August 6, 1999

Shortly after our meeting began in his Washington, D.C., office, my congressman, Tom Campbell (R-Calif.), was paged. He was being called to the floor of the House of Representatives for a series of four votes. My heart sank.

I had gone to the nation's capital in May for APA's 1999 annual meeting. Prior to the trip, I had arranged a meeting with Rep. Campbell to discuss APA-supported legislation he had introduced, titled the Quality Health Care Coalition Act of 1999. This legislation would affect many psychiatrists and their patients by allowing physicians to form units that could bargain collectively with health plans. I thought that the page for him to come and vote signaled the end of our meeting.

Instead, the congressman invited me to walk with him to the Capitol, where he said we could talk between votes that would take him away only a couple minutes at a time. Shortly thereafter, Rep. Campbell and I were sitting in a reception room just off the House floor. There, under a larger-than-life, full-length portrait of George Washington, we addressed the various matters I had come to discuss.

Here are the main points (many verbatim) that Rep. Campbell made about his bill:

• Description: Physicians would be allowed to form coalitions that could bargain collectively with health care insurance plans regarding matters such as patient care and reimbursement.



• Rationale: "The rationale is better patient care. I believe that doctors and other medical professionals overwhelmingly practice medicine conscientiously because they wish to help patients. Therefore, I believe empowering doctors to bargain will result in better patient care."



• Advantages: A structure would be in place in which physicians and medical professionals could advocate on behalf of themselves regarding the terms and conditions of contracts as well as advocate on behalf of patients for quality care.



• Disadvantages: "The Federal Trade Commission [FTC] and the Department of Justice argue that the act will add to the cost of delivered health care. They argue that doctors would use this exemption to price fix. I disagree with them." The congressman went on to say that if bargaining by doctors results in higher compensation for them, it is more likely that the money will come out of the profits of health care plans, compensation to their employees, or dividends to their shareholders than lead to increased costs to patients.



• Supporters: "The supporters include every medical professional I know and every medical professional association I know, including the American Medical Association and the National Medical Association. We are supported by several labor unions, and we are very close to obtaining support from several consumer groups."



• Detractors: "The detractors are the insurance companies, HMOs, and the Federal Trade Commission (FTC). The FTC, which first applied antitrust laws to the medical profession, is traditionally opposed to exemptions from the antitrust laws."



• Prospects: "The prospects turn on one man, Rep. Henry Hyde, the chair of the House Judiciary Committee. If he allows a vote in that committee, we will win because a majority of the members of the committee is already sponsoring the bill."

In the past decade or so, powerful forces have been unleashed in the health care marketplace that many psychiatrists and other physicians believe have threatened quality of care. These same forces have induced feelings of helplessness, vulnerability, frustration, and even anger in many physicians. How are we to become empowered?

The Quality Health Care Coalition Act of 1999 seems to offer the hope that doctors, if they are willing to join together as bargaining units, will have more say both over patient care issues and their own destinies. As Rep. Campbell pointed out, much of organized medicine supports this legislation. Now, individual physicians should be making up their own minds about its merits by considering what it will mean for them and their patients.

Overall, I view this legislation favorably because it offers the possibility of at least some empowerment to psychiatrists in particular and to physicians in general. But more information would be helpful, because the skeptical part of me wonders what pitfalls may appear.

For example, what will become of doctors who do not wish to join bargaining coalitions or who are not allowed to join? Will they be left out in the cold? Also, if there is competition among physician bargaining units in negotiations with health care plans, will physicians end up making better livelihoods than they do now, or will they be the same or worse? It would be worthwhile to hear more from organized medicine about potential hazards of this legislation.

Is this bill an answer to the terrible situation in which many doctors and their patients find themselves? Perhaps. One thing is certain: Very few, if any, physicians in the private sector are happy with the current state of affairs. As one exasperated colleague recently said to me, "The status quo is not an option!"

Dr. Fitzsimmons is a psychiatrist in private practice in Los Gatos, Calif. The author thanks Maurice Rappaport, M.D., Ph.D., the California Psychiatric Association, and the APA Division of Government Relations for their help in preparing for the meeting with Rep. Campbell. Dr. Fitzsimmons was one of a number of APA members who took advantage of the Washington, D.C., location of APA's 1999 annual meeting to meet with their members of Congress while in town.