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| DATE | 2023-12-07 |
| FROM | Ruben Safir
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| SUBJECT | Subject: [Hangout - NYLXS] Md and PharmD on stike - NY Times
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Why Doctors and Pharmacists Are in Revolt
Noam Scheiber
16–20 minutes
A portrait of Dr. John Wust, wearing a lab coat, glasses and a bow tie.
When Dr. John Wust, an obstetrician at Allina, and his colleagues voted
to unionize in March, they were one of the largest groups of
private-sector doctors ever to do so.Credit...Jenn Ackerman for The New
York Times
Once accustomed to a status outside the usual management-labor
hierarchy, many health professionals now feel as put upon as any
clock-punching worker.
When Dr. John Wust, an obstetrician at Allina, and his colleagues voted
to unionize in March, they were one of the largest groups of
private-sector doctors ever to do so.Credit...Jenn Ackerman for The New
York Times
Noam Scheiber
Noam Scheiber has been writing about working conditions for doctors and
other professionals since 2015.
Published Dec. 3, 2023Updated Dec. 5, 2023
Dr. John Wust does not come off as a labor agitator. A longtime
obstetrician-gynecologist from Louisiana with a penchant for bow
ties, Dr. Wust spent the first 15 years of his career as a partner
in a small business — that is, running his own practice with
colleagues.
Long after he took a position at Allina Health, a large nonprofit
health care system based in Minnesota, in 2009, he did not see
himself as the kind of employee who might benefit from collective
bargaining.
Listen to This Article
But that changed in the months leading up to March, when his group
of more than 100 doctors at an Allina hospital near Minneapolis
voted to unionize. Dr. Wust, who has spoken with colleagues about
the potential benefits of a union, said doctors were at a loss on
how to ease their unsustainable workload because they had less input
at the hospital than ever before.
“The way the system is going, I didn’t see any other solution
legally available to us,” Dr. Wust said.
At the time he and his colleagues voted to unionize, they were one
of the largest groups of private-sector doctors ever to do so. But
by October, that distinction went to a group that included about 400
primary-care physicians employed in clinics that are also owned by
Allina. The union that represents them, the Doctors Council of the
Service Employees International Union, says doctors from dozens of
facilities around the country have inquired about organizing over
the past few years.
And doctors are not the only health professionals who are unionizing
or protesting in greater numbers. Health care workers, many of them
nurses, held eight major work stoppages last year — the most in a
decade — and are on pace to match or exceed that number this year.
This fall, dozens of nonunion pharmacists at CVS and Walgreens
stores called in sick or walked off the job to protest
understaffing, many for a full day or more.
The reasons for the recent labor actions appear straightforward.
Doctors, nurses and pharmacists said they were being asked to do
more as staffing dwindles, leading to exhaustion and anxiety about
putting patients at risk. Many said that they were stretched to the
limit after the pandemic began, and that their work demands never
fully subsided.
Image
A portrait of Dr. Alia Sharif, wearing a lab coat and crossing her
arms, inside a home office.
“We’re seen as cogs in the wheel,” Dr. Alia Sharif said, “You can be
a physician or a factory worker and you’re treated exactly the same
way by these large corporations.”Credit...Jenn Ackerman for The New
York Times
But in each case, the explanation runs deeper: A longer-term
consolidation of health care companies has left workers feeling
powerless in big bureaucracies. They say the trend has left them
with little room to exercise their professional judgment.
“People do feel put upon — that’s real,” said John August, an expert
on health care labor relations at the Scheinman Institute at Cornell
University. “The corporate structures in health care are not evil,
but they have not evolved to the point of understanding how to
engage” with health workers.
Allina said that it had made progress on reducing doctors’ workloads
and that it was partnering with health care workers to address
outstanding issues. CVS said it was making “targeted investments” in
pharmacies to improve staffing in response to employees’ feedback,
while Walgreens said it was committed to ensuring that workers had
the support they needed. Walgreens added that it had invested more
than $400 million over two years to recruit and retain staff
members.
Professionals in a variety of fields have protested similar
developments in recent years. Schoolteachers, college instructors
and journalists have gone on strike or unionized amid declining
budgets and the rise of performance metrics that they feel are more
suited to sales representatives than to guardians of certain norms
and best practices.
But the trend is particularly pronounced in health care, whose
practitioners once enjoyed platinum-level social status at high
school reunions and Thanksgiving dinners.
For years, many doctors and pharmacists believed they stood largely
outside the traditional management-labor hierarchy. Now, they feel
smothered by it. The result is a growing worker consciousness among
people who haven’t always exhibited one — a sense that they are
subordinates constantly at odds with their overseers.
“I realized at end of the day that all of us are workers, no matter
how elite we’re perceived to be,” said Dr. Alia Sharif, a colleague
of Dr. Wust’s at Allina who was heavily involved in the union
campaign. “We’re seen as cogs in the wheel. You can be a physician
or a factory worker, and you’re treated exactly the same way by
these large corporations.”
