AMA & AAMC Embrace of Anti-Immigrant Tom Price/Donald Trump May Be Costly.

Posted on | January 30, 2017 | 4 Comments

Kaparaboyna Ashok Kumar, M.D.

Mike Magee

When the AMA and AAMC made the decision to announce their “strong support” for Tom Price to head HHS, they were fully aware of his support for armour piercing bullets, for not regulating tobacco as a drug, against mental health care parity, against SCHIP, for privatizing Medicare, against the reauthorization of the Violence Against Women Act, against stem cell research….and his uncompromising stance on immigration.

Their organizational voices were strong and clear as they blessed what others have defined as a “guild” candidate. And some of their institutional members went along – a few COTH teaching hospitals like Emory, and a few specialty and state societies like the AAFP and the Texas Medical Society. But most went mute.

With Trump’s latest assault on human dignity, a clumsy and disruptive ban on immigration from 7 Muslim majority countries, both the AMA and the AAMC have suddenly lost their voice. And its not as if they have nothing at stake.

Let’s just focus on Texas for a moment, the home of the AMA  member Texas Medical Society which declared on November 19, 2016 that “The physicians of Texas are extremely pleased” with Price’s nomination.

This is Texas – the 45th worst state in the union for access to a physician. (They have 177 doctors per 100,000 citizens when the national average is 236.) This is the state whose doctor shortage was so severe in 2007 that the Texas Medical Board instituted a “fast-track” scheme to attract doctors to the state who would focus on under-served patients. Over the next three years 1000 were licensed with 400+ being IMG’s. The numbers from Pakistan educated doctors outnumbered those educated in neighboring states like Oklahoma or Louisiana. 20% of all Texas doctors are IMG’s and that number is growing with nearly 25% of new physician entrants having attended medical school outside the US.

Now, of course, there is nothing wrong with that. Although the AAMC has, from time to time expressed concern about it, the AMA has seen membership of IMG’s as a potential growth area. They even have a separate  International Medical Graduates Section whose current president is India trained gastroenterologist Bhushan Pandya. Dr. Pandya has been a strong supporter of organized medicine, strong enough to be elected this year as president of the Medical Society of Virginia which asserts that  “No other organization better understands the needs of physicians today. That’s because we’re a diverse group of physicians who know that medicine now extends beyond caring for patients. Today, physicians must be business people, insurance experts, community leaders and regulatory watchdogs.”

But back in Texas, after Trump’s weekend performance, some AAMC COTH teaching hospital execs are getting nervous. University of Texas at Austin president, Greg Fenves, commenting on Trump’s 7-state surprise to Seema Yasmin at the Dallas News said, “We have 110 students, faculty members and scholars who are citizens of the seven affected countries — Iran, Iraq, Libya, Syria, Yemen, Somalia and Sudan. The talents that brought them to UT are deeply valued, and their perspectives represent an essential part of the university.” Baylor College of Medicine professor, Peter Hotez MD, said the policy sent a “chilling message”, adding that,  “My concern is that any doctor or scientist from an Arab or Muslim country will now think twice about coming to the US for post-doctoral study or a faculty position. I’m concerned that two months from now the ban will extend to other countries in the Middle East.”

As for the medical students the AAMC so proudly represents, consider Texas College of Osteopathic Medicine, MS1 Suna Burghul, a 22 year old Palestinian American, who said “I’m scared for so many people and not just in the countries he put the executive ban on but people who even look like they could be Muslim. I even mentioned it in my medical school interviews and now I’m like, should I hide it in case it will affect my career? I worry what people will think if they know I’m Muslim.” By the way, the American Osteopathic Association reacted to Tom Price’s nomination with “cautious optimism”.

This weekend, proud AAMC member, the Cleveland Clinic, had to absorb the embarrassment of their new incoming internal medicine resident, Suha Abushamma, 26, who holds a Sudanese passport, being held up this weekend by TSA guards dangling deportation papers in front of her face. That must have hurt. Did they call the AAMC lawyers and lobbyists for help?

Finally, before the American Academy of Family Physicians  congratulated anti-immigrant Tom Price , they might have sought council from one of their own – Kaparaboyna Ashok Kumar, M.D. – you remember, the one the Texas Academy of Family Physicians honored as 2016 Physician of the Year. After medical school in India, and additional training there and in Edinburgh, he did a family medicine residency at UT Health Northeast in Tyler. On IMG importance in 2010, he said, “The impact is not only in Texas, but nationwide. These are the doctors who are going to serve Texas’ rural patients, urban patients, underserved patients.”

