Why the AMA is in decline, and should doctors care?

The American Medical Association recently released its membership numbers, and they’re declining.

According to MedPage Today, the AMA “saw another steep drop in its membership in 2010 — this time losing about 12,000 members or 5% of its total membership.”

It’s been well publicized that the AMA only represents a minority percentage of physicians, depending on what you read, it’s between 20 and 30%.  But it seems many physicians have little positive to say about the organization.

In a provocative opinion piece, former JAMA editor George Lundberg asks, “Why do so many physicians hate the AMA?

He lists a myriad of possible reasons, including previously opposing Medicare, lack of progress on malpractice reform, and support for the Affordable Care Act.  Although that may all be true, he concludes it’s because doctors are unhappy and the AMA is a convenient punching bag:

It could be as simple as that every unhappy person needs a whipping boy, and the AMA has been an attractive target for so long.

Perhaps, but let’s dig deeper.

The AMA traditionally has been a politically conservative organization, opposing national health insurance in 1948, and, as mentioned previously, resisting Medicare in 1966.

But, in a turn, it supported the Affordable Care Act, angering a core segment of supporters.  According to MedPage Today, “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 (ACA).”

However, the AMA had no choice but to become more politically moderate, or risk extinction.  More doctors are becoming salaried employees, and salaried doctors tend to be more progressive.  The New York Times recently wrote how the political leanings of doctors are shifting left:

Because so many doctors are no longer in business for themselves, many of the issues that were once priorities for doctors’ groups, like insurance reimbursement, have been displaced by public health and safety concerns, including mandatory seat belt use and chemicals in baby products.

Even the issue of liability, while still important to the AMA and many of its state affiliates, is losing some of its unifying power because malpractice insurance is generally provided when doctors join hospital staffs.

But will a pivot to the center save the AMA? It’s an uphill climb.  Like most centrist groups, the AMA angers both sides of the political spectrum. Conservatives are quitting because of the Affordable Care Act’s support, and progressive physicians are loathe to back an entity that had historically opposed Liberal values.

In the end, however, it’s in the medical profession’s best interest to keep the AMA politically relevant.  Despite having a minority of physicians in its membership, what other choice do doctors have?  Fragmenting physicians into smaller political niche and specialty groups will only guarantee that they be further ignored by policy makers.

The AMA may not be every doctor’s cup of tea, but it’s the best voice we have.  And that is better than no voice at all.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • Frank57

    It’s time that people stop punishing the AMA over Medicare. That was almost 50 years ago, for heaven’s sake!

  • primaryMD

    What substantial trends in medicine have they significantly altered?
    Major insurance companies and the govermernment do what they want to do. The AMA pretends it influences those entities, but I’m not convinced.

    I think a lot of physicians see the AMA as an impotent organization.

    • Kevin

      Perhaps, but what alternative to the AMA do you suggest?

      Kevin

      • Bobbo

        A true physicians advocacy group. Patient advocacy and “seatbelts and chemicals” are important, but should not be the role of the AMA.

        Rather than taking sides on divisive issues, the AMA should restrict itself to lobbying for activities that benefit the physician community as a whole. Namely malpractice reform, increasing (or preventing decreasing) reimbursement, restriction of practice rights of mid-level providers, etc.

        • ninguem

          What Bobbo said.

          If more and more physicians are employed, the AMA could take strong positions on matters that really do apply to employed physicians. Bad-faith peer review. Restrictive covenants. The many, many “responsibility without authority” issues that affect salaried doctors. I could probably think of more.

        • primaryMD

          Bobbo has it right.

          If the AMA focused in on lobbying for the important issues, I bet more physicians would lend their support.

        • Matt

          “. Namely malpractice reform,”

          Do you want them working for physicians, or liability insurers? If you wanted the former, you’d be pushing for insurance reform.

