Dr. John Wust does not appear as a labor troublemaker. A longtime Louisiana obstetrician and gynecologist with a love of flying, Dr. Wust spent the first 15 years of his career as a partner in a small firm – meaning he ran his own practice together with colleagues.
Long after he took a job in 2009 at Allina Health, a large nonprofit health system based in Minnesota, he didn’t see himself as the type of worker who could benefit from collective bargaining.
But that changed in the months before 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 don’t know how to reduce their unsustainable workload because they have less influence at the hospital than ever before.
“The way the system works, I didn’t see any other solution that was legally available to us,” said Dr. Wust.
When he and his colleagues voted to unionize, they were one of the largest groups of private-sector doctors ever to do so. But in October, that award went to a group that included about 400 family doctors who worked at clinics also owned by Allina. The union that represents them, the Doctors Council of the Service Employees International Union, says doctors from dozens of facilities across the country have inquired about organizing in recent years.
And doctors aren’t the only health care professionals organizing or protesting in larger numbers. Health care workers, many of them nurses, had eight major work stoppages last year – the most in a decade – and are on track to meet or exceed that number this year. This fall, dozens of nonunion pharmacists at CVS and Walgreens stores called in sick or quit to protest staffing shortages, many for a full day or more.
The reasons for the recent industrial action seem clear. Doctors, nurses and pharmacists said they were being asked to do more as staff dwindled, leading to exhaustion and fears of harm to patients. Many said they were stretched to the limit after the pandemic began and that their work demands never fully subsided.
But in each case, the explanation runs deeper: Longer-term consolidation of healthcare companies has left workers feeling powerless in large bureaucracies. They say the trend has left them little room to exercise their professional judgment.
“People feel disadvantaged — that’s real,” said John August, a health care labor relations expert at Cornell University’s Scheinman Institute. “The corporate structures in healthcare are not bad, but they have not yet evolved to the point where they understand how to work with healthcare workers.”
Allina said it has made progress in reducing doctors’ workloads and is working with health care workers to address outstanding issues. CVS said it was making “targeted investments” in pharmacies to improve staffing levels in response to employee feedback, while Walgreens said it was committed to ensuring employees have the support they need. Walgreens added that the company invested more than $400 million over two years in recruiting and retaining employees.
Experts from various fields have protested against similar developments in recent years. Schoolteachers, college professors and journalists have gone on strike or unionized as budgets shrink and performance metrics rise that they say are more suited to salespeople than guardians of certain norms and best practices.
But the trend is particularly pronounced in health care, where doctors once enjoyed platinum-level social status at high school reunions and Thanksgiving dinners.
For years, many doctors and pharmacists believed they were largely outside the traditional management-worker hierarchy. Now they feel suffocated by it. The result is a growing worker consciousness among people who have not always shown it – the feeling that they are subordinates who are constantly at odds with their superiors.
“I ultimately realized that we are all workers, no matter how elite we are perceived,” said Dr. Alia Sharif, a colleague of Dr. Wust at Allina, which was heavily involved in the union campaign. “We are seen as cogs in a machine. You can be a doctor or a factory worker and be treated the same way by these big corporations.”
“We were all partners.” Then came the key figures.
The details vary by healthcare sector, but the trend lines are similar: a pre-dawn era in which healthcare professionals say they had the latitude and resources to do their jobs properly, followed by a descent into the ranks of micromanaged healthcare professionals.
As a pharmacy intern and pharmacist at CVS in Massachusetts beginning in the late 1990s, Dr. Ed Smith found that the stores were consistently well staffed. He said pharmacists have time to build relationships with patients.
Around 2004, he became a district manager in the Boston area, overseeing approximately 20 of the company’s locations. Dr. Smith said CVS executives were paying close attention to pharmacists’ suggestions – such as increasing pay for technicians during shortages or updating cumbersome software. “Every decision was based on something we said we needed,” he remembers.
