In Washington, the American Medical Association is like the person who has everything-good looks, money and influence.
And also like such people, the AMA has more than a few bitter associates in its peer group.
Whether sparked by jealousy or justified resentment, antipathy toward the giant physician group runs strong among capital lobbyists and lawmakers. Common complaints are that the group waffles on commitments and stubbornly demands everything on its political agenda, refusing to compromise.
One healthcare official who asked not to be identified describes the AMA's view of the healthcare marketplace as backward-looking.
"I don't have any contact with them the same way I don't have any contact with the Flat Earth Society," the lobbyist said. "We just don't want them against us. Put them on the sidelines. If they're there, I'm happy."
Clumsy giant. The AMA, an association of 290,000 physicians, is the best-organized, best-funded healthcare lobby in the capital. Its organization and clout make it one of the most formidable opponents one can face on Capitol Hill-or a powerful, if sometimes unreliable, ally.
Other lobbyists and congressional insiders say the AMA sometimes uses its organization and clout clumsily, damaging its relationships with potential allies and the real power brokers.
An example of such fumbling occurred against the backdrop of Congress' rancorous debate on Medicare reform in October 1995. The AMA initially backed the Republican spending reform efforts, but its support wavered when it realized that a big chunk of the planned $270 billion in savings would come from Medicare physician payments.
House Speaker Newt Gingrich (R-Ga.) then met with top AMA officials in his Capitol office. Gingrich wanted the group to stand by its pledge of support for the GOP Medicare plan and to purchase advertisements and mobilize its politically powerful physician advocacy network.
AMA officials announced after the meeting that they and GOP leaders had reached agreement. They also told reporters they cut a great deal that averted billions of dollars in Medicare physician fee cuts. That statement-described as a "bonehead maneuver" by one Capitol Hill insider who attended the meeting-gave Democrats an opening to attack the deal as a "bribe" aimed at getting the support of organized medicine.
It not only required the Republican leadership and the AMA to spend the following day trying to put a good face on the agreement, it also created an icy relationship between the two groups to the point where some congressional staff aides would not talk to AMA lobbyists.
"It took a very positive story and put a negative spin on it," said one source who attended the meeting and who asked not to be identified.
Some sources knowledgeable about the incident said the AMA's relationship with House Republicans still has not recovered from what they consider a mischaracterization of the meeting.
"There's a degree of frustration when people, for whatever purpose, misrepresent what goes on at a meeting," said Rep. William Thomas (R-Calif.), who as chairman of the House Ways and Means Committee's health subcommittee attended the meeting. "That was a bizarre situation."
An AMA official, however, denies the incident had any lasting impact.
"I think we have a good relationship with the leadership," said Richard Deem, the AMA's vice president for federal affairs and coalitions.
Deem added: "We are aggressive, forceful advocates. We do not step out of bounds. If we did, we would no longer be as effective."
Tricky business. Lobbyists for other providers say the AMA's power can make forming an alliance with the group a tricky business. Many lobbyists describe the AMA as bullies when they are invited into the provider-group coalitions that frequently form around issues.
These lobbyists, who spoke on condition of anonymity because they don't want to jeopardize future alliances with the AMA, say the association frequently refuses to compromise its positions for the greater good of the coalition. They contend it splits off when circumstances force the coalition to veer slightly away from the AMA's course.
The issue has resurfaced as hospital groups have begun pitching members of Congress on the idea of federal licensing of provider-sponsored organizations, or PSOs, so they can contract directly with Medicare.
Although the AMA and the coalition of hospital groups led by the American Hospital Association want to give greater freedom to provider-led networks to contract directly with Medicare, the AMA would not come out in support of an AHA provision that has been introduced in the Senate by William Frist (R-Tenn.), a heart and lung transplant surgeon.
Some healthcare lobbyists said the physician group would like the federal government to permit the networks to provide a greater portion of services through contract providers than the AHA-led group wants.
It is, in essence, a question of who will control the provider networks of the future. If a substantial portion of the services must be provided by the network members themselves, it means doctors can't be solely in the driver's seat in the networks because they will need to include hospitals and other institutions.
But to lower the threshold raises question of risk, financial reserves and consumer protection. A network of physicians with only a contractual relationship with hospitals can only guarantee inpatient care for its capitated population if it has substantial financial reserves and can buy the services.
An integrated physician-hospital network, however, has more capacity to guarantee inpatient care for its enrollees.
One hospital lobbyist said he believes the AMA will seek to weaken the language in the AHA-supported PSO bill that requires a substantial portion of services to be delivered by network providers. However, the lobbyist predicted the groups will wind up working together on the issue.
Indeed, Deem said the AMA is "working with" both Frist and the AHA.
"What's the big picture? We support PSOs," Deem said. He added: "It's very common that people have differences over details."
But despite the resentment of the AMA by some healthcare lobbyists, the hospital industry publicly welcomes any alliance with the organization.
"We have the highest regard for their lobbying team and always enjoy working with them on the same sides of the issues," said Richard Pollack, AHA executive vice president of federal relations.
Thomas Scully, president and chief executive officer of the Federation of American Health Systems, said it's not surprising that the AMA and other provider groups might not always agree.
"The AMA is a big organization, and they have interests that aren't always identical to other people," Scully said. He added: "I've had no problems with the AMA."
Source of power. The AMA's power comes from the two most important commodities in the political marketplace: money and members. In fact, the Capitol Hill newspaper Roll Call last year rated the AMA as one of the 10 most effective interest groups because of its abundant political resources.
In the 1995-1996 federal election cycle, the AMA and its state chapters spent about $3 million on political activities, according to Federal Election Commission data compiled by the Center for Responsive Politics, a Washington-based advocacy group (See chart, p.76).
That spending came in the form of direct contributions to political campaigns by political action committees, or PACs; "soft money" contributions to political party committees that are designated for such activities as generic voter registration, education or mobilization; and "independent expenditures" that assist political campaigns but are not direct contributions.
By comparison, the AHA spent $1.3 million on political activities, and the Federation of American Health Systems just $216,926.
Although interest groups and members of Congress frequently deny that such contributions buy votes, money gives them greater access to the lawmakers. And the AMA's healthy contributions give its representatives an edge when trying to visit members of Congress to make their case on numerous issues, one House staffer said.
"They do get in the door in front of Joe Schmoe, who doesn't have a PAC," the staffer said.
What sets the AMA apart is who it gets inside the door of the members' offices. Congressional staffers say they are more often visited by the AMA's individual physician members than the organization's paid Washington lobbyists.
What makes that scope of political activity possible is that the AMA counts 107,000 of its 290,000 members as participants in its "physician grass-roots network."
That political activity gives the AMA a virtually unmatched army of activists who can write, call or visit members to explain the organization's position on key healthcare issues.
In the districts, those doctors also frequently are active in local politics, making them constituents who have the ear of senators and representatives.
"They have a zillion docs who are some of the most politically active people in any district," said one healthcare lobbyist. "Every congressman has a doc or a couple of docs who are on their steering committees."
Even without the political involvement, doctors often develop close relationships with members of Congress because of one fundamental truth of healthcare, as put by another hospital lobbyist: "Every politician's got to go to the doctor."
But Capitol Hill sources also contend that because the AMA has such sway with members of Congress, it doesn't moderate what it asks of Congress.
When the GOP leadership was negotiating for the AMA's support on Medicare reform, for instance, the source who attended the October 1995 meeting between Gingrich and the top AMA officials said: "They asked for the world and didn't understand why that wasn't an option. They always want to extract a pound of flesh."