        • Leo Holm MD

          A group that advocates for physicians and patients jointly. There needs to be more collective power against insurance companies, CMS and other illegitimate third parties interfering with patients access to health care. The AMA is a rip off. Patients don’t like ‘em. Docs don’t like ‘em. They have little power to influence anything. They are too busy with CME, meetings, posing etc. When we advocate for our patients, we will have the collective power to stop the nonsense that the AMA is too weak to address.

      • MarylandMD

        Kevin,

        Based on your arguments for supporting the AMA, here are a few taglines that they should use in their advertising for new members:

        “The AMA: What other choice do doctors have?”
        “The AMA: We may not be your cup of tea, but we’re better than no voice at all”
        “The AMA: Perhaps impotent, but what alternative do you suggest?”

        Seriously, though, when I saw the title, I was hoping your article would provide a robust positive argument for joining the AMA. Unfortunately, I don’t see anything that persuades me to join. Can you or a guest author perhaps give us a more substantive rationale for joining?

        • horseshrink

          “The AMA: We may not be your cup of tea, but we’re better than no voice at all”

          That’s about it for me. (I retain AMA membership, but let my APA membership go.)

          However, I think another, potent variable is spelled out in great detail in Putnam’s “Bowling Alone.”

          As a society, we are shifting away from involvement in service organizations.

        • Jo

          Well said

      • Ed

        Kevin, isn;t it obvious that doctors now need to unionize and the primary group speaking for docs would be their union?

  • Linda Ray, M.D.

    The AMA has always been over represented by academics and subspecialties due to a variety of reasons. Neither of these groups know much about cost containment and are the least prepared to identify waste. Our internist group belongs to state organizations, but has never belonged to the AMA. It is too costly and does not represent mainstream on the front line physicians. We don’t have time to take extended CME, buddy up to the politicians, sell our coding manuals. We are seeing patients, many of which cannot afford their health or are under insured. We quietly make sure their needs continue to be met , even when medicare withholds payment for legitimate work for months at a time last year. We continued to pay nurses and overhead on 50% of our revenue.
    70% of physicians do not belong to the AMA because it represents the 30% and not the 70%, and then it speaks for us politically.

  • paul

    http://www.docs4patientcare.org
    would be the alternative i see being touted on sermo.

  • http://drdavemd.com David Winchester

    Thank you for your comments regarding the AMA, Kevin. No organization is a capable of equally representing all the opinions on the political spectrum of physicians, but the AMA is the closest thing there is. While many may consider the AMA to be “impotent”, it is still the primary organization that Presidents and members of Congress consult on matters of health care reform. Dwindling support for the AMA only weakens the representation of physicians on Capitol Hill.

    • http://www.BocaConciergeDoc.com Steven Reznick MD

      Ditto. Well said

  • http://drdavemd.com David Winchester

    Another perennial falsehood about the AMA is who the members are. The AMA House of Delegates has proportional representation from primary care, specialties, sub specialties, each of the 50 states, organized staff, academics, students, residents, fellows, and foreign graduates, all of whom participate in setting AMA policy in a debate that is usually healthy, but sometimes overheated. Opinions from the far left to the far right are heard but the end result of that debate is all that ever makes the news and is what many base their opinions of the AMA on.

    • David Telasha

      Well said. We have had similar debates within the leadership of our state medical society stemming from the wide diversity of opinion from various specialists vs. primary care providers and liberal vs. conservative outlooks. While the AMA only speaks for 30% of physicians, no other group that I am aware of comes close to representing any block of comparable size. Welcome the the downside of democracy!

  • ninguem

    “…..And that [the AMA] is better than no voice at all……”

    Actually, I am one of many physicians……really the majority of physicians……..who feel the AMA is worse than nothing.

    • Leo Holm MD

      Ouch! But quite true.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    “70% of physicians do not belong to the AMA because it represents the 30% and not the 70%”

    Isn’t this the other way around, i.e. the AMA represents those who belong?
    What would happen if the remaining 70% joined the AMA, took an active role and changed it from the inside? Would the AMA then represent something else?
    Seems to me as a terrible waste to dismember the AMA instead of fixing it. There are very few professional organizations that have such major lobbying power, but then employees usually don’t lobby. Maybe they have a union, but it’s sort of too late for that I think.

