Like other healthcare organizations, Medalia HealthCare is wrestling with some tough issues: How can we improve the quality of care while holding down costs? And how can we deal with a marketplace characterized by turmoil, diminishing margins and increasing pressure to do more with less?
But unlike most healthcare companies, one option being considered at Medalia is a physician union.
Ballots were sent last week to about 230 Medalia physicians who were deemed nonmanagers by the National Labor Relations Board. The doctors must return their ballots by June 2 to vote on whether they want to be represented by the United Salaried Physicians and Dentists Union, which is affiliated with the Service Employees International Union. The local collective bargaining unit would be called Northwest Physicians Alliance.
In creating Medalia three years ago, the Providence and Franciscan health systems recognized the importance of physician leadership in a marketplace heavily influenced by managed care. So Medalia was established with physicians' needs at the forefront and a structure that places doctors at every decisionmaking level, from the exam room to the boardroom.
Although Medalia gives its physicians opportunities for leadership and participation, it hasn't always been able to insulate them from marketplace pressures. They have been affected by declining payer reimbursement and the need to get more managed-care contracts. Medalia's financial pressures have caused changes in physician compensation based on productivity.
We've worked to meet the demands of our marketplace by making organizational adjustments, including the consolidation of our computer systems. When Medalia was formed, 22 different computer systems were used across our network of 46 clinics in a 150-mile area. We reduced the computer systems to just two, which has made us more efficient. But switching systems at busy clinics, whose lifeblood is timely information, has been enormously difficult.
Some physicians have been concerned about legitimate problems: Medical records have lacked timely information; patients who have called to make appointments have had to talk to more than one person or have been placed on "terminal hold"; and patients haven't always been able to be seen at convenient times or places.
Physician compensation is based on the number of patients seen by individual doctors. So administrative glitches like the ones experienced when we consolidated our computer systems are especially problematic.
Medalia will continue making changes to better meet our patients' needs and marketplace demands. That mission helped raise the question of whether a union representing Medalia's doctors would enhance patient care and give doctors a stronger voice.
Many Medalia physicians believe a union will do those things. But management believes that many doctors recognize there would be problems with a union. Introducing a nonphysician third party into our day-to-day management would diminish each doctor's voice on patient care, compensation and the group's direction.
Unions have a narrow scope within which to negotiate. They deal primarily with working conditions and compensation. But if, for instance, a physician is on the verge of losing accumulated vacation time and wants to discuss carrying it over, that could be negotiated now. With a union, however, physicians can't cut side deals, and they lose individual flexibility.
A key union strategy is to get a signed contract with management as soon as possible. To do that, some issues that are important to individuals may be set aside. Union contracts include management rights provisions that may exclude certain issues-staffing levels, for instance-from negotiation.
A union also may add another layer of bureaucracy to decisionmaking, slowing the process and complicating responses to rapid-fire marketplace shifts. A physician union at Medalia will not change the marketplace, but it will change how Medalia responds to it.
Admittedly, Medalia is going through an awkward adolescence. For one thing, we're not a cohesive group yet, partly because our physicians come from a wide variety of practice settings. We employ private practice entrepreneurs and doctors who are right out of residency. In addition, physicians are individual thinkers who are not used to delegated decisionmaking, especially when it comes to issues like compensation.
One area we don't perceive as a problem is quality of care, which is usually part of pro-union rhetoric. Our patient monitoring shows continued satisfaction.
The problems I've noted can be resolved but not through collective bargaining. Operational issues are largely beyond the scope of unions. We also don't think that adding people or spending more money are the answers.
Our problems can be resolved through the involvement of everyone concerned, from the custodial staff to the chief executive officer.
In March, Derick Pasternak, M.D., was named our CEO. One of his goals is a partnership with physicians, who provide most of the professional care and leadership for our medical group and support staff.
He believes in total quality management principles: solving problems from the ground up, looking at processes, basing decisions on data instead of gut reactions, and constantly refining work based on study and data. This approach is a natural fit with doctors' evidence-based training.
Like many of the healthcare organizations with which we work or compete, we are striving to care for our patients despite turbulence and other challenges. But we are confident that by working with all our physicians-ideally without the intrusion of a union-we can further the mission of Medalia and its sponsors.
Bales is chief medical officer at Medalia HealthCare, Seattle.