Dr. Glass highlights some of the thorny issues that ACP–ASIM struggled with in developing its position paper. The College recognized that it will be a major challenge for physicians to fulfill their individual and collective responsibilities for professionalism in the face of organized activity to negotiate collectively with managed care organizations and other third-party payers. The College felt strongly that as members of the medical profession, physicians have ethical responsibilities and obligations to patients that must limit the scope of negotiations and restrict physicians from engaging in activities, such as strikes or other organized actions, that would jeopardize patient care. Consequently, the College sought to differentiate between collective bargaining, which implies an adversarial relationship between unions and employers, and joint negotiations that would be limited primarily to issues that affect quality of and access to patient care. Determining which issues affect quality and access is, as Dr. Glass points out, extremely difficult.

Dr. Oberlender highlights the option of alternative dispute resolution as a means of resolving disputes. The College agrees that conflict resolution mechanisms, such as mediation services, must be available for resolving impasses in joint negotiations on behalf of physicians.

Dr. Ross asks, "Who should be the negotiator for our patients?" The College maintains that physicians must play this role. This is a major justification for empowering physicians to negotiate with managed care organizations on a more equal basis than currently exists. Physicians could advocate for patients about provisions restricting referrals to specialists, use of practice guidelines, limits on medical treatments, and restrictions on communications to patients. Dr. Ross's suggestion to include impartial representatives of patients in the negotiations was also considered in the development of the position paper. The College recommended that bargaining units for physicians should include patient representatives in meaningful advisory roles.

The College does not advocate a single national health insurance program, nor does it see such a system as a remedy for all of the problems of the marketplace. Extension of negotiation rights for physicians is not a means of expanding access to health insurance, but the College is committed to working in other ways to achieve affordable health insurance for all Americans.