With its role and relevance under increasing scrutiny, the American Medical Association may cease to exist in its present form, re-emerging in coming years as an umbrella organization with no direct members of its own.
The transformation, outlined in an internal report that has not yet been made public, would be a revolutionary change for the 154-year-old organization, which after a long, steady decline in membership represents less than 30% of America's doctors.
Under this radical scenario, the AMA-still the largest doctors' group in the U.S. with about 290,000 dues-paying members-would become the core organization for most, if not all, of the nation's several hundred medical specialty groups and state and local medical associations.
Much like the role of the United Nations, the AMA's role would be to help develop policy but act essentially as a figurehead for a diverse, largely autonomous collection of specialty societies whose growing clout and membership has come at the direct expense of the once-dominant industry leader.
"It would appear to me that the handwriting is on the wall," said Joe Sanders, M.D., executive director of the 55,000-member American Academy of Pediatrics and part of the AMA committee that developed the proposal at the request of the organization's House of Delegates.
"Unless they make some adjustments, they're just going to . . . cease to exist," he said. "I don't know whether it'll be 10 years or 20 years, but you can't have this kind of a declining membership and sustain yourself."
The AMA's membership decline, Sanders said, hinders the group's lobbying efforts in the nation's capitol.
Dues-paying members of medical societies who join this new federation automatically would become members of the AMA, but the Chicago-based doctors' group would have few if any direct dues-paying members of its own. Instead, an as-yet undetermined portion of the dues paid by doctors to their specialty society or local medical association would be funneled to the AMA, an automatic "tithe" that has upset some groups in the past. It's not clear whether the AMA's dues would rise or fall under this plan.
"The principal means of membership would be through your specialty society, or a state or ethnic medical group," said Jack Lewin, M.D., chief executive officer of the California Medical Association, which represents more than 34,000 physicians.
The surprising restructuring proposal is a reflection of deep concerns about the AMA's financial well-being. Dues revenue has plummeted even more precipitously than membership, falling to an estimated $50.1 million in 2002 from $66.7 million in 1998, a 25% drop. As recently as 1993, dues revenue represented 35% of operating revenue; that figure plunged to about 21% last year.
Walter McDonald, M.D., the executive vice president and CEO of the American College of Physicians-American Society of Internal Medicine, described the proposal as a logical progression for a national group that already functions largely as an umbrella organization.
"This ultimately moves (the AMA) from a membership organization to one where the individual organizations hold the membership," said McDonald, who was chairman of the committee that first floated the idea of the AMA's new role. "I think it's a step in the right direction."
But there remains a threat that non-AMA members who belong only to a specialty society would rebel at the notion of being involuntarily linked to an organization that has alienated many doctors in recent years with internal political battles and a 1997 product endorsement fiasco with Sunbeam.
When the Illinois State Medical Society voted overwhelmingly two years ago to end a policy that required its members to pay dues to the AMA, about 3,500 doctors left the national group. About 1,500 eventually returned. All told, the AMA has suffered a five-year average membership decline of 4% through the year 2000, the same period in which top AMA officials were emphasizing the vital importance of increasing those numbers.
Lewin called the controversial proposal a "general sense of direction" rather than a "blueprint," noting that it is almost certain to trigger contentious debate within the AMA. He said the report does not even address hot-button issues such as whether the AMA should eliminate individual memberships, how much specialty societies would pay to the AMA or what the core organization would do if a disgruntled member organization or multiple groups decided to pull out en masse.
"Certainly, some members of the AMA will see this as too big a departure from the tradition," Lewin said. "Others, who are young physicians or medical students, may see it as absolutely essential if the AMA is to continue. I think some change is clearly necessary."
The idea of the AMA as a core organization has enjoyed strong support for years from reform-minded AMA members such as Raymond Scalettar, M.D., a Washington rheumatologist and former board chairman who lost a bid for the organization's presidency in 1998.
"I think the AMA is going to survive," Scalettar said. "The question is, `Will it have significant influence in the future?' I've always felt we needed a strong umbrella organization to represent medicine. The only way you're going to have that is through an association of associations."
The outline of this new role is contained in a report issued about two weeks ago by a special advisory group of the AMA, which has been at work on the project for more than a year. Though the report has been distributed to top officials of many specialty societies and state associations, the AMA has not released a copy, saying the proposal will be publicly discussed for the first time at its annual meeting in Chicago in June.
A reconfigured AMA would be one way to deal with the increased clout and appeal of specialty groups, which have cut deeply into the AMA's market share by offering doctors more tangible benefits and better-focused advocacy efforts. Tough economic times haven't helped the AMA's pitch for about $420 per year in dues per physician, since many physicians are loath to absorb the cost of dual memberships.
For instance, the American Academy of Pediatrics has 55,000 dues-paying members, but fewer than 7,000 belong to the AMA, according to a June 2001 AMA survey. The American Academy of Family Physicians has 93,100 members, only 18,100 of whom also pay dues to the AMA; and the ACP-ASIM, which represents about 115,000 members and ranks as the second-largest doctors' group in the U.S., has 29,100 dual members.
Another revealing statistic: Only about 11% of AMA members are 40 years old or younger, according to the AMA. The AMA characterizes nearly one-third of its members as "senior" physicians age 56 and older, which contributes to a common perception that the organization is hidebound and resistant to change.
Not counting medical students and residents, who are lured by deep discounts in annual dues, AMA members account for only about 29% of 726,000 practicing doctors in America (See chart, p. 10). Just a decade ago, the AMA represented 45% of the nation's doctors.
As the titular head of this new "association of associations," Sanders explained, the AMA could legitimately claim to represent a far larger number of individual doctors than it does now, despite the fact that those physicians would not be paying their dues directly to the AMA. Lewin said the AMA, as the umbrella for so many other groups, could claim to represent anywhere from 90% to 95% of all practicing doctors, a huge constituency more likely to attract the attention of politicians and policymakers.
Numbers aside, McDonald and others said, the AMA's revised role would allow it to concentrate on what many believe to be its principal role as the national advocate for broad issues that affect doctors and their patients.