    • http://www.youtube.com/watch?v=ji_G0MqAqq8 AustrianSchool

      Except that when I belonged to the AMA and repeatedly sent letters expressing my concerns as a solo FP nothing changed. So, I dropped out this year and kept my $420 in dues (money well saved.)

      • Jo

        Same here

      • IowaSoloFp

        Ditto. I even called the AMA while I was still a member asking how I could get more involved, and all they suggested was filling out their surveys.

        My impression was that the AMA had become heavily fragmented with many sub-committees (women’s issues, students, minority, GLBT, etc) none of which applied to me, and had lost touch with what should have been their primary focus – advocating for the interests of all physicians.

  • rich md

    i think med students/residents/new physicians join the ama when they first start in medicine, then after starting practice and they get into “kill self” mode, they drop out because they realize they made a mistake going into medicine…

  • solo fp

    The AMA’s CPT codes are part of what is wrong with medicine. Docs are supposed to choose around 10 different CPT codes for the care of the patient, with the majority of them narrowed to level 3 and 4 visits. Each insurance company pays a different amount for the same level of care, and Medicare comes in to redefine what is required from the office visit notes. In the end, poor fees and complicated documentation make medicine less enjoyable.

    • Leo Holm MD

      All physicians complain about this system. Nothing is ever done about it. Too much money for the AMA to turn down.

    • horseshrink

      In private practice, I had a spreadsheet of CPT codes and corresponding Medicare allowable $$/minute.

      The more time I spent with someone, the less money I made. (not subtle)

      Now, the new “norm” for psychiatrists is 20-25 patients per day. How fast can a shrink really listen?

      CPT Frankenstein on a hamster wheel.

    • Jo

      Exactly! How can an organization who thought up the CPT codes be an advocate for the people who they force to buy their product in order to be paid then allow them to be paid so little for prevention and coordination of care? How about the 29 “secret” people that meet at a hotel each year to decide which CPT codes will no longer be paid? Why they make CPT codes for “non-covered” services but will not provide a list of those codes to physicians? With that kind of entity “representin” who needs enemies?

  • Guest

    I’m not sure anyone can prove the AMA represents the 30% of it’s members. I’m sure the 30% would support malpractice reform and an end to frivolous lawsuits, and the AMA has done zero in that regard. (If you say it’s not their fault how come the ATLA accomplished so much for lawyers?) I’m sure the 30% see no benefit in the AMA profiting from CPT codes. IMHO, the AMA represents………the AMA, and those who make a living working for it. Just like any government agency, the AMA’s only function is to defend it’s right to exist.

  • MarylandMD

    Dr Lundberg pretends he wants to find out why doctors aren’t joining the AMA, but asks questions like this:

    “Maybe they reject the ethic that physicians should care for all in need, regardless of their ability to pay, an AMA position since 1846.”

    Heh. Yeah, right, George.

    If the AMA wants members, they are going to have to make the case. Have George Lundberg come to a local meeting of the Maryland Academy of Family Physicians, tell us why we should join, and then take a few questions.

    I have seen nothing that the AMA has done or could do for me that would justify spending $420/year on dues. Lower the dues to $20/year and show me what the AMA specifically does for me, a primary care FP, and I will think about it.

    Maybe the AMA should institute a new dues policy: “Join us and pay for dues what you think we are worth.” Maybe that will help membership?

    • ninguem

      Well said Maryland MD

      Lundberg: “Maybe they reject the ethic that physicians should care for all in need, regardless of their ability to pay, an AMA position since 1846.”

      Here’s a copy of the American Medical Association’s Code of Ethics, dated May 1847
      http://www.ama-assn.org/resources/doc/ethics/1847code.pdf
      Dr. Lundberg’s reading is highly selective, to put it mildly.

      Page 84
      “Being required to expose his health and life for the benefit of the communit, he has a just claim, in return, on all its members, collectively and individually, for aid to carry our his measures, and for all possible tenderness and regard to prevent needlessly harassing calls on his services and unnecessary exhaustion of his benevolent sympathies.”