By endorsing Tom Price, the AMA and the AAMC have tied themselves to an individual who may be compatible with their business interests, but whose policy positions are antithetical to their highest ideals. Tom Price is intolerant on many levels – his anti-immigrant stance is just one. But it has the potential to disrupt manpower needs for caring and scientific advancement, and that could generate serious blowback.

House of Medicine Mute On Ban of Muslim Physicians and Scientists

Posted on | January 29, 2017 | Comments Off on House of Medicine Mute On Ban of Muslim Physicians and Scientists

Yesterday U.S. Airports went into a virtual shut down in response to the Trump order to block all entry into the U.S. from seven predominantly Muslim nations. The response from Silicon Valley was immediate and led by Tim Cook of Apple who said:

Team,

In my conversations with officials here in Washington this week, I’ve made it clear that Apple believes deeply in the importance of immigration — both to our company and to our nation’s future. Apple would not exist without immigration, let alone thrive and innovate the way we do.

I’ve heard from many of you who are deeply concerned about the executive order issued yesterday restricting immigration from seven Muslim-majority countries. I share your concerns. It is not a policy we support.

There are employees at Apple who are directly affected by yesterday’s immigration order. Our HR, Legal and Security teams are in contact with them, and Apple will do everything we can to support them. We’re providing resources on AppleWeb for anyone with questions or concerns about immigration policies. And we have reached out to the White House to explain the negative effect on our coworkers and our company.

As I’ve said many times, diversity makes our team stronger. And if there’s one thing I know about the people at Apple, it’s the depth of our empathy and support for one another. It’s as important now as it’s ever been, and it will not weaken one bit. I know I can count on all of you to make sure everyone at Apple feels welcome, respected and valued.

Apple is open. Open to everyone, no matter where they come from, which language they speak, who they love or how they worship. Our employees represent the finest talent in the world, and our team hails from every corner of the globe.

In the words of Dr. Martin Luther King, “We may have all come on different ships, but we are in the same boat now.”

Tim

In contrast, the House of Medicine was mute – nothing in defense of patients, guest scientists, physicians who are international medical graduates, or employees. This stands in stark contrast to the AMA and AAMC’s  full-throated willingness to engage on behalf of HHS nominee Tom Price, who has fully endorsed the Trump policy. So mush for “the art and science of Medicine and the betterment of public health.”

Contrasting the AAMC Endorsement of Tom Price with Jordan Cohen’s Support of Humanism and Professionalism.

Posted on | January 27, 2017 | 4 Comments

Mike Magee

The decision by the AAMC to aggressively endorse Tom Price’s candidacy for HHS Secretary has confused and concerned more than a few of my academic colleagues. In light of the organization’s work on reinforcing social consciousness and empathy in medical students, it struck a remarkably discordant note.

In 2002, I approached the AAMC with an idea. What if they were to empower their Organization of Student Representatives (OSR), a body made up of one elected student from each of the MD granting Medical Schools, to select each year the single physician nationwide who best embodied the doctor these medical students hoped to become? “Real doctors. Real Teachers. Real Heart.”

With the support of then CEO Jordan Cohen, we explored a list of seminal values the awardee would possess, and settled on five:

1. Patient-Centered: A personal commitment to a patient-centered, pride-filled approaches to the organization and delivery of health care.

2. Professional Collaboration: Promotes collaborative processes across all disciplines.

3. Community Service and Leadership: A community servant who believes in equal access to information and health care for all.

4. Continuous improvement: Recognizes personal imperfections and seeks scientific and humanistic solutions that ensure positive and coordinated outcomes.

5. Professional Positivity: Commitment to personal revitalization, recognizing the responsibility to provide hope and reassurance to all we serve, and to promote courage, strength and positive attitudes.

The program was called the “Humanism in Medicine Award”. It was a great success as measured by the number of participating medical schools, the integrity of the student-led selection process, and (most of all) the quality of the awardees.

More than a decade after my departure from the scene, the program survives under a new title, the Arnold P. Gold Humanism in Medicine Award which “annually honors a medical school faculty physician who exemplifies the qualities of a caring and compassionate mentor in the teaching and advising of medical students.”

