challenges facing Minnesota physicians today.
However, you didn't mention one of the largest challenges -- how do we reduce health disparities and promote health equity for our patients, communities, and within our profession?
Health disparities among our African American, Native American, and citizens living in poverty are some of the largest in the nation. And we are given no extra resources, time, or community support to do this. This places a huge emotional, ethical, and clinical burden on physicians and our clinic staff. And as we saw, the pandemic magnified this greatly.
Of course, building health equity cannot happen by physicians only -- it must be taken up by all enterprises and government agencies.
So yes, there is a crisis in Minnesota medicine -- clinical, ethical and yes, justice.
You are correct. We cannot do this alone. Please take every opportunity to highlight health equity and health justice to our physicians, our leaders, and our communities.
Christopher Reif, MD, MPH
It is great to see the MMA continuing in these turbulent times (it seems the times are always turbulent) to assist Minnesota’s physicians with these difficult choices while they provide best practices healthcare to their patients.
Bob Christensen, MD
Responding to the 3/24 email: “Difficult Choices in Turbulent Times” has the MMA forgotten about equity? After George Floyd was murdered, the MMA was big into achieving racial equity. Now I see the MMA is putting a focus on physician challenges. OK, I may be being a little unfair. It is OK to look at challenges physician face, but we do need to remember physicians are a privileged group and actually have significant power to influence their environment if they choose to use that power.
What about a change to address some social/economic equity problems and physician problems simultaneously? Consider the advantages which could come to physician practices and to improving equity if the US or Minnesota adopted a sound single-payer health insurance system. The massive administrative complications and inefficiencies of our multi-payer situation would suddenly be reduced and physicians would once again find it feasible to practice solo or in small groups. Everyone would have sound health insurance and a massive part of the inequity impacting those in low-earning jobs without adequate health insurance would be solved. Savings from reduced administrative overhead, effective negotiations on pharmaceutical prices and predictable payment from all patients would allow us to have universal, comprehensive, affordable health insurance without having to cut physician compensation.
Isn't that a sensible strategy?
Mark Brakke, MD
Unfortunately, the old days of private practices and doctor-owned clinics and active medical associations are mostly gone.
Most physicians don't participate in 'physician' organizations. In the old days, physicians helped teach other about best practice strategies, but that is mostly gone and, unfortunately, most don't know what the advantages of the old days were really like! Healthcare organizations don't really encourage physician-to-physician interactions, i.e. "just stay in your office and see your patients.” I learned tremendously from other senior physicians and from specialists.
I even made a habit of spending half a day at a specialist’s office before I sent them referrals. I learned from them and they got to know me and my skills. We, us physicians, have lost that skill set of talking and learning from each other. Many physicians in primary care don't even know the doctors that they refer to, and I think that is a big mistake.
I also don't see the MMA promoting these interactions especially in the rural areas. Too bad most medical associations have disappeared. We learn from each other.
Mark Nupen, MD
That was a really thoughtful and excellent article/insight. Thank you for the good work that you are doing.
Bill Manahan, MD
Well said. Thank you both. Keep up the good work!
Marshall Hansen, MD
Well written, Dr. Nicholson. Until the government values us we will not be valued by any.
Stephanie Davison Iannazzo, MD