Physicians

How Relevant is the American Medical Association?

Like most doctors, I was busy seeing a full schedule of patients when President Obama addressed members of the American Medical Association at their annual meeting in Chicago.  The speech was billed as a crucial confrontation over health reform, and anticipation had been building for quite some time.   So I was too busy to learn anything about his remarks and the response until I got home.

Then again, I’m not a member of the AMA.  I never have been.  Neither are very many of my  physician friends and colleagues.  In fact, the odds are that your doctor isn’t a member of the AMA, because at best, only between 25-30% of the approximately 800,000 doctors in country belong to it.  And a good percentage (up to half of members according to one report) of those include residents and medical students, who get big discounts on membership and a free subscription to a journal when they join.

Given those numbers, how relevant is the AMA?  And why did President Obama stump for health reform there?

First, like so many influential organizations, the number of doctors who comprise the AMA matters less than their influence in the beltway—they still are a potent Congressional lobby with plenty of cash to spend.

Second, since Barack Obama does his homework, he knows who and what he’s up against.  During the Great Depression, FDR wanted to make comprehensive health reform part of the New Deal.  In doing so, like Obama, he was forced to confront the AMA. We all know who won that battle, but think about how different things might have been if the AMA’s leadership had the foresight to see what a mess American health care has become today.

Indeed, the AMA has a long history of winning wars.   Since its inception in 1847, the group has enjoyed many victories on its way to consolidating physician power.  To its credit, it helped raise the social stature of the medical profession in this country. Prior to its inception, medicine was a trade that included everybody from an educated MD (though the extent and depth of that education varied from medical school to medical school) to snake oil salesmen pushing miracle tonics to cure all your ills.  As it gained traction, the AMA helped to create and implement educational and licensing standards for doctors.   It also emphasized a highly scientific approach to medical care.  In many ways, therefore, the AMA is the reason our image of doctors is one of a white-coat wearing, cerebral and scientifically-minded group of professionals.

But to its critics the AMA is nothing more than a guild that protects its own at all costs.  For example, it successfully marginalized non-physician health care providers (osteopaths and nurse midwives, for example). By doing this, critics state the AMA was able to control the price of health care through controlling the supply of the nation’s doctors.  The most absurd example of the haves versus the have nots were African American doctors. For decades, the AMA discriminated against black physicians (a policy that it finally apologized for last year).

Probably the AMAs most lasting impact on American medicine has been its unconditional marriage to traditional fee-for-service medicine, which tilts higher incomes toward specialists and expensive tests and procedures.  That has have helped drive costs through the roof.  Because of that bias toward specialists, it’s also not a stretch to hold it responsible, in some ways, for helping to create the shortage of  primary care doctors in our country today (according to Matthew Holt of the influential Health Care Blog, the AMA’s membership “over-represents specialists and those in small practices.”).

It’s also been an organization very weary of innovation. In California, during the Depression and Second World War, Dr. Sydney Garfield and construction magnate Henry J. Kaiser joined forces to create Kaiser Permanente, a health plan where Kaiser’s shipyard, steel and construction workers prepaid for their care, which was provided by doctors from different specialties.  It was one of the earliest, if not the first, example of integrated health care that focused on prevention instead of illness.  When the powers that be at the AMA heard about the Kaiser experiment, they perceived as a threat to the status quo (after all, for most doctors, a sick patient is what pays the bills), and discouraged doctors form joining it or attempting to emulate a model where health, not illness, was rewarded.  While the Kaiser model has been successful in California and several other parts of the country, the model has not yet spread widely (full disclosure: I’m a Kaiser doc—though my views here do not necessarily represent those of my medical group).

All those victories, however, are in the past.  Today, with health care costs out of control, millions uninsured and underinsured and an incredibly-shrinking base of members, the AMA is vulnerable to the voices of reform.   Still, history teaches us that it knows how to protect its interests, even if those interests don’t  adhere to its motto “helping doctors help patients.”

If you’re wondering just what its interests are are, look where the two greatest sources of tension are between the Administration and the AMA.  The first is the real possibility of creating a public insurance plan to broaden coverage and get more of the 48 million uninsured Americans relief. Publicly, the AMA hasn’t quite come out against the plan—in fact, the organization spent the better part of last weekend trying to “correct” New York Times reports suggesting its opposition to it.   But there’s no doubt that the AMA doesn’t see “public option” as code for “socialized medicine,” and it worries about a lower cost public plan becoming the first choice for employers and individuals will force doctors profits down.