I was reminded of this program last week while reviewing a special JAMA issue from 2015 dedicated to “Professionalism in Medicine”. I reread all of the articles, including one from my old friend, Jordan Cohen, now Emeritus at the AAMC. His article was titled “Tasking the ‘Self’ in the Self-governance of Medicine”. It explored the rights and responsibilities of physicians in a modern society.

When we juxtapose Dr. Cohen’s words with those in a recent NEJM article evaluating the legislative record of Rep. Tom Price, we see stark contrasts. The NEJM piece, written by two HHS directors, says: “Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.”

Jordan’s view: “Medicine’s social contract with society is the implicit, mutual understanding of the obligations physicians individually and collectively agree to on the one hand, and the privileges they are accorded by the public in return on the other hand. ‘Society grants physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral, and would address the health care needs of individual patients and society’¹… medicine in the United States enjoys an astonishing degree of autonomy. However, this skew also saddles medicine with an enormous degree of vulnerability for unwelcome constraints on that autonomy.”

He furthur cautions: “The hallmark of medical professionalism is a subordination of self-interest to the best interest of patients and the public.⁸ Maintaining that commitment to professionalism in the face of the many temptations afforded by today’s commercialized and overstressed health care system is, to be sure, no easy task. There are so many opportunities to give in to greed, to be arrogant, to abuse the power gradient inherent in the patient-physician relationship, to exploit conflicts of interest, to fail in the duty to be conscientiousness. But succumbing to temptations such as these, and abandoning the commitment to professionalism, is tantamount to physicians’ forfeiting the right to self-regulation.”

On “humanism”: “…humanism denotes an intrinsic set of deep-seated convictions about one’s obligations toward others.⁹ It is the passion that animates true professionalism. It is the passion that motivates many, if not most, young people when they choose a career in medicine. It is the passion that is all too often dampened by the rigors of medical education and by the hassles of medical practice. But it is the passion that must be nurtured, reinforced…”

And finally, on public trust: “No matter how effective professional organizations are in the pursuit of self-regulation, sustaining public trust in the profession is ultimately the responsibility of individual physicians being faithful to their obligation as professionals and being earnest in upholding the interest of their patients and the public…Trust in physicians is the foundation upon which the social contract with society rests. But trust in physicians is not a birthright. Trust is earned, not owed. The only way physicians can earn trust is by being trustworthy as true professionals.”

By endorsing Tom Price, the AAMC has granted him a “dehumanizing award”. The organization is much better than that.

Emory’s Center for Ethics, Tom Price, and AMA &AAMC 990’s: An Imagined Senior Seminar Class

Posted on | January 22, 2017 | Comments Off on Emory’s Center for Ethics, Tom Price, and AMA &AAMC 990’s: An Imagined Senior Seminar Class

Mike Magee

The recent endorsements by the AMA and AAMC of Tom Price to head HHS should provide a remarkable future senior seminar in situational ethics for Emory’s Center for Ethics and their much lauded “Health, Science & Ethics Pillar”. The case study’s syllabus will most likely include the recent AMA endorsement, the AAMC press release, and the congratulatory and laudatory pronouncements of the CEO of Emory Healthcare, Dr. Price’s original home base.

These will contrast with a range of other documents, including the recent critical NEJM article penned by two HHS directors which stated, “Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.” Recommended readings will also include the 2014 990 IRS filings of the AMA and the AAMC, a collections of comments under #NotMyAMA, and an ever growing list of names on an online petition titled “The AMA Does Not Speak for Us”.

In Part I, question 1 of those 990’s, required of all non-profit organizations, students will find instructions stating “Briefly describe the organization’s mission or most significant activities. The AMA stated, “To further the interests of the medical profession by promoting the art and science of Medicine and the betterment of Public Health.” The AAMC wrote, “AAMC leads the Academic Medicine Community and strengthens the world’s most advanced medical care by supporting education, research, and patient care activities conducted by our member institutions.”

A careful reading will reveal that the two organizations combined assets exceeded $1.1 billion, and they employed just under 3000 individuals whose compensation exceeded $218 million that year. 546 of those employees received compensation of greater than $100,000. Combined, the programs and services offered that year generated $475 million in revenue. Almost half of the revenue generated by the AMA came from royalties and sales associated with their exclusive control of the nation’s CPT codes and the Physician Masterfile Database that fuels physician prescription profiling. Just under 2/3 of the AAMC revenue derived from three data driven and monopolistic product sales – ERAS (Electronic Residency Application Service – The Match: $69.2M), MCAT (Medical College Admission Test: $33.2M), and AMCAS (American Medical College Application Service: $30.4M).