‘We were all partners.’ Then came the metrics.
Image
Pharmacists at Walgreens and CVS have complained of understaffing
and overly aggressive performance targets. Credit...Spencer
Platt/Getty Images
The details vary across health care fields, but the trend lines are
similar: A before-times in which health care professionals say they
had the leeway and resources to do their jobs properly, followed by
what they see as a descent into the ranks of the micromanaged.
As a pharmacy intern and pharmacist at CVS in Massachusetts
beginning in the late 1990s, Dr. Ed Smith found the stores
consistently well staffed. He said pharmacists had time to develop
relationships with patients.
Around 2004, he became a district manager in the Boston area,
overseeing roughly 20 locations for the company. Dr. Smith said CVS
executives were attentive to input from pharmacists — raising pay
for technicians if there was a shortage, or upgrading clunky
software. “Every decision was based on something that we said we
needed,” he recalled.
Dr. Wust looked back on his days in an independent practice of about
25 doctors with a similar wistfulness. “We were all partners,” he
said. “It was relative workplace democracy. Everybody got a vote.
Everybody’s concerns were heard.”
Over time, however, consolidation and the rise of ever-larger health
care corporations left workers with less influence.
As so-called pharmacy benefit managers, which negotiate discounts
with pharmacies on behalf of insurers and employers, bought up
rivals, retail giants like Walgreens and CVS made acquisitions as
well, to avoid losing market power.
The chains closed many of their newly owned locations, driving more
customers to existing stores. They sought to cut costs, especially
labor costs, as the benefit managers reined in drug prices.
Around 2015, Dr. Smith stepped down from his role as a district
manager and became a frontline pharmacist again, reluctant to
supervise co-workers under conditions he considered subpar. “I
couldn’t ask my pharmacists to do what I couldn’t accomplish,” he
said.
Among his frustrations, he said, was the need to strictly limit the
number of workers each pharmacy could schedule. “Every week that
you’re over your labor budget, you get a call, regardless of
prescription volume, from your district manager,” Dr. Smith said.
“If your budget for tech hours is 100 and you used 110, you get a
phone call. It’s not much money — maybe $180 — but you’re getting a
call.”
Asked how labor budgets were applied, CVS said managers were
“provided guidance” based on expected volume and other factors, with
adjustments made to ensure adequate staffing.
Dr. Smith and other current and former CVS and Walgreens pharmacists
said their stores’ allotment of hours for pharmacists and pharmacy
technicians had dropped most years in the decade before the
pandemic.
The pharmacists also described being held to increasingly strict
performance metrics, such as how quickly they answered the phone,
the portion of prescriptions that are filled for 90 days rather than
30 or 60 days (longer prescriptions mean more money up front) and
calls made urging people to fill or pick up prescriptions.
For years, Walgreens and CVS pharmacists could largely ignore these
narrower metrics so long as overall profits and customer
satisfaction stayed high. But in the early to mid-2010s, both
companies elevated the importance of these indicators, several
pharmacists said.
At Walgreens, many pharmacy managers began reporting to a
districtwide retail supervisor rather than a supervisor trained as a
pharmacist. “It coincided with more pushing of the metrics,” said
Dr. Sarah Knolhoff, a Walgreens pharmacist from 2009 to 2022.
“Never having been a pharmacist, they would push the pharmacy the
same way they would push the front end,” Dr. Knolhoff added,
alluding to the rest of the store.
CVS said that performance metrics were needed to ensure safety and
efficiency for patients but that in recent years it had reduced the
number of metrics it tracked. Walgreens announced last year that it
would no longer rely on “task-based metrics” in performance reviews
for pharmacy staff members, though it still used them to track
store-level performance.
‘Corporate tells you how to manage your patient.’
Image
At health systems like Allina, doctors have incentives to talk to
patients about conditions that may not be relevant to their
immediate care. Health experts say it can help ensure that high-risk
conditions are attended to.Credit...Jenn Ackerman for The New York
Times
The transition for doctors and nurses came around the same time. As
independent medical practices found they had lost leverage in
negotiating reimbursement rates with insurers, many doctors went in
house at larger health systems, which could use their size to secure
better deals.
The passing of the Affordable Care Act in 2010, along with federal
rule-making efforts, rewarded bigness by tying reimbursement to
certain health outcomes, like the portion of patients who must be
readmitted. Getting bigger helped a hospital system diversify its
patient population, the way an insurer does, so that certain groups
of high-risk patients weren’t financially ruinous.
Administrators increasingly evaluated their medical staff according
to similar metrics tied to patients’ health and put a variety of
incentives and mandates in place.
Doctors and nurses chafed at the changes. “Corporate tells you how
to manage your patient,” said Dr. Frances Quee, president of the
Doctors Council, which represents about 3,000 doctors, most of them
at public hospitals. “You know that’s not how you’re supposed to
manage your patient, but you can’t say anything because you’re
scared you’re going to be fired.”