With similar melancholy, Dr. Wast back to his time in an independent practice with around 25 doctors. “We were all partners,” he said. “It was a relative democracy in the workplace. Everyone got one vote. Everyone’s concerns have been heard.”
However, over time, consolidation and the rise of ever larger healthcare corporations meant that workers had less influence.
As so-called pharmacy benefit managers, who negotiate discounts with pharmacies on behalf of insurers and employers, bought competitors, retail giants like Walgreens and CVS also bought to avoid losing market power.
The chains closed many of their new branches, attracting more customers to existing stores. They sought to reduce costs, particularly labor costs, as benefit managers reined in drug prices.
Around 2015, Dr. Smith resigned from his role as district manager and reverted to being a front-line pharmacist because he was reluctant to supervise colleagues in conditions he considered substandard. “I couldn’t ask my pharmacists to do something I couldn’t accomplish,” he said.
Among his disappointments, he said, was the need to strictly limit the number of employees each pharmacy could hire. “Every week if you exceed your work budget, regardless of prescription volume, you will receive a call from your district manager,” said Dr. Smith. “If your technical hour budget is 100 and you’ve used 110, you’ll get a call. It’s not a lot of money – maybe $180 – but you get a call.”
Asked how labor budgets would be applied, CVS said managers were provided “guidance” based on expected volume and other factors and adjustments were made to ensure adequate staffing levels.
Dr. Smith and other current and former CVS and Walgreens pharmacists said hourly quotas for pharmacists and pharmacy technicians at their stores declined in most years in the decade before the pandemic.
Pharmacists also described being held to increasingly strict performance criteria, such as: B. how quickly they answered the phone, the proportion of prescriptions filled for 90 days rather than 30 or 60 days (longer prescriptions mean more upfront), and urgent calls to people filling or picking up prescriptions.
For years, Walgreens and CVS pharmacists were able to largely ignore these narrower metrics as long as overall profits and customer satisfaction remained high. But in the early to mid-2010s, both companies emphasized the importance of these indicators, several pharmacists said.
At Walgreens, many pharmacy managers began reporting to a district retail supervisor rather than a pharmacist-trained supervisor. “It coincided with greater enforcement of metrics,” Dr. Sarah Knolhoff, pharmacist at Walgreens from 2009 to 2022.
“Having never been pharmacists, they pushed pharmacy forward in the same way they pushed the front end,” added Dr. Knolhoff added, alluding to the rest of the store.
CVS said performance metrics are needed to ensure safety and efficiency for patients, but that it has reduced the number of metrics it tracks in recent years. Walgreens announced last year that it would no longer rely on “task-based metrics” in performance reviews for pharmacy employees, but it continues to use them to track performance at the store level.
“Corporate tells you how to treat your patients.”
The transition for doctors and nurses occurred around the same time. As independent medical practices realized they had lost leverage in negotiating reimbursement rates with insurers, many doctors turned to larger health systems that could leverage their size to get better deals.
The passage of the Affordable Care Act in 2010 and federal rulemaking efforts rewarded scale by tying reimbursement to specific health outcomes, such as the proportion of patients requiring readmission. The expansion helped a hospital system diversify its patient population, just as an insurer does, so that certain groups of high-risk patients were not financially ruined.
The administration increasingly assessed its medical workforce on similar metrics related to patient health and instituted a variety of incentives and regulations.
Doctors and nurses were upset about the changes. “Corporate tells you how to treat your patients,” said Dr. Frances Quee, president of the Doctors Council, which represents about 3,000 doctors, most of them in public hospitals. “You know you shouldn’t treat your patient like that, but you can’t say anything because you’re afraid of getting fired.”
At Allina, primary care physicians are incentivized to talk to patients about their high-risk or chronic conditions, even if they are well-treated and not relevant to a visit.
“Is this a valuable use of our 25 minutes together?” said Dr. Matt Hoffman, a family doctor at an Allina clinic that unionized in October. “No, but it means Allina gets more money from Medicare.”
