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Private Practice Column

Episode 25:  Common Sense Isn’t Common:  AMA and the Private Practice Physician

“You simply must do things. If you want to make peace with your enemy, you have to work with your enemy. Then he becomes your partner. The enemy is within the gates; it is with our own luxury, our own folly, our own criminality that we have to contend.”   -Ray Bradbury

The American Medical Association is the largest and most recognized collective organizational body in medicine.  It is the de facto voice of physicians when legislators want to know what physicians think of policy.  It is also one of the oldest collective medical bodies in the United States.  Its relationship to its membership has been fraught with distrust and feelings of abandonment.  Now, more than ever, we have to evaluate where the AMA plays a role in our everyday lives.

Since its inception from an 1845 resolution at the New York Medical Association and its establishment in 1847, the American Medical Association has held itself out as the voice of physicians.  It is involved in policymaking, the creation of the current procedural terminology (CPT) that are the bedrock of our payments system, and concerns of public health.  The criticisms of the AMA have ranged from being manipulated by the very insurers it claims to fight, betraying its members by colluding with anti-physician policymakers, to simply being out of touch and becoming a political organization.  And finally, many physicians feel just by sheer number, the AMA does not represent physicians.

From statista.org:

“As of May 2023, the total number of professionally active physicians in the United States amounted to 1,077,115 physicians. From a state perspective, California had the most active physicians with 117,674 physicians, followed by New York. On the other hand, with just 1,256 physicians, Wyoming had the least active physicians in the United States.”

As of 2022, there were 271,660 members of the AMA (wikipedia- sorry).  That is around 1 in 4 physicians are members – IF the members are all doctors.  Like many stats, the devil is in the details.  So how many members of the AMA are actually physicians?  From putative numbers ten years ago ( I was sent to the Byzantine Labyrinth of 3rd parties to get accurate number) less than half were physicians. Considering less than 1 in 5 people vote in midterm elections in the United States, that is not insignificant.  As members of the AMA, physicians can feel very small and insignificant.  Especially as private practice doctors, we really feel like no one hears us.  We see the recent losses in the legislative field, like the cuts in Medicare reimbursement which actually leads to about a 30% reduction in our reimbursement over past 2 decades, scope creep, and unethical corporate medical practices leading to patients being hurt and physicians being blamed all the while for the inflating cost of healthcare.

In a New York Times article from pre-pandemic 2016 (https://www.nytimes.com/2016/10/07/upshot/your-surgeon-is-probably-a-republican-your-psychiatrist-probably-a-democrat.html), people in the surgical specialties lean very much to the right and those in primary care and psychiatry lean heavily to the left. 

This is from a Medscape Physician Survey, republished in the same NYT article

According to a KFF article from November, 2023 (https://kffhealthnews.org/news/article/health-202-ama-reconsidering-single-payer/#:~:text=So%20it%20was%20a%20big,a%20whole%20’nother%20story) , medicine is becoming less white and less male.  The organizations supported by mostly younger and more active youth, therefore have responded policy wise.  The reaction to the leftward shift of the AMA is not surprising.  In another article from Duke University Press in the Journal of Health, Policy and Law from 2020, analyzed that younger physicians have turned sharply to the left.  Many policymakers have made it a priority to address racism as it is in many institutions, like the healthcare system in the hopes it will make things better (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8855762/).  The COVID-19 pandemic increased the schism in politics. 

So why bother?  If the AMA is “too woke” why support it?  If the AMA doesn’t speak for us, why pay dues?  If we keep losing with the AMA, why don’t we change teams?

OK, so if you take a beat, and understand just how many connections the AMA has within our daily practice, it might be better to join them, rather than beat them.  The AMA is heavily involved in interactions with Congress.  It supported the establishment of the Affordable Care Act.  This legislation is also known as ObamaCare, and it created the current insurance marketplace.  It is seen as a very heavy-handed effort to bring cost under control.  It has not worked and the insurers, who helped craft the legislation continue to post record profits as the cost of care rises.  Many see the AMA as culpable as those who crafted the legislation. 