At Allina, primary care doctors are given incentives to talk to
patients about their high-risk or chronic medical conditions, even
if those conditions are well managed and aren’t relevant to a visit.
“Is that a valuable use of our 25 minutes together?” said Dr. Matt
Hoffman, a primary care doctor at an Allina clinic that unionized in
October. “No, but it means Allina gets more money from Medicare.”
Dr. Wust said hospital administrators increasingly relied on
management theories borrowed from other industries, like
manufacturing, that sought to minimize excess capacity.
For example, he said, obstetricians at Allina had one or two hold
spots a day of 15 minutes each, in case of a patient emergency, when
he began working at the system. Several years ago, Allina took away
these buffers, instructing obstetricians to double book instead.
Asked about the hold spots, Allina said, “We’re always looking at
how we’re using our resources to deliver high-quality care.” It said
the incentives tied to high-risk conditions could still be achieved
if a doctor stated that the problem was no longer relevant. Dr. Josh
Scheck, another Allina primary care doctor, said he found the nudge
helpful and not very time consuming to address. He said the health
system had allowed his clinic to experiment with ways to make its
work flow more efficient.
Other health workers complained that some of the metrics they’re
evaluated on, like patient satisfaction, made them feel like retail
clerks or dining employees rather than medical professionals.
Adam Higman, an expert on hospital operations at the consulting firm
Press Ganey, said consolidation and the increased use of metrics had
arisen in response to a need to lower U.S. health care costs, long
the world’s highest per capita, and ensure that the spending
actually benefits patients.
He pointed to data showing that more empathetic and communicative
doctors and nurses — factors that affect patients’ experience — lead
to healthier patients.
But Mr. Higman acknowledged that many health systems had increased
tensions with doctors and nurses by failing to involve them more in
developing and putting in place the system of metrics on which they
are judged. “The progressive, smart health systems and medical
groups are listening to physicians, looking at their experience and
turnover and creating venues to have discussions,” he said. “If not,
that’s one of the contributing factors to organizing.”
‘I would not have put unions and physicians in the same mind.’
Image
Nurses went on strike for three days in January at Mount Sinai
Hospital in New York to protest understaffing.Credit...Gregg
Vigliotti for The New York Times
The pandemic magnified these strains.
As retail chains rolled out Covid-19 vaccines, pharmacists
complained of being overworked to the point of skipping bathroom
breaks and said they worried constantly about making mistakes that
could harm patients. (CVS said it began closing most pharmacies for
30 minutes each afternoon last year to give pharmacists a consistent
break. Walgreens said “dedicated pharmacist meal breaks” began in
all stores in 2020.)
Doctors and nurses found that their already backed-up inboxes were
suddenly bursting, as frightened patients clamored for medical
advice. Administrators sought to squeeze more patients into
overloaded hospitals and clinics.
The breaking point came when the height of the pandemic passed, but
conditions barely improved, according to many workers. Although
health systems had promised to add staffing, many found themselves
running deficits amid inflation and a shortage of doctors and
nurses.
Professionals who had never considered themselves candidates for
union membership began to organize. When she started at Allina in
2009, Dr. Sharif said, “I would not have put unions and physicians
in the same mind — it would have been a totally alien concept.” She
reached out to the Doctors Council last year for help unionizing her
colleagues.
Dr. Quee, the union president, said that inquiries from doctors were
up more than threefold since the second group of Allina doctors
unionized last month — and that as a result, the Doctors Council was
hiring more organizers. (Allina is appealing the outcome of the
union vote at the hospital but not at its clinics.) Even pharmacists
are reaching out. “Two days ago, pharmacists called me from
Florida,” she said. “We’ve never done pharmacists before.”
In September, Dr. Smith, who long ago shifted from CVS district
manager to frontline pharmacist, took on an additional role: labor
organizer. After CVS fired a district manager who had refused to
close some stores on weekends to address understaffing, Dr. Smith
helped organize a series of coordinated sick days and walkouts in
the Kansas City, Mo., area, where he has worked for the company in
recent years.
The walkouts affected roughly 20 locations and drew the company’s
chief pharmacy officer and a top human resources official to town
for a meeting with the renegades. A few weeks later, CVS said it
would rein in vaccination appointments and add work hours for
pharmacy technicians, though it had not increased their pay.
CVS said several Kansas City-area pharmacists had called in sick on
certain days in September, “resulting in about 10 unexpected
pharmacy closures” on one day and part of another. In response, it
said, executives met with pharmacists to listen to and address their
concerns.
During an interview in October, while Dr. Smith and his colleagues
were still awaiting the company’s response, he made clear that his
patience had run out. “I’ve been asking and asking and asking for
improvements for years,” he said. “Now we’re not asking any more —
we’re demanding it.”
Audio produced by Patricia Sulbarán.
Noam Scheiber is a Chicago-based reporter who covers workers and the
workplace. He spent nearly 15 years at The New Republic, where he
covered economic policy and three presidential campaigns. He is the
author of “The Escape Artists.” More about Noam Scheiber
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