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Jul. 12 2010 - 8:22 pm | 374 views | 2 recommendations | 14 comments

The death of the American Medical Association

Once one of the most powerful lobbies in all the nation, the American Medical Association (AMA) no longer appears capable of putting much bite into its bark.

To illustrate the point, one need only examine the organization’s complete and utter ineptitude at handling the most important issue facing American physicians – the ever present axe that hangs over their heads as they attempt to fight off the 21% reduction in Medicare payments payable to doctors willing to treat the nation’s elderly.

It’s not like they haven’t had their chances.

The first misstep came with the AMA’s willingness to accept and support the Obama healthcare plan without gaining anything in return. Surely, a promise to deliver on a repeal of the law that is producing the threatened cuts – or at least a commitment to table the cuts for a meaningful period of time – could have been accomplished in exchange for AMA support of the health care reform bill.

But then, when it comes to politics, one must ask before one can expect to receive. And when asking politely doesn’t work,  one must be prepared to threaten with the checkbook.

But not so the AMA.

The AMA says it endorsed reform because the law would help doctors and patients by expanding coverage, adding it never took part in a quid pro quo to support the bill.

“We make no apologies for our strong, principled advocacy on behalf of patients and physicians,” Cecil B. Wilson, president of the AMA, said in a statement to POLITICO. “We have been vocal advocates for covering the uninsured since before the last presidential election — before the issue became divisive and politicized.”
Via Politico

I suppose I can respect such a noble and principled approach. But then, I’m not a physician struggling to keep my office open while accepting elderly patients on what little Medicare already pays, let alone trying to do it with a further 21% cut in pay.

Having let the moment pass them by at the outset of reform, the AMA determined not to make the same mistake twice. Last month, they went full force for a complete repeal of the threatened cuts – a repeal that would cost  the national treasury some $240 billion. Once again, a noble objective. But in an election year where Democrats are already getting their heads handed to them for ballooning deficits, it doesn’t take a strategic genius to understand that such an approach is not going to succeed and that an unwillingness to compromise is just plain stupid – especially when Congress offers a reasonable compromise.

And that is precisely what Congress did.

Unable to push through an expensive repeal of the law, for all the obvious reasons, Congress suggested a five-year fix that would have given the docs a little breathing room while we see how reform develops. But the AMA refused. Instead, they launched a multimillion – dollar television campaign attacking the U.S. Senate for walking away from the problem.

What did the AMA win for their efforts? Rather than the five- year deal they had within their grasp, they achieved only a one-month reprieve. That’s right – having turned down a five-year deal, they spent millions of dollars only to end up with just 30 days until the ugly problem raises its head once again. Does it get any more embarrassing for a political lobbying group? Is it any wonder that membership in the AMA has dwindled to a mere fraction of what it once was?

For those physicians who continue to belong, I can only hope that they show better judgment when cutting us open than they do when it comes to political decision making. While taking a principled, all-or-nothing approach may be admirable – it is usually the province of interest groups who seek only to be heard in the press and on cable TV rather than those who actually mean to accomplish something in Congress. Our collective health demands much more. Medicine in America is very much about politics. And if the physicians can’t handle it, you and I will pay the price.

It is worth keeping in mind that the AMA is the very same organization that has managed to get its way on healthcare policy since first taking on Teddy Roosevelt to defeat a national health insurance program. Indeed, they have defeated every single president they’ve taken on when it comes to healthcare proposals that did not meet with their approval.

But those days are over.  The time has come to pronounce the AMA dead and hope that the nation’s physicians will respond by creating an organization with the requisite skill and courage required to represent their interests.

Why do we care? Because while you may have gripes about how much money physicians earn (and I hear them all the time), I assure you that the interests of America’s physicians are very much tied to our own. You simply cannot have a health care system without the doctors who diagnose the illnesses, dispense the treatments, work the cures and alleviate our pain. This is not an abstract proposition. Should you or a member of your family become ill, it won’t be politics or disgust over how much the other guy earns that is on your mind. You’re going to want a doctor and you’d better hope there is a competent one available to provide what you need.

The AMA has given a whole meaning to the adage, “Physician, heal thyself.” The nation’s doctors would be wise to take the advice and get themselves properly organized before it’s too late- if it isn’t too late already.


