Misunderestimating the AMA

CMS just released their proposed MACRA regs (Cliff Notes version), and as you could expect, every specialty society and interested party dug in and critiqued.  The rule runs a thousand pages and will have a substantial effect on the future of provider payment.  In case, you have not heard.

Each organization will cut their sections of interest out, parse them, synthesize their analysis, and return a long letter to CMS. They will offer the correct paths on which the agency should proceed–lest they go forward uninformed taking down entire blocks of the healthcare system on account of willful neglect and ignorance.  The letters will start with a friendly salutation along the lines of, “We commend the Secretary on her wisdom and hard work….BUT, we have an eensy weensy problem on some issues,” and so the turn goes.

The inpatient docs will hit the rough patches as they relate to fitting hospital-based practitioners into an outpatient focused model; the nephrologists will sound off on integrating dialysis payments within a medical home; the surgeons will focus on attribution of adverse post-op events weeks after patients leave the hospital; and the pathologists will just throw their hands up and say, “huh, should we just skip this party.”

Every society concerns themselves with their piece of the pie.  Not a shock.

But one thing that most folks overlook is the role the AMA plays in the MACRA narrative–and all other high-level policy plays that come down the regulatory pike.  Having attended the AMA House for some years now, I can affirm that many of the issues that would present a collective action fail for medicine writ large, get dealt with en masse in the one organization both the legislative and executive branches look to for a unified response.

For example, meaningful use and technology burdens, the SGR fix, reporting measures, etc., all get a more active play through one main voice.  This as opposed to what would be a meager projection of all the less weighty players involved in the crafting of whatever end product happens to be on the burner for that quarter–if they each hacked it solo.

Outsiders will have many gripes with how the AMA views medical malpractice, rule delays, scope of practice laws, our level of pay and much more (“doctors carping again”)–as will docs inside the organization I should add.  However, when it comes to conditions amenable to gain that create havoc and misery for a majority of practitioners, around which most docs and non-docs would concur, the AMA brings the A game.  But for this one sizable entity calling the plays and circulating the “Dear Secretary,” letters, a lot would get left on the cutting floor.

The AMA gets beat on for myriad reasons, but disregarding free riding should not be one of them.  That’s in addition to all the public health, patient and provider equity, and environmental and educational issues they do serious, serious work on.

If you have seen the movie A Few Good Men, Jack Nicholson’s Colonel Jessep, a jingoistic hard-driving character, and general tough guy exclaims back to Tom Cruise as the cross-examining attorney:

You don’t want the truth because deep down in places you don’t talk about at parties, you want me on that wall, you need me on that wall. We use words like honor, code, loyalty. We use these words as the backbone of a life spent defending something. You use them as a punchline. I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the blanket of the very freedom that I provide, and then questions the manner in which I provide it. I would rather you just said thank you, and went on your way, Otherwise, I suggest you pick up a weapon, and stand a post.

Now that does not bring the AMA exactly to mind, but you get the spirit of the reference.  It’s easy to sit back and let someone else handle the big stuff while everyone else focuses on their little fiefdoms.

What got me thinking about this was the degree to which the AMA (still) has hefty weight at the lobbying table.  Despite how cynics see things today, it’s an incrementalist’s world and opinions from all groups must be aired out.  Our lobbyists are no better than the next well-monied outfit, and everyone deserves their say.  The AMA certainly has some money to spend on saying what needs saying.

Here are some visuals to ponder on culled from OpenSecrets.org.  You also can dismiss the American Medial Association at your peril: Wilting on the vein, huh?  Lagging membership you say? They speak for no medical group these days.

Not so fast.

Think a fly by night operation has $22 million per year to throw around for bingo night and bake sales? That is fourth highest in the arena.  Not just for healthcare, but from everybody!  And if you want to pick out the notable healthcare players in this echelon, we sit above Pharma, AARP, AHIP and the AHA (just after school clubs).

Top Spenders 2015 


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Let’s take a look at healthcare professionals then. I believe the gap between $22M and the silver medalist at $3.5 will buy a few additional Teslas.  Think the Whitehouse and Congress do not pay attention?  


Speaking of politics, here is the split on AMA giving.  Of late, more PACs with a GOP tilt (mostdocs are Republicans, however).

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If you think the AMA is not longer relevant, you are mistaken.  What will be in a decade I cannot say, but as for today, dollars and a bully pulpit trump conventional wisdom every time.



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10 replies »

  1. Some clarification:
    1) I am neither endorsing nor denouncing the AMA. Moreover, I have been active in policy and advocacy circle for years. I know the score and am far from naive on AMA matters. Also, I am a generalist, not a specialist: the RUC. Leave it at that.
    2) The AMA has juice. The WH and congress pay attention. You may not like it, but its fact. I was careful to point out in the post the AMA takes stands folks disagree with–and I am one of those folks. However, on those issues where there is consensus, or close to it, the letters they circulate get signed on to and get moved through the pipeline. They have influence. You may not know it, but your society is likely signing on.
    3) Like any organization, where the money comes from can be a puzzle–but in most cases, it’s probably not from dues. No one should think their societies are funded on the backs of its members. My point was the AMA has cash. Lots of it. You should note it (but don’t have to like it).
    4) Everyone focuses on the issues of the day: SGR, MACRA, MU, Med Mal, etc. In some ways like the United Nations and the Security Council, the AMA gets linked with only narrow topics that steal all the O2. But also like the UN–who does exceptional work on the compassion front, the AMA has multiples of people participating who don’t concern themselves with the hot, political stuff, but the smaller, less sexy things. Most of the resolutions on the books weigh in on matters that don’t make the papers. Other societies don’t touch them.
    5) The AMA is its House. Its state societies, professional societies, identify groups (LBGT, ethnic, ideological, military, etc) and they all vote. The house of medicine is one big messy soup and we all know it. No one organization can speak to that. Throw in the specialty tilt and you have a volatile mix of things. The future of the AMA and how this will all play is anyone’s guess. I don’t have a crystal ball.