      Page 97
      “A patient should, after his recovery, entertain a just and enduring sense of the value of the services rendered him by his physician; for these are of such a character, that no mere pecuniary acknowledgement [can] repay or cancel them”

      Page 105-106
      “There is no profession, by the members of which, eleemosynary services are more liberally dispensed, than the medical, but justice requires that some limits should be placed to the performance of such good offices. Poverty, professional brotherhood, and certain public duties referred to in section I of this chapter, should always be recognized as presenting valid claims for gratuitous services; but neither institutions endowed by the public or by rich individuals, socities for mutual benefit, for the insurance of lives or for analogous purposes, not any profession or occupation, can be admitted to posess such privilege. Nor can it be justly expected of physicians to furnish certificates of inability to serve on juries, to perform militia duty, or to testify to the state of health of persons wishing to insure their lives, obtain pensions, or the like, without a pecuniary acknowledgement. But to individuals in indigent circumstances, such professional services should always be cheerfully and freely accorded.”

  • Matt

    If the AMA really cared about physicians, one would think they’d be aggressively moving you away from the third party payment model, the source of over half your ills. But for some reason, they don’t. Why is that?

    • imdoc

      Matt, the AMA will support the status quo payment model because it greatly favors highly paid procedures, imaging, and specialty care. All protest to the contrary, there is no chance patients would pay some of these prices out of their own pockets. The RVU committee in its composition and structure is the best example of this. The public should abolish the RVU committee. Medicare would have been better served to hire its own consultant physicians and actuaries to create a payment mechanism that serves goals of cost management and service. The politics are now entrenched and unfortunately there is not enough groundswell of opposition.

  • Primary Care Internist

    I agree with ninguem and the sentiment of some other posters here in the sentiment that the AMA is worse than no representation at all.

    When they stand passively with white coats and listen to Obama say there isn’t clearly a malpractice crisis, and similarly the Amer Acad of Pediatrics does nothing when our politicians say that pediatricians are carving out kids’ tonsils for money rather than “giving an allergy pill”, then that “representation” is worse than nothing. Because, to the lay public this passivity VALIDATES these erroneous statements. Without any representation at all, at least we’d have perhaps a few physicians with the RIGHT responses have a voice that’d stand out.

    Also, I’m so sick of these organizations seeming to have as their PRIMARY mission patient well-being. Of course that is a laudable goal but their primary loyalty should be toward DOCTORS! Not that the two should be disparate, but advocating for public health vs. medicare reimbursement? should be a no-brainer. There are many many many groups that advocate for the former, and NO other groups for the latter.

    What a waste of money it was when i was a member, and even MSSNY, sat on one of their committees, meetings are a waste of time, all 80+ year-old retired doctors who come for the free lunch and don’t make any actual decisions.

  • http://Richmonddoc.blogspot.com RichmondDoc

    I joined the AMA after med school, because it seemed like the right thing to do. I have kept my membership active b/c I have my disability insurance through the AMA’s program and, given the fact that I have a retinal tear, I can’t get reliable coverage elsewhere. I have not remained and AMA member because I am a strong supporter of the organization.

    As a primary care doc (family medicine), I have not found the AMA to represent my views or my specialty very well. As witnessed by the AAFP’s recent actions calling for the reform of the AMA’s RUC, I am not alone in this opinion. I do not feel that the AMA speaks for me very often. The AMA’s support of the ACA health care reform law is one exception…but even then, the AMA’s support was slow in coming and somewhat lukewarm. I have kept my AMA membership alive in part because of this support, though: if the AMA had come out against the ACA I would probably have left the group.

    A few years ago I joined the National Physicians Alliance (www.npalliance.org) because I appreciated their perspective on health care access for all, removing ties with PhRMA and other industries, and the fact that their policy positions align more strongly with my own. I usually refer to NPA as the AMA with a soul, and am happy and proud to be an active member.