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4 T/S Member Comments Called Out, 14 Total Comments
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  1. collapse expand

    The AMA continues to achieve important advocacy victories for patients and physicians, and our support for health system reform helped Congress pass landmark legislation. An independent poll by Kaiser Family Foundation found that the public has high trust and confidence in physician groups like the AMA, and we’re considered a key voice to have on your side in the political arena.

    Mr. Ungar ignored the critical fact that there were not enough votes in the House or Senate to pass the proposed five-year Medicare payment fix, which would have increased the size of the problem and the ultimate cost to fix it. The AMA is committed to permanently fixing the Medicare physician payment problem. During the debate last month in the U.S. House of Representatives, both Republicans and Democrats vocally supported our call for a permanent fix, but could only pass a six month delay. Congress created this problem, and they need to solve it.

    We will work with elected officials on both sides of the aisle to secure a permanent fix to this perennial problem, but we will not accept proposals that grow the problem and make it nearly impossible to solve. The AMA is the nation’s largest physician organization, and we continue to work for policies that help physicians do what they do best – help patients.

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    With all due respect, it is difficult to see this response as an adequate defense.

    I’m afraid that I cannot agree that the AMA has achieved much in the way of victories for physicians or patients in recent years. What’s more, the AMA’s support for the the reform legislation ultimately proved to be of little or no value as your support was never properly utilized as a chip to accomplish desired benefits for either your members or the patients they serve. Indeed, I have yet to come across a vote in either house of Congress which was affirmatively registered as a result of AMA support – and I do track them rather closely. What I have often come across are legislators surprised by the AMA’s lack of relevance in the debate.

    With regard to your second paragraph, we very much do not know that there were not enough votes in pass the proposed five-year payment fix because you never threw your muscle behind the proposition. It was crystal clear from the outset that a permanent fix was not a realistic goal in an election year such this. Had the AMA flexed whatever muscle you may still possess – and it is highly questionable whether that muscle continues to exist – I believe the votes could have been accomplished to get the 5 year deal. Indeed, my information indicates that it is highly likely that either this would have been the result or, at worst, a compromise of 2 years or some such thing could have been achieved. Going the route of spending millions to attack Congress (when those millions could have been spent in the service of gaining votes) was clearly a useless strategy as is borne out by the result. After millions spent, we now face the issue just 30 days after the last time we faced the issue. I’m simply not clear on how you can quantify this as successful lobbying.

    Whether or not the public has high trust in physician groups like the AMA is certainly not the issue. I, for one, hold physicians in the highest possible regard considering that there is not a chance I would be alive today but for the extraordinary skills of more doctors than I want to say. And I want those physicians to be well represented because i believe we all benefit when they are well represented.

    Frankly, from what I can see, the only impact the AMA has had in recent years is the delivery of faulty survey data to the CMS resulting in a nearly catastrophic result for cardiologist and others who have seen their reimbursements take a nose dive for CT scans, etc.

    Being the nation’s largest physician organization does not, unfortunately, equate to effectiveness. Frankly, the fact that physician’s in this country continue to face the Medicare payment cut on a monthly basis sadly speaks to the reality of this fact.

    I bear no ill will towards the AMA or anyone who stands up for the nation’s physicians. I am simply calling out the AMA for its lack of effectiveness in serving the physicians – and, thereby, the patients – who have long relied on the organization’s skills to serve the political needs of medicine. For whatever reason, the organization has lost its “mojo” at the moment when it is needed the most.

    A final note — since organizations don’t write responses, it would be helpful if you a attached a ‘human’ name should you want to continue this conversation -as I hope you will.

  3. collapse expand

    I stopped renewing my membership in the AMA when they came out against health care. The AMA has been against government regulation or involvement in health care since day one. So? Now physicians are ruled by the insurance industry. Patients and physicians sacrifice as the insurance industry takes money out of the system and gives nothing back.

    Physicians should organize. However, the AMA is a dinosaur.

  4. collapse expand

    The AMA dates from a time when physicians were the medical industry in the US. Modern medicine is a highly complex, multi-skill product delivery system in which physicians are a minority. The medical community needs a more inclusive entity which represents the interests of the various practitioners, i.e., nurses, pa’s, technicians, et al. The oligarchic nature of the AMA seems to have been the cause of its current ineffectiveness.