  2. One comment just below was notably demonstrating that physicians were enriched if they participated in the Medicare benefit. Is that an attempt to place any dissenting physicians in a bad light? Does that mean the legislation is good? This is all foolishness as everyone that is eating off of big tuna is trying to turn the law in their favor while the taxpayer who is also the patient pays the bill receiving worse care because of all of this intervention.

  3. All lobbying organizations have limited political capital. As the ACA was being debated, according to Rahm Emanuel who was President Obama’s Chief of Staff at the time, the AMA’s top priority was the SGR fix which it eventually got passed. Didn’t all doctors who participate in Medicare benefit from that?

    As for MACRA, send in your public comments. The final rules are often changed in significant ways in response to comments, especially from people and organizations directly affected by them.

  4. Peril in reading this piece is concluding AMA isn’t toothless but rich & toothless. This would be travesty to author

    – via TweetBot

  5. I am a specialist and the AMA has done zilch for me, and bent over and solipsistically accepted every government rule and mandate for the past 50 years.

  6. AMA was AWOL with every single federal rule, PPACA, MU, PQRS, and reg that has directly affected every physician in the USA, without any success in effectively curtailing liability costs from accepting and participating these federal regs! The mission and purpose of the AMA, as seen directly from their website, “to improve the healthcare of America” is too broad and pollyanna-ish to achieve anything for the MEDICAL professional carrying out the task.
    What about the health of physicians? What about the stability and supply of the physician workforce? Physicians have retired early in droves, or become like Harlows’ monkeys accepting abuse like zombies–or switched to alternate careers in record numbers because of the persecution and unsustainability of the over-reach of government on every aspect of their professional lives.
    Consider this flow chart ( http://www.vbpmonitor.com/index.php/component/k2/item/127-developing-an-effective-pqrs-quality-measures-reporting-strategy-for-2016?showall=1) on how to implement and participate in PQRS, and if you don’t do it right, you can be charged with a felony, and if you don’t do it all, you will fined 6% of your earnings. We have to spend at minimum $50K for an administrator to oversee this, to then gain $7000. Net outflow–$43,000.
    Where is the PQRS for pharmaceuticals, medical devices that fail, pharmacy wholesalers, and pharmacies? Where is the PQRS for my deficient and grotesque Epic EHR that gave millions to the politicians to be the biggest seller of medical EHR in the USA?
    Bakers can bake cakes, own bakeries, respond to online Yelp! critiques in an honest fashion, and have a life.
    Physicians cannot heal patients, own hospitals, nor enjoy freedom of speech regarding online insults–never mind even expressing our unhappiness directly to our corporate/government–dare I say it–fascist masters.
    We are muzzled, tied and bound. Thank you AMA. You will never see another penny from me again. Go sell the disability policy (that you mail me every month) to someone else.

  7. AMA is hardly for me as a specialist! AMA has consistently sold us down the river. MACRA is yet the next best example. Now the pathetic “physician resiliency training” shows a complete deaf ear to us on the front lines. We are stronger than anyone. But we are getting killing by the continuous barrage of complicated regulatory activity by CMS from ICD-10 (um how much did that improve care?), HIPAA, MACRA with its MIPS, renaming MU PQRS, now Clinical Practice Improvement Activity, AAPMs which may be more complicated to achieve than mining a bit coin. AMA is about to feel some blowback, along with CMS and ONC like that have yet to ever see. When John Halamka says he’s out of medicine if we stay on this course, I hope people listen. He was an insider and respected. I am amazed that no one stood back and looked at the policy nightmare MACRA unfurled. Said “wait, why?” Don’t expect much change from the proposed rule, historically its nearly identical.
    I don’t think Andy Slavitt is a bad guy, but he is trying to please everyone and pleasing no one. Karen DeSalvo, I have my suspicions that she is not on my side on any of this. Patrick Conway and Karen, they obviously do not attest, count numerators, denominators, get audited, etc. I am willing to bet if ANY one of the ‘deciders” had to do what we have to do, along with the responsibility of caring for our patients, they would have a completely different view.

  8. Pretty arrogant post. So the AMA is loaded, so what? Where did they get all that money? And what “big stuff” have they accomplished? It is because a bully pulpet and dollars trump conventional wisdom that every free thinking physician should seek to eliminate the influence of the AMA. Doctors are just as fed up with the unrepresentative back door greasing as everyone else is. BTW, Jack Nicholsons character was jailed in the next scene, if I remember correctly.

  9. The AMA: of the specialists, for the specialists, by the specialists. Any generalist who pays the AMA a dime is slitting his/her own throat.