Students will surmise from these two organization’s strong and immediate public support for HHS candidate Tom Price that  both organizations also support political action, but in two different forms. They will find that the AAMC is a non-profit 501(c)3. These organizations are “absolutely prohibited from engaging in political campaign activities…ie. election or defeat of a candidate.” “Insubstantial lobbying” however is allowed. The IRS doesn’t use the word “lobby” but rather the phrases “carrying out of propaganda” and “attempting to influence legislation”.

The AMA, in contrast is a 501(c)6, as are the National Football League, the American Bar Association, and the Independent Insurance Agents of America. Student research will reveal that these non-profits are permitted to engage in unlimited lobbying, and may engage in political activity, but are required to pay a 35% excise tax on their total political expenses. However, these activities may not be “the organization’s primary activity”.

The AAMC 990 will reveal 2014 listed expenditures of $3.9 million under the title “Influencing public opinion or legislation”. The report will further explain that “The other activities include meeting with or calling government officials or legislators, placing advertisements and issuing press releases to direct the organizations efforts to influence public opinion on legislative matters”.

Students querying Maplight and Open Secrets will report to the class that AMA lobbying expenditures for 2014 were in the area of $20 million. That funded close to 50 lobbyists (including 24 registered AMA employees) generating over 100 reports, many to effect the outcome of 81 different pieces of legislation. Those lobbyists made 43 visits to the House, 42 to the Senate, 17 to HHS, 15 to CMS, 11 to the White House plus 5 to the Executive Office Building, and 8 to the FDA.

In an interview with one of those future students who will reach out to me for comment, I will report that, “In a conversation with the then CEO of the AMA some years back, he expressed his desire to move the AMA headquarters to Washington since this was the organization’s primary focus. He was just being honest.” The student however will not be able to validate this in the public record. However, she will surmise that these inconsistencies may, in part, explain why only 17% of the nation’s doctors are AMA members. But she will also wonder out loud whether that matters with the AMA Federation of state and specialties in its hip pocket, and non-member revenues from CPT and Physician Masterfiles a monopolistic lock.

The students in general will not express surprise at the AMA’s full-throated endorsement of Tom Price. Their spread sheets will reveal that some Federation members went along (ACS, AAFP, a spattering of medical and surgical sub-specialties), and others went mute (AAP, ACOG, ACP-ASIM). One student, in open class discussion, will wryly remark that ”Apparently, for these organization members, you are part of the Federation, except when you’re not. What’s not to like?” Others with public health aspirations and “generalism” in their bones will wonder aloud why Family Medicine doctors at the time tolerated an endorsement of such a socially compromised legislator as Tom Price without a huge human outcry from AAFP members.

One student, an aspiring physician scientist, will sternly proclaim that “the halo around the head of the AAMC is undeserved.” He will explain to the others that the organization is governed by giant academic hospital enterprises, detached entrepreneurial medical school deans, and the vaulted “thought leaders” of medical research in America, now nearly indistinguishable from their industry counterparts. He will explain that he is deeply conflicted since support of the organization and its entities is all but essential to his own career advancement including access to NIH grants, publications, and placement on government and industry advisory committees in the future.

He’ll say he feels “ethically trapped”, supporting as he does the AAMCs highly publicized focus on new medical school curriculum, advances in physician empathy, and concerns for hospital safety and the rights of human research subjects, but dismayed by his own course work which reveals “conflict of interest in publications, patient advocacy organizations and in Twitter postings for God’s sake”. He’s especially dismayed that his own school’s top health care officer openly and enthusiastically supported the successful nomination of Emory’s former orthopedist Tom Price, who went on (after his confirmation) “to lead the nation’s survival curve, not just for the vulnerable but for everyone, due south.”

In the final week of this high level seminar class, the professor will assign her 12 students to provide four concrete recommendations that might address their concerns and begin to re-establish appropriate checks and balances. The following week, they will return with these recommendations, provided in writing on a piece of Emory stationary. It will read:

1. In this trumpian era, every single doctor in America needs to make a list of all the organizations of which each is a member or a provider, including medical associations, hospitals and health systems.

2. Each must then ask, “Are any of these associated with, represented by, or a collaborator with the AMA or AAMC?”

3. If the answer is yes, you must consider yourself a member as well, because you are!

4. Now you must determine what you are going to do about it.

More next week.