  5. collapse expand

    This isn’t an especially useful explanation of the Medicare reimbursement problem, or the issues surrounding fixing it – I’d assume the AMA’s opposition to the “five year fix” has to do with both the cut it would represent to doctor’s fees and the fact that it’s really no fix. This is a much bigger, more substantive issue than many people realize, and indeed is probably the heart of healthcare reform, one reason I, like others with some understanding of the subject, opposed healthcare “reform” that avoided the central issue: a failure on the part of government to better control the cost of Medicare.

    Let’s be clear: there’s essentially no will in Congress to see the 21% cut go through, because what it will mean, in practical terms, is large numbers of doctors and institutions exiting Medicare, which in turn will affect services for seniors, and one thing we know, as the sun rises and sets, is that seniors vote on Medicare. Thus the AMA, and everyone else, have Congress over a barrel; the question isn’t “will they wilt on the 21% cut”, but how much and for how long.

    The reality here is that the forced reduction in Medicare reimbursements is a farce and should, probably, be done away with entirely (it should, most certainly, not have been used as it was to pretend that healthcare reform wouldn’t cost as much as it will turn out to cost). Instead, Medicare reimbursement rates should probably undergo a full scale reassessment; this is politically unpopular, and would, most likely, be very painful – not even so much for docs as it will be for hospitals, which are far more dependent on the steady stream of predictable revenue from set fees. The other point here is that what we should do, in fact, is end “fee for service”, which is what drives not just Medicare but from it, all the pricing of healthcare in America as we know it. This, then, is the crux of “single payer” discussions and too is a political nonstarter, especially on the right.

    By focusing this post on some narrow assessment of supposed “weakening” of the AMA – which, really, has weakened mostly because it no longer has monopsony power over medical lobbying – the bigger issue is ignored: the AMA doesn’t want a five year fix; it wants the “doc fix” repealed… and come thirty days, or ninety days, or whenever, that choice gets no easier for Congress, or the rest of us. I don’t think it’s surprising that the AMA thinks the odds for them are better in August… or even better, say, when October rolls around.

    • collapse expand

      To say that your comment is confusing would be something of an understatement.

      “I’d assume the AMA’s opposition to the “five year fix” has to do with both the cut it would represent to doctor’s fees and the fact that it’s really no fix. This is a much bigger, more substantive issue than many people realize, and indeed is probably the heart of healthcare reform, one reason I, like others with some understanding of the subject, opposed healthcare “reform” that avoided the central issue: a failure on the part of government to better control the cost of Medicare.”

      1. Uh…huh? I think you’re saying here that resolving the 21% cut is no fix at all? I don’t think physicians would agree.
      Further, with all due respect, your suggestion that you – and others like you – are the ones who “understand” the subject, is just a bit condescending. If you really understood health care policy, you would understand that fixing cost issues through national legislation is nearly impossible. That was the red herring of the legislation. Health care costs can only be successfully dealt with on the local level. If you understood this as well as you seem to think you do, you would understand that there was a will to resolve the SGR cuts in the main body of the legislation however, it would have added about $600 billion to the bill – something that the politicians had little stomach for. I might suggest that you read all the posts here before suggesting that discussing one small issue indicates the full knowledge of a writer’s understanding. I think you’d find you are way off base.

      “The reality here is that the forced reduction in Medicare reimbursements is a farce ”

      It appears that you believe the SGR, that you deem a farce, was created in the recent legislation. This is incorrect. It has been in existence since 1998 when it was instituted as a means of holding down physician reimbursement costs. The problem is that the formula did not take into consideration the rapid rise in the cost of medicine and never intended the deep cuts that have accumulated.

      “Medicare reimbursement rates should probably undergo a full scale reassessment; this is politically unpopular, and would, most likely, be very painful – not even so much for docs as it will be for hospitals, which are far more dependent on the steady stream of predictable revenue from set fees. The other point here is that what we should do, in fact, is end “fee for service”, which is what drives not just Medicare but from it, all the pricing of healthcare in America as we know it. This, then, is the crux of “single payer” discussions and too is a political nonstarter, especially on the right.”

      While there are a few dramatic statements of the obvious here, I would very much disagree that fee for service is what is driving the single payer discussion. Again, if you really wish to understand the single payer discussion, you might wish to read a few more posts here.

