The American Medical Association, which continues to struggle with its mission and identity as its annual meeting approaches, has scuttled a controversial proposal from an internal committee to radically change the way it functions.
Under a plan devised by a 30-person committee that sorted through proposed changes for more than a year, the AMA would have been transformed into an umbrella organization for medical groups without any direct members of its own, receiving much of its funding through state and specialty societies. This lean "new" AMA would have curtailed many of its far-flung enterprises, cut costs and focused primarily on national political advocacy, ceding membership issues almost entirely to medical-specialty societies and state associations.
But the board of trustees last month rejected the most radical recommendations by the "special advisory group extraordinaire," calling instead for an incremental approach to change. Its decision, which surprised and angered some AMA members who had hoped for rapid change, is likely to trigger heated debate about the AMA's future when the 550-member House of Delegates gathers in Chicago later this week for the organization's annual meeting.
"The AMA is a shell of what it used to be," said Tom Garcia, M.D., a cardiologist from Houston and an outspoken member of the special advisory committee. "In my opinion, if we don't change, we are on the last few hours of the Titanic."
AMA officials dispute Garcia's grim assessment, saying the board decided to act conservatively after receiving little agreement on the fundamental changes recommended by the special advisory committee. The mixed reaction, officials said, prompted the 20-member AMA board to reject the most radical proposals for change.
Michael Maves, M.D., the AMA's chief executive, described the report as a "vision for the future" that some members mistakenly regarded as "sacred." Instead, he said, the organization must use those recommendations to help slowly design a blueprint for the future that most members can agree upon.
"You can't just throw a switch and expect all this to happen," Maves said.
Timothy Flaherty, M.D., chairman of the AMA's board of trustees, acknowledged the lack of unanimity about the report, saying the recommendations have provided "another reality test to the whole issue of how much change is acceptable."
"There's a certain group that wants more change, and a group that wants less change, or a different type of change," said Flaherty, a radiologist from Neenah, Wis. "Sometimes, when you hear that much variety, maybe it's the right (kind of) report. It's the small issues that divide us, and the big issues that unite us."
The AMA's five-day annual meeting, which kicks off June 15, is expected to feature several lively debates on controversial topics, including the board's decision in early May to halt funding to Physicians for Responsible Negotiation, a labor group that has eaten up almost $3 million in AMA loans since its formation in 1999. Among more than 250 reports and resolutions, delegates will consider a strict limit on resident work hours, and issues concerning pharmaceutical company marketing and medical-liability costs.
But few issues are as emotionally charged as the board's decision to rebuff the committee's key recommendations to restructure the AMA. Critics view the decision as a huge blunder, warning that it may cost the association more members.
"I wish the board had been a little more visionary in its approach," said Richard Roberts, M.D., board chairman of the 93,500-member American Academy of Family Physicians. "What the board of trustees' report does is keep the status quo, and allows for no change at all. I think they've certainly diluted, or weakened, what I thought were some very progressive ideas from the (special advisory group). And that's disappointing."
Garcia went a step further, denouncing the board's report as a "whitewash" that betrayed the work of the committee.
Though many doctors say they barely give the AMA a second thought these days, the Chicago-based association, which has about 278,000 members, remains a key lobbying voice and a vital link between doctors and hospitals.
Yet the organization, which represented about 50% of U.S. physicians as recently as the mid-1970s, continues to shrink, losing members along with political muscle in Washington. Last year, the AMA lost 12,000 members and now represents only about 28% of all the licensed, active doctors in the nation, a percentage that will continue to fall unless the organization can change with the times, critics such as Garcia said.
Based on the recommendations by the special advisory group, the AMA, as an umbrella group, would have derived its membership from specialty and geographic societies (March 3, 2002, p. 10). Under this scenario, the AMA would have collected a portion of the membership dues from all of its affiliated groups.
The board's decision to reject this model could increase tensions between the AMA and some medical-specialty societies that support the plan, limiting national lobbying efforts on issues such as the patients' bill of rights and Medicare reimbursements.
"The AMA needs to downsize, to pay attention to advocacy and get out of some of the business interests," said Glenn Johnson, executive director of the 37,000-member American Society of Anesthesiologists, which supports the key portions of the committee report. "The AMA can't go on the way it has. They continue to lose membership. Something has to be done."
Garcia and others have vowed to "go to war" during the annual meeting, helping lead a growing legion of like-minded members in demanding that the AMA reconsider the proposals developed by the special advisory committee.
"I'm going to push for everything that was in that (special advisory group) report to get done," said Walter McDonald, M.D., executive vice president and chief executive officer of the 115,000-member American College of Physicians-American Society of Internal Medicine. "This report is a good, solid attempt at the kind of reform that is needed."
Despite spending about $18 million last year on lobbying and advocacy, the AMA has alienated many of its traditional Republican supporters in Congress as well as other medical associations with its stance on the patients' bill of rights. The AMA's staunch support for the right of patients to sue insurers triggered a nasty insurrection by about a dozen smaller associations, sparking the creation of an offshoot doctors' advocacy group called the Alliance of Medical Societies. Many of those same societies, concerned about being tarred through an association with the AMA, also formed the Coalition for Fair Medicare Payment last year to plead their case against federal cutbacks in reimbursements.
The AMA failed thus far to win passage of any of its top legislative priorities-including the patients' bill of rights or an antitrust exemption to allow doctors to bargain collectively with insurers. Recently, though, a wide-ranging coalition led by the AMA has made significant progress in halting future cutbacks in Medicare reimbursements, successfully pushing Republican-sponsored legislation in the House that would add about $20 billion in payments over five years. If it passes, the legislation would be a tremendous victory for the AMA, wiping out a scheduled 14.2% reduction in payments over the next three years and replacing it with gains of 7.2% through 2005.
Still, some critics said, the AMA won't wield the kind of clout it did in the past unless it undertakes the dramatic change laid out by the special advisory group, said Richard Reiling, M.D., a member of the committee and a longtime AMA delegate representing the American College of Surgeons.
"To me, the board has emasculated the report," Reiling said. "We need to move ahead. We need this change. I think we're losing some of our effectiveness."
Still hobbled by financial and public relations turmoil in recent years, the AMA created its special advisory committee as a way to foster the change necessary to address a host of problems. But the latest effort, like others before it, appears to have little momentum.
The 155-year-old association has considered at least three significant changes in its governance and structure in the past decade. The efforts all have been rejected or short-circuited by the organization's power structure.
In rejecting the committee's most radical calls for change, the AMA's traditionally conservative board of trustees also dismissed another key recommendation that the association trim its house of delegates to 218 members within five years.
The board endorsed one proposal that enjoyed near-universal support, the elimination of the AMA's midyear interim meeting, which would save the organization about $800,000. It also recommended the creation of a forum to work with societies to craft an annual lobbying plan that meets