Dr. Wust said hospital administrators are increasingly relying on management theories borrowed from other industries, such as manufacturing, that aim to minimize excess capacity.
For example, he said, when he started working on the system, Allina’s obstetricians had one or two 15-minute waiting areas per day in case of a patient emergency. A few years ago, Allina eliminated these buffers and instructed obstetricians to double-book instead.
When asked about waiting places, Allina replied: “We are always careful about how we use our resources to provide high quality care.” It said the incentives associated with high-risk diseases could be achieved even if a doctor determined that the problem is no longer relevant. Dr. Josh Scheck, another Allina primary care physician, said he found the push helpful and that it wasn’t very time-consuming to address. He said the health system has allowed his clinic to experiment with ways to make its workflow more efficient.
Other healthcare workers complained that some of the metrics they assessed, such as patient satisfaction, made them feel more like retail clerks or food service workers than medical professionals.
Adam Higman, a hospital operations expert at consulting firm Press Ganey, said the consolidation and increased use of metrics arose in response to the need to reduce U.S. health care costs, long the highest per capita in the world, and to ensure The fact that the expenses are actually incurred benefits the patients.
He pointed to data showing that more empathetic and communicative doctors and nurses – factors that impact the patient experience – lead to healthier patients.
However, Mr Higman acknowledged that many health systems had exacerbated tensions with doctors and nurses by not involving them more in the development and implementation of the system of benchmarks by which they would be judged. “The advanced, intelligent health systems and medical groups are listening to physicians, examining their experience and revenue, and creating spaces for discussion,” he said. “If not, that’s one of the contributing factors to the organization.”
“I wouldn’t have brought unions and doctors on the same page.”
The pandemic has increased these pressures.
As retail chains rolled out Covid-19 vaccines, pharmacists complained that they were so overworked that they had to miss bathroom breaks and said they were constantly worried 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 it implemented “special meal breaks for pharmacists” at all stores in 2020 .)
Doctors and nurses found their already overflowing inboxes suddenly overflowing as frightened patients clamored for medical advice. The administration tried to accommodate more patients in overwhelmed hospitals and clinics.
The tipping point came when the pandemic was at its peak, but conditions showed little improvement, according to many workers. Although health systems promised to increase staffing, many faced shortfalls due to inflation and shortages 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: “I wouldn’t have brought unions and doctors together – that would have been a completely alien concept.” Last year she turned to the Medical Council and asked them for help in organizing her colleagues into unions.
Dr. Quee, the union leader, said requests from doctors have increased more than three-fold since the second group of Allina doctors unionized last month – and that the medical council has hired more organizers as a result. (Allina is appealing the result of the union vote in the hospital, but not in the clinics.) Even pharmacists are coming forward. “Two days ago, pharmacists from Florida called me,” she said. “We’ve never done pharmacists before.”
In September, Dr. Smith, who long ago transitioned from CVS district manager to front-line pharmacist, an additional role: work organizer. After CVS fired a district manager who refused to close some stores on weekends to address staffing shortages, Dr. Smith helped organize a series of coordinated sick days and strikes in the Kansas City, Missouri, area, where he worked for the company in recent years.
The work stoppages affected around 20 locations and targeted the company’s pharmacy manager and another employee top official in the human resources department into the city to meet with the renegades. A few weeks later, CVS announced that it would limit the number of vaccination appointments and increase hours for pharmacy technicians, although it did not increase their pay.
CVS said several pharmacists in the Kansas City area called in sick on certain days in September, “resulting in approximately 10 unexpected pharmacy closures on one day and another day.” In response, leaders met with pharmacists to listen to them and address their concerns.
During an interview in October, when Dr. While Smith and his colleagues were still waiting for the company’s response, he made it clear that his patience was running out. “I’ve been asking and asking for improvements for years,” he said. “Now we don’t demand more – we demand it.”