The next point of contention is tort reform, and limiting the scope and awards of malpractice suits.  As a doctor, it’s hard to argue against this point—many of us practice “defensive medicine” and order plenty of tests and drugs not out of necessity, but rather out of the fear of being sued. In reality, however—and as a piece in this week’s New England Journal of Medicine points out, nobody really knows how much defensive medicine contributes to the overall cost of health care.  Still, as the article points out, even if its 1% of annual GDP spending, it’s more than enough to justify some reform.

But Obama isn’t backing down on tort reform either—he came out and told his audience yesterday that tort reform isn’t on the table because it’s not fair to those who may have been truly injured by a doctor. For that, he received some scattered boos from the audience.  Yet it’s probably not a very risky bet to make that the Negotiator-in-Chief will support some form of medical malpractice reform as a way to garner the AMA’s formal support for a public plan and other aspects of his package.

In the end, however, the fact that most doctors don’t pay much attention to the AMA anymore should be a strong signal to President Obama to keep seeking out opinions from the 70-80% doctors who don’t belong to it.  Some of these doctors  have started new groups, like Doctors for America, and are growing rapidly.  The difference between the old and new thinking were showcased in a News Hour piece the day Obama delivered his speech.   It contrasted the views of a relatively highly-paid orthopedic surgeon, expressing concern about paying his bills, to a relatively underpaid Primary Care doctor, ready to take a small cut in pay so health care can get better for everyone.

Getting back to the question:  Is the AMA still relevant? Only time will tell, but given it sinking numbers and traditional resistance to change and innovation in the delivery of health care in the wake of a groundswell of support for change, it’s hard not to see this grand old institution of American medicine slowing getting sick and slipping into critical condition.  The only thing that could save it is sharing the spotlight with some new, progressive doctor’s groups and coming to the table ready to make some serious reforms.

Dr. Rahul Parikh is a Pediatrician in the San Francisco Bay Area and a frequent contributor to Salon.com and THCB.  Dr. Parikh practices with the Walnut Creek Medical Center and Kasier Permanente.

Livongo’s Post Ad Banner 728*90

23
Leave a Reply

23 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
17 Comment authors
Hoyt PinillaCanDocShirleySP LegalAl Vassall Recent comment authors
newest oldest most voted
Hoyt Pinilla
Guest

Im no professional, but I suppose you just made the best point. You definitely fully understand what youre talking about, and I can really get behind that. Thanks for staying so upfront and so honest.

CanDoc
Guest
CanDoc

26 YEARS MEDICAL PRACTICE _
10 YEARS IN CANADA – NEVER SUED EVEN ONCE
16 YEARS IN US – SUED 4X AS CO-DEFENDANT and released after confiscatory billable hours by All the lawyers who deposed everyone but my Dog -for billable hours, even though I was released each time
Imagine that premium on everything we do, make , use, insert, operate with.etc, etc

Shirley
Guest
Shirley

I loved your article – it was some great information. I think you and your readers might be interested in another article I found, about Dry Eyes.
http://Www.whatistheeye.wordpress.com

SP Legal
Guest

Affordable Accessible Legal Care for All Now! One in eight black males is in prison on any given day. Small businesses and working families are crushed by nearly a trillion dollars of tort costs every year. Attorneys and law firms cherry pick lucrative cases while casting off disparity groups to public defenders. Remove the profit incentive and restore the client-attorney relationship! This is reform we can believe in: http://www.SinglePayerLegal.org

Al Vassall
Guest

It was very interesting to see the interchange between persons. It was easy to tell who was an attorney and who was physician. It was also easy to tell who was in private practice versus large group practice. It is easy to blame the insurance companies. It is easy to blame physicians. It is easy to blame providers. It is easy to do these things, because each person who receives health care believes that he has a perfect right to it. Beyond that he believes that he has a right to consume as much of it as he thinks that… Read more »

Manel Silva, MD
Guest

Thanks Dr. Parikh for your post. I echo your comments of how little the AMA represents most practicing physicians. In fact, in response to President Obama’s address to the AMA, a group of progressive physician organizations sent a letter to the President noting their support for the public plan option (which you can read here: http://www.seiu.org/images/pdfs/Joint_Physician_Statement_20090615-1.pdf ), and collectively represented 215,000 MD’s. In fact, one of the organizations, the National Physicians Alliance, grew directly out of the need for an alternative physician voice to the AMA. Your comment of how the AMA discouraged physicians to join Kaiser despite how effective… Read more »