      “By focusing this post on some narrow assessment of supposed “weakening” of the AMA – which, really, has weakened mostly because it no longer has monopsony power over medical lobbying – the bigger issue is ignored.:

      Uh…sorry…but I didn’t really intend to tackle the entire health system issue in one post. My goodness, but you expect a lot! I suppose I could simply reprint my book here (as it took a book to even begin to deal with what you seem to feel should into a 1000 word post), but I’d rather you go out and buy it.

      “the AMA doesn’t want a five year fix; it wants the “doc fix” repealed… and come thirty days, or ninety days, or whenever, that choice gets no easier for Congress, or the rest of us.”

      Did yo actually read this post or are you simply restating what was written as you suggest that it hasn’t covered what you think are the appropriate points? I’m pretty sure that this is precisely what this posts says…yup…just read it again..that’s what it says.

      Do you actually think that the AMA – or anyone else- believes they will get a better result as we get closer to the mid-term elections? Again, no disrespect, but your understanding of politics kind of mirrors your understanding of health care policy. You don’t seem to get the problem here. Congress is not against getting rid of the SGR cuts. They’ve delayed the cuts every year of the past five years. How do you think it added up to 21%? They’re problem is political – if they remove the cuts, they add $600 billion to the Medicare budget estimates. Think that’s something anyone wants to run on?

      In response to another comment. See in context »
      • collapse expand

        I don’t think there’s a monopoly on naivete, or expertise, here; I’m also not sure, given your follow up, that we especially disagree, though I suspect we’re coming to the same conclusions from different directions.

        Still, on a fundamental level, I disagree with your assertion that there’s no “national” way to achieve some level of cost control. Medicare and Medicaid reimbursements. clearly, serve as a vehicle for determining some basic levels of cost – if not, why would docs and hospitals be so up in arms about the setting of the fee structure?

        That said, it seems to me we’re both looking for the same thing – a better, more sensible approach to determining Medicare’s payment structure. And I maintain my original point that this post – and not some body of work – doesn’t particularly describe the “doc fix” clearly, or why the AMA would not support a five year fix, rather than, say, a flat out repeal of the planned cuts.

        Again, you suggested – not me – that this failure to find agreement on a fix reflected badly on the AMA, and suggested a loss of power. I’d say, and I thought I did, that the AMA has lost power primarily because it no longer serves as the sole or primary representative of medical doctors. But I think to suggest that a “kick the can” slightly closer to the fall temporary solution is proof of failure on their part is mistaken. As you say, seriously trying to address medicare reimbursements is a budget busting, unpopular move. I agree; but I think the AMA is probably right that they can wait awhile and watch Congress blink without having to give up all that much. The alternative of letting the 21% cut go through is simply implausible. Which, it seems, is another place where we probably agree.

        Finally, I stick by the point I was making – we need an end of fee for service. Medicare reform is a key element of that, and I think the healthcare reform we got – which I think was ultimately a poor bill which will generally make our situation worse – is poorer for how little serious work was done reforming Medicare and more crucially, Medicaid. I do favor, in the long term, a move to a single payer system. But I have no use for the buzzy progressive popularity of “medicare for all” partly because of elements precisely like the doc fix. A government which can’t properly manage the Medical insurance programs it currently manages is to my mind terribly ill-equipped to expand that same program on an even larger scale. And that is why, perhaps awkwardly, I tried to make this point – it would be more sensible to do away with the fantasy of the doctor fee cut (21% and growing, as you say) rather than endlessly kicking it down the road as if, in some odd future, it will be more attractive. And yes, that huge budget reality – which, I’d point out, is the reality – is deadly for members of Congress. That, I think, is the point many are trying to make about just how bad the government’s budgeting stands, at this point.

        Oh, and I think this is also important: I grow weary of this “we have to face the political realities of what’s doable on healthcare reform”. I’m not denying political realities… but I think acknowledging them doesn’t absolve anyone – especially anyone with any good sense of just how broken our healthcare systems are – of advocating the best solutions possible. Unless we hold to some ideals and stick to our guns about the reforms we care about… we really can’t change those political realities. And God knows… if we want serious reforms, we’ll need some better political realities.