So the schism in politics, inherent in medicine, exacerbated by a de-whitening, and younger demographic in medicine has caused many to ask why the AMA is even a thing anymore.  One asks the question why be a part of something that doesn’t stand for me, that doesn’t speak for me, and works with the very people I detest?

The answer is simple: agency. 

In order to be at the table, we have to buy a ticket.  One of my colleagues frequently asks me “how much money does the AMA make off CPT codes?”

From an article by Influence Watch, which is a project of the Capital Research Center, itself a “conservative non-profit”:

In 2022, the American Medical Association generated about $493 million in revenue. Of that sum, less than $34 million came from membership dues. By far the largest revenue source was “royalties and credentialing products,” at over $293 million. Other significant revenue sources included insurance commissions ($33.2 million), journal revenues ($30.8 million), and advertising ($13.3 million). The AMA’s reliance on commercial sources for revenue rather than membership dues has drawn criticism that the organization is beholden to business interests and does not adequately represent American physicians. Critics have alleged that the AMA has sold data harvested from its members to private companies.

A key source of funding for the AMA is the licensing of Current Procedural Technology (CPT) codes, a system for medical expenditure reimbursement to which the AMA has exclusive intellectual property rights. In 1983, the federal government declared that CPT would be the sole reimbursement system used for Medicare and Medicaid expenditures. Critics argue that this arrangement constitutes a government-backed private monopoly.

So there you have it, only 7% of its revenue comes from member dues and 60% from its most prevalent product.  So why bother?  If we all quit, what would it matter to them?

It would matter a whole lot.  As a specialty, neurosurgery gets delegates based on the number of members who are AMA members.  If we had zero delegates to the AMA, we would have zero voice, which is even less than we have now.  We understand that the AMA makes a LOT of money from their licensing of CPT codes.  There is no way OUTSIDE of the AMA to influence the practice.  It is very possible, that the AMA does not need an entire building in the River North Area, right off of Michigan Avenue, one of the most expensive areas to have an office in the city of Chicago.  How then would you convince such an organization it needs to trim down other than from within? If we want to change policy we hold elections. 

At the end of the day, lawmakers, stakeholders, and basically everyone besides us looks to the AMA to speak for us.  It would take decades to create a parallel organization and longer to create one robust enough to garner the necessary attention.  In this author’s opinion, we need to be at the table and not on the menu.  It is only through change from within that change will come.  The wrong approach to take all of our toys out of the sandbox and go home.  We need to look at the current sociopolitical quagmire as it is, not as it needs to be.

That may mean holding court with folks you would rather not spend time with or trust with your most sacred professional thing – your career and your art.  Neurosurgery, as a collective has to suck it up and work with and within the AMA if we want policy to work in a common-sense fashion rather than whatever way the wind blows. 

A possible way to re-create the AMA is to make CPT freeware.   Much like Linux operating systems where there is no charge for its use, and the source code is freely available to all users who can modify it as they like and share fixes, upgrade, and modifications to the channels so we all benefit.  If this is too socialist for the most discerning, creating a market place of CPTs put out by respective entities like the AAOS, CNS/AANS, and ABIM (for example) that act much like a committee and create a work product that the AMA oversees.  In other words, de-incentivize the need to own CPTs by opening the marketplace and deregulate it.  One might argue the AMA is functioning a bit like a monopoly, and it needs to function more like a regulatory board or advisory commission.  Thereby more societies become involved, and they can do away with quite a bit of administrative bloat.  It would be a bold move and arguably it could implode the organization.  We cannot even be at the table for such a discussion if we huddle amongst ourselves and moan about how no one listens to us.  Certainly, we could not look ourselves in the mirror and feel legitimized by our ill-humored misanthropy.

If we want it to change, we have to work within, not without.  Democracy is a participatory sport and if neurosurgery wants to be heard, we have to be in the game.  If we are not, then we deserve to be on the sidelines.  Nothing will change and we would only have ourselves to blame.