    I have mixed feelings on the AMA: I feel that as the largest and most recognized physician organization, the AMA still carries political weight and as such I don’t think I can let it go. Put if I could find a good option for the disability insurance, I might reconsider.

  • Marc Gorayeb, MD

    Political ideology has infected more than just the AMA. Look at AARP, for example. In fact, political ideology has infected some of the physician specialty societies. Supporting physicians on financial issues, tort reform, physician practice autonomy, overbearing government regulations, insurance company abuses of physicians, government witch hunts using “evidence-based guidelines,” … all these issues are relatively apolitical and deserve the AMA’s foremost attention. I don’t see the AMA engaging government or industry on these issues. Instead its leadership has deliberately steered the organization into the pockets of political ideologues. Well done. You reap what you sow.

  • Leo Holm MD

    The George Lundberg opinion actually answers all the questions posed here, including his own. Everyone should watch it. It clearly demonstrates how detached AMA leadership is from the physicians they claim to represent. What outrageous arrogance. If he ever gets a moment away from his board and committee meetings, he might try asking one of the physicians in the trenches why they hate the AMA.

  • ninguem

    “….The AMA traditionally has been a politically conservative organization, opposing national health insurance in 1948, and, as mentioned previously, resisting Medicare in 1966…..”

    And late from the starting gate as well.

    Lyndon Johnson signed the Medicare bill, with Harry Truman by his side, on July 30, 1965 .

  • http://www.movingforwellness.com Bobby Fernandez

    Great comments about how docs need a voice for issues they care about. A happy healer means happy, healthy and wealthy patients.

  • Penny

    I don’t know anything about the AMA of course, but one thing that has discouraged me from joining some clubs was that they took a particular political stance. Unless I’m joining a political party itself, I don’t care to witness the stance that any other organization is taking, especially if it disagrees with mine. I think organizations should convey as much neutrality as possible. It’s so disappointing to discover that you’re joining a club that seems to have more hidden beneath its cloak besides the issues you thought it represented, and that it really appears to be more of a backbone pusher for a particular political party instead.
    The key trouble with taking a political stance is that when that stance falls out of favour with the majority of the people, the club goes down with it ASAP.

  • gioacchino aj patuto, MD

    been a member for 15 years. have not seen much in favor of doctors. however, i still pay my dues just in case the AMA should represent us drs. better.
    it is like waiting for interest rates to rise in banks, so that, one can invest and get a return.

    • horseshrink

      Heaven forbid that patients “suffer” any more. (Check etymology of “patient.”) Nay, they “consume” (means to “destroy”). In my local area, some people a step ahead on the euphemism treadmill must have realized this etymological bungle and concocted a replacement. No more “consumers.” It’s “prosumer.” Yup.

      And re: insurance. It’s not a universal entitlement system from which everyone’s eventualities must, by rights, be paid. It’s a tool for preventing financial ruin in catastrophe.

      I don’t buy home owner’s insurance to cover leaking faucets, air filter replacements and unplugging toilets. I have the policy in case my house burns down. Other costs are out of pocket … which subjects them to market forces. I don’t buy a $100 toilet plunger just because a third party is paying the bill. I buy the $5 one because the cost comes directly from my pocket … and that keeps the cost of plungers down. No special managed care or governmental process is required to contain that cost.

      • horseshrink

        Build a public health clinic system and correspondingly downsize (eliminate?) Medicaid.

  • Robert Luedecke

    It is very interesting to me that I have heard groups of primary care doctors dissing the AMA for contributing to the disparity in primary care vs. specialists incomes. I have also heard groups of specialists dissing the AMA because they believe the AMA too heavily represents primary care interests. If both cannot be true, there is confusion about what the AMA really does. The recent statement by the new AMA president was very much worth reading and helped convince me to send in next year’s dues.

  • Raphael

    As an active member in the AMA, the conversation taking place he is of Particular interest.
    The frustration voiced by many would be far better served at the national stage at the AMA convention than on an anonymous Internet board.
    Please take your ideas, get in touch with your state medical society and “be the change you seek”!

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