        In response to another comment. See in context »
        • collapse expand

          I didn’t say there was no rational way to accomplish cost control – I said that cost control is difficult to achieve on a national basis. It has to addressed on the local level.Certainly we address Medicare & Medicaid fraud nationally – a healthy chunk of change – but finding ways to reduce the actual cost of medicine, and the reverberation that accomplishes throughout the system- must start at the state and local level where the issues can be addressed in a way that works for that locality.
          I’m also fine with moving away from free for service payment basis.
          I think my overall point here was that you appeared to want me to discuss every issue touching the American health care system in one blog and, if you think that is possible, maybe there’s a bit more you need to know about those problems.

          In response to another comment. See in context »
          • collapse expand

            Certainly we address Medicare & Medicaid fraud nationally – a healthy chunk of change – but finding ways to reduce the actual cost of medicine, and the reverberation that accomplishes throughout the system- must start at the state and local level where the issues can be addressed in a way that works for that locality.

            A) The national discussion is about more than fraud. We need a much more fundamental reassessment of Medicare’s payment structures, and we need to face the reality that Medicaid’s block grant structure simply doesn’t work. The fact that both of these elements were so “politically untenable” during the reform negotiations goes back to some very painful realities about ever doing reforms properly. As long as we’re fiddling on the margins (fraud alone is no solution to this crisis), we’re not accomplishing much.

            B) I’m symnpathetic to your “all pricing is local” take, but I think that may be a fairly basic difference in how we’re viewing all of this: I think there’s too much emphasis in the current discussions on cost over care. If we want to be sure that most people have access to the care they need when they need it, then we need a more national solution; doing this piecemeal, by locality, pretty much assures that the care you get will depend, tremendously, on where you are (I’m thinking especially of the deep south, which has not historically shown great ability to handle stuff like this). This is a national problem, even though specific issues vary locally; I’m convinced we need a solution that’s more national in scope, which reduces regional differences.

            You seem determined to define what it is I want to say. I, too have been writing about these issues long enough, and extensively enough, to know that you can’t encompass all our problems, or all our solutions in one post (lord knows, I tried). That’s neither what I meant nor what I said. What I said, and what I maintain, is that your initial post did not do as good a job laying out the Medicare reimbursement issue as it could have done, making it hard to detail why the AMA’s negotiating tactics may not be the disaster you implied. That’s not asking you to solve the world’s problems in a blog post… just to be clearer on the topic you chose.

            In response to another comment. See in context »
  6. collapse expand

    most family physicians have already been driven out of private practice, and more of this will happen. The AMA has only 17% of doctors as members.
    Now doctors work for corporations and big non-profits they need a union. In New Zealand doctors have a union, and doctors here need one. Why are any hospital workers working 12 hour shifts especially at night? Doctors don’t even get good benefits now.
    On a related topic , patients are getting stuck with big bills…
    Medicare Link to Bloomberg article
    http://www.bloomberg.com/news/2010-07-12/hospital-fraud-audits-spur-unintended-cash-penalty-to-elderly-on-medicare.html

    • collapse expand

      Not really true.
      Certainly, there has been some exodus from the private practice – particiularly among OB/GYN practitioners who simply couldn’t handle the high malpractice insurance rates. The problem that primary care, family physicians are leaving – its that only 5% of graduating medical students want to go into family practice when they can make so much more in certain medical specialties. The AMA now has about 25% as members and that too is not the result of family physicians bailing out on their practices.
      As for doctors working for corporations and non-profits – not so much. The largest states in the country – such as California -specifically prohibit physicians working directly for hospitals except in certain circumstances. Not sure what kind of corporations you have in mind. Many physician practices are professional corporations, but that is simply the legal mechanism for how they conduct their private practices.
      The doctors could unionize if they desired. As someone who represents a lot of doctors, I can tell you that this is not appealing to them.

      In response to another comment. See in context »
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    About Me

    I am an attorney in Southern California, and a frequent writer, speaker and consultant on health care policy and politics. To that end, I am active member of the Association of Health Care Journalists. Based in beautiful Santa Monica, California, I'm very pleased to have the opportunity to be a contributing editor to True/Slant. I've recently finished a book designed to make the health care debate understandable to the average reader, and expect it to be out in the next five months or earlier. In my 'spare time', I continue to write for television and, occasionally, for comic books.

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