“The AMA (and the AAMC) Does Not Speak For Us.” – Oh, Yes They Do!

Posted on | January 18, 2017 | 1 Comment

Mike Magee

President-Elect Trump’s nomination of Rep. Tom Price for HHS Secretary has been ethically compromised from the start. The NEJM article last week, penned by the current and former department heads for HHS, simply defined the myriad of issues that undermine his candidacy in black and white.

The AMA and AAMC’s bullish recommendations of a strong “BUY” simply demonstrated how far these “guild” organizations will go to defend their vested interests, and served to highlight the medical and generational opposition, and the tools that opposition will use in the future to dog organized medicine’s power elite.

Two notable reactions were the appearance of the Twitter hashtag, #NotMyAMA, and the creation of an online petition titled “The AMA Does Not Speak for Us” signed by nearly 10,000 physicians. But a cursory examination of the structural design of both the AMA and the AAMC, and their reach, suggests otherwise. They do represent you, whether you like it or not.

The truth is that both organizations have evolved purposefully over more than a century to control and direct and protect the position of the physician guild and its role in care delivery, education and research. Together and intertwined, they are the pearl within the Medical Industrial Complex oyster.

Even if you are not a member of the AMA, it is very likely that you are represented by at least one of the organizations or associations that is a part of the AMA. The organization may be housed in Chicago, and represented by offices at 1101 Vermont Ave. NW, in walking distance from the Capitol, but their true power is nationwide and widely distributive. Fundamental is their highly orchestrated infrastructure of county medical societies, which feed state societies, which elect members to serve in the House of Delegates of the national society.

This system provides a career-ladder proving ground for up and comers, like Georgia AMA delegate Tom Price. It also has the ability to energize a wide political response, for or against an issue, which has a lively history including the coffee clutch days when AMA spouses gathered to listen to an AMA provided LP recording of Ronald Reagan warning that Medicare was the same as “socialized medicine” and would inevitability result in the government telling physicians where they could practice medicine.

In addition to this network, the AMA has deftly bestowed its generous moniker of “specialty society” on over 100 different organizations which are part of the AMA Federation. Originally designed to enhance membership and maintain “big tent” order on the House of Medicine, its lack of disciplined quality control is rapidly exposing the organization’s flank to some outsized potential class action liability.

The original Federation members like the American College of Surgeons, the American College of Physicians/American Society of Internal Medicine, the American Academy of Pediatrics, the American Congress of Obstetrics and Gynecology, and more recently the American Academy of Family Physicians are more than well-established and have lives of their own. The same is true for the multiple sub-specialty organizations they have spawned over the years, including the American Urological Association which I belonged to for years.

In more recent years, the tent has expanded to include others like the American Academy of Pain Medicine ,whose origins were so deeply entangled with the rise of Purdue Pharma and the overselling of “pain as the 5th vital sign”(which the AMA has subsequently rejected) and Oxycontin, that the subsequent downward bending of U.S. survival curves is viewed by critics as part of the organization’s work product. The deaths of thousands, and compromised human potential of many thousands of their children, raise high liability stakes for both the Pain people, and the Federation, should those harmed discover each other and seek out legal representation to track liability back to source.

Then there is the Association of American Medical Colleges or AAMC. As with the AMA, this is a carefully structured and overlapping group of organizations under one roof. The organization is almost as old as the AMA, originating as a group of 22 medical schools in 1876 with the stated objective “to consider all matters relating to reform in medical college work.” Now, nearly a century and a half later, their influence is far more extensive and far more organized.

At the core of the AAMC’s power structure, exercised from their offices at 655 K Street NW in Washington, DC, are their Council of Deans (includes the Deans of all U.S. MD granting Medical Schools), Council of Faculty and Academic Societies (more than 370 faculty representatives appointed by member medical schools and academic societies) and Council of Teaching Hospitals and Health Systems (400 member teaching hospitals in addition to its medical school community.) In addition their management also staffs 18 different affinity groups. And, like the AMA, their Government Relations program is aggressive and activist, not shy in mobilizing outreach at a moment’s notice. As they say, “Collaborations are key to advancing the AAMC’s advocacy agenda.”