MG
Guest
MG

Greg – Thank you for your posts on malpractice reform. As with almost every topic, the AMA’s solution to malpractice is simply one that almost exclusively benefits the AMA and its members. Never mind anyone else who might be affected by the resolution to this issue. The AMA’s solution to medical malpractice the past several years has largely a hard cap on pain & suffering at $250k. Granted their needs to be reform of the legal process and it likely involves a heavy hand of meditation before proceeding to the courts. Frankly, all parties would be likely better served by… Read more »

pp
Guest
pp

Greg, It sounds like your legal practice is thriving. You lawyers talk big but you take no responsibility when you make mistakes. Then it is, “Oh everyone makes mistakes”. You guys charge 300, 400, 500 per hour and if you make a mistake, we have to pay you to correct it. Most Physicians have to worry and doublecheck, triple check their work, document like crazy because we can be sued for outcomes. Not for medical mistakes, but bad outcomes. All you trial lawyers have so much money and marketing power that you blast through radio, tv, billboards constantly trying to… Read more »

Greg Pawelski
Guest
Greg Pawelski

It seems like the California model (MICRA System) certainly is working. In the State of California, medical malpractice premiums rose 450% in the 13 years following passage of California’s cap on victim compensation. California’s Proposition 103, a 1988 voter-approved insurance reform initiative decreased medical malpractice premiums 2% in the 13 years following enactment of insurance rate regulation. Perhaps that is why some of our more intelligent governement representatives, in an effort to protect consumers from dubious insurance industry tactics, legislation was introduced that would mandate medical malpractice insurers to provide reduced rates for doctors in good standing. This provides the… Read more »

Tom Leith
Guest
Tom Leith

Dr. Dussia writes:
> It takes alot of $1,500 payments for pregnancies
> with 6 to 7 months of prenatal care to pay for a
> $260,000 insurance premium in South Florida. And
> we still have to pay the light bill.
Yes, around 175 of them. This sounds like a Medicaid global fee, is that right?
t

Evan Earl Dussia, II, MD
Guest

Mr. Pawelski, Physicians began to be abandoned by big name insurance companies in the mid-1970’s so instead of “going bare” we started our own companies. As we continued to have ups and downs in the malpractice insurance market, more physician oriented companies appeared. Doctors now prefer companies started by other doctors and run by other doctors because these companies fight for their share holders rather than settle with plantiffs attorneys in order to avoid court room battles. Cost of the premiums is determined by actuarial analysis and watched closely, at least in my state, by the Commissioner of Insurance. If… Read more »

Greg Pawelski
Guest
Greg Pawelski

Why do malpractice premiums keep rising to astronomical levels? The doctors are the insurance companies! According to the Physician Insurers Association of America, a trade group of about 50 doctor-owned malpractice insurers, they cover about 60% of U.S. doctors in private practice and hospitals. Why are the profits of these doctor-owned insurance companies that doctors want to protect? Limits on the rights of people hurt by medical malpractice will victimize them and their families further while helping neither patients nor doctors. The real beneficiaries will be insurance companies, including the doctor-owned malpractice insurers. Solving this crisis will involve a three-legged… Read more »

bev M.D.
Guest
bev M.D.

Yes, if malpractice is such a small part of health care costs, then why do malpractice premiums keep rising to astronomical levels? The other point is that it is the FEAR of being sued, not actual malpractice payouts, that drives defensive medicine. People who point to parity of costs in states with and without malpractice caps are missing the point. Once sued, no matter the outcome, a doctor must report that on every single reaccreditation form or application for insurance panel for the rest of his professional life. Ironically, doctors would be better protected against malpractice premiums if they gave… Read more »

Evan Earl Dussia, II, MD
Guest

Mr. Leith, The facts show that in California, where caps were put on pain and suffering more than 30 years ago, medical malpractice premiums continue to be about 20-30% of premiums paid in Florida for the same coverage for the same specialties. When California looked at increasing the $250,000 cap on pain and suffering several years ago, they left it unchanged because of the effect it had on keeping premiums down–for decades. Do you know of anything else that costs less in California? Malpractice premiums are another overhead expense for clinicians just like the electric bill. It takes alot of… Read more »

Tom Leith
Guest
Tom Leith

MG writes: > Medical malpractice is largely a complete > red herring when it comes to medical costs. Yeahbut. The “MedMal comes to 2%” argument is also a red herring. It is true that MedMal premiums total maybe 2% of the total spend for medicine, and it runs 5 – 10% of practice expense depending on specialty. So from this point of view it seems “just a cost of business” and not such a big deal. But: Getting sued is a huge distraction for the docs individually — they don’t get paid for defending themselves, they get paid to take… Read more »