Were this not enough, the two organizations are close and historic controlling partners of the Accreditation Council for Continuing Medical Education (ACCME) and the Accreditation Council for Graduate Medical Education (ACGME). The origins of these organizations date back to 1942 with founding partners being the American Medical Association, the American Board of Medical Specialties, the American Hospital Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. Today they have their fingers in any and all deliberations regarding funding, manpower needs, educational reforms, conflict of interest, research funding and more. They also provide a meaningful interface for physician leaders like Tom Price intent on moving their careers up legislative or academic ladders.

The institutional reach outlined above and their non-profit status (AMA, a 501(c)6, AAMC, a 501(c)3), combined with historic professional autonomy that creates partial immunity from public criticism and prosecution, has helped fuel and foster a remarkable consolidation of power and influence over the past half-century, reinforced by both government and industry.

“The AMA (and the AAMC) Does Not Speak for Us” . Oh yes they do! And it will take more than signing an online pledge to re-establish appropriate checks and balances. How will legitimate grievances, such as the AMA and AAMC’s strong endorsements of Tom Price whose values are so clearly in opposition to those stated by both these organizations, be reconciled? Likely the push back will come through the back door as our legal system probes the weakest links of each of these highly profitable “non-profits”. Liability often finds its way back to source. More on that next week.

Why Did The AMA Support Tom Price?

Posted on | January 13, 2017 | Comments Off on Why Did The AMA Support Tom Price?

Mike Magee

Not a few health professionals have been asking themselves, “Why did the AMA support  Tom Price for head of HHS”? Their concerns took voice in this week’s New England Journal of Medicine in a piece titled “Care for the Vulnerable vs. Cash for the Powerful – Trump’s Pick for HHS”. In the article, written by the current and former Assistant Secretaries for Planning and Evaluation at HHS, Price’s record and value system are contrasted unfavorably with two former physician directors – Otis Bowen and Louis Sullivan. The authors concerns include:

1. “Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.”

2. “Price has sponsored legislation that supports making armor-piercing bullets more accessible and opposing regulations on cigars, and he has voted against regulating tobacco as a drug.”

3. “ …he was one of only 47 representatives to vote against the Domenici–Wellstone Mental Health Parity and Addiction Equity Act, which improved coverage for mental health care in private insurance plans.”

4. “He also voted against funding for combating AIDS, malaria, and tuberculosis; against expansion of the State Children’s Health Insurance Program; and in favor of allowing hospitals to turn away Medicaid and Medicare patients seeking nonemergency care if they could not afford copayments.”

5. “Price favors converting Medicare to a premium-support system and changing the structure of Medicaid to a block grant — policy options that shift financial risk from the federal government to vulnerable populations.”

6. “He also opposed reauthorization of the Violence Against Women Act and has voted against legislation prohibiting job discrimination against lesbian, gay, bisexual, and transgender (LGBT) people”

7. “He opposes stem-cell research and voted against expanding the National Institutes of Health budget and against the recently enacted 21st Century Cures Act”

8. “Price has also been a vociferous opponent of the Affordable Care Act (ACA)”

9. “The Price plan would eliminate the guaranteed-issue and community-rating requirements in the ACA and create anemic substitutes for these commitments to access to comprehensive coverage for Americans with preexisting conditions.”

10. “Whereas Price’s actions to date have not reflected the tradition of the physician as advocate for the poor and vulnerable, they do harken back to an earlier tradition in American medicine: the physician advocate as protector of the guild.”

In that final quote, the one referencing the “guild”, the authors point an arrow directly at the AMA’s heart. Why did they rush to support Price? Why not push “Neutral” over “Buy”? A substantial part of the answer may be found in the chart below tracking the percentage of active physicians who belong to the AMA. (full disclosure: I am one of them, and have been for nearly 50 years, as was my father before me.)

Source: Mother Jones

As the chart notes, in my father’s day 75% of active physicians were AMA members. These were the heydays when the organization teamed up with a younger Ronald Reagan to unsuccessfully fight Medicare. In the new Millennium, the AMA faced slow and steady continued declines in membership of 1 to 2%, from 2000 to 2007. In that period, they went from roughly 1/4 of the nation’s active physicians as dues paying members to 1/5. The downward slide was briefly halted in 2007 by offering 8,577 free memberships to residents in training.

The descent resumed with a 2% loss in 2008, 3% in 2009, and a record breaking 5.3% in 2010, bottoming at 17% of active physicians. What happened? Most track the cliff back to March 19, 2010, when AMA President Jim Rohack announced AMA support for Obamacare. To say that conservative members, especially those from southern states, were displeased is something of an understatement.

The losses were announced at the 2011 House of Delegates meeting, but no specific state breakdowns were provided. But MedPage, without citing sources at the time, wrote, “Membership declines were most acute in Southern states – the same region in which state medical societies have been championing opposition to the Affordable Care Act.”

According to MedPage’s report, in some of those states, AMA delegates like nephrologist Daniel Edney appeared to dislike the President’s signature legislative achievement so much, he not only wouldn’t call it “Obamacare”, he wouldn’t even use the acronym ACA, preferring the more bureaucratic original initialing PPACA for the Patient Protection and Affordable Care Act. “It’s PPACA and we all know it. PPACA is what is driving all our doctors crazy”, he said then with extreme confidence. In his home state of Mississippi, he claimed that 3/4 of their roughly 2400 AMA members had resigned over the issue. Same thing in Alabama, where resignations were so steep that only “good will” saved them from losing one of their proportional seats in the AMA’s House of Delegates.

So why did the AMA step way out front to support Georgia’s ultra-conservative orthopedist Tom Price? It certainly wasn’t because he aligned with the AMA list of the top 5 state legislative priorities for 2017 which includes strengthening and expanding Medicaid, funding solutions to the opioid epidemic, and improving public health funding for vaccinations, firearm safety, and reproductive health.

Far more likely is that the organization has a “southern strategy” of its own. It’s likely we’ll never know for sure. But one thing is for certain, it’s more about numbers than money. Through the years of declining membership dues, AMA profitability has continued to rise from publications, CME and business offerings like their Masterfile Database used to empower PhRMA physician specific prescription profiling. They had over $500 million in reserves in 2012. Money funds lobbying.  But total numbers of doctors represented ground the legitimacy of AMA’s government relations program.

Many younger physicians have fled the AMA state and national organization, and proudly proclaim that they have instead chosen speciality options like the AAFP, ACOG, ASIM or APA. What they seem to be unaware of is that, through the AMA Federation or ACCME or ACGME, they and their institutions continue to be represented by the AMA whether they like it or not. We’ll discuss that more next week.

AMA Signals Donald Trump (and Tom Price): “Enter At Your Own Risk.”

Posted on | January 3, 2017 | 8 Comments

AMA member Tom Price

The AMA took an unusual step this evening when it released the open letter below addressed to Congress, warning against removal of Obamacare without a suitable replacement. While addressed to Congress, the message is clearly intended for President-elect Trump, and secondarily to hard-liner orthopedist Tom Price. The latter has the support of the AMA in his nomination to head HHS, but the AMA took a great deal of heat from members in doing so. This letter clearly signals to Price the limits of their support.

Here’s the letter:

Congressional Leaders on Reform of Health Care System

CHICAGO – The American Medical Association (AMA) released the following letter today to congressional leadership from Chief Executive Officer and Executive Vice President James L. Madara, M.D., concerning legislative efforts to reform the health care system.

Dear Majority Leader McConnell, Leader Schumer, Speaker Ryan and Leader Pelosi:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing regarding our ongoing commitment to reform of the health care system and potential legislative actions during the first months of the 115th Congress.

The AMA has long advocated for health insurance coverage for all Americans, as well as pluralism, freedom of choice, freedom of practice, and universal access for patients. These policy positions are guided by the actions of the AMA House of Delegates, composed of representatives of more than 190 state and national specialty medical associations, and they form the basis for AMA consideration of reforms to our health care system.

Health system reform is an ongoing quest for improvement. The AMA supported passage of the Affordable Care Act (ACA) because it was a significant improvement on the status quo at that time. We continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans. We also recognize that the ACA is imperfect and there a number of issues that need to be addressed. As such, we welcome proposals, consistent with the policies of our House of Delegates, to make coverage more affordable, provide greater choice, and increase the number of those insured.

In considering opportunities to make coverage more affordable and accessible to all Americans, it is essential that gains in the number of Americans with health insurance coverage be maintained.

Consistent with this core principle, we believe that before any action is taken through reconciliation or other means that would potentially alter coverage, policymakers should lay out for the American people, in reasonable detail, what will replace current policies. Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform.

We stand ready to work with you to continue the process of improving our health care system and ensuring that all Americans have access to high quality, affordable health care coverage.

Sincerely,

James L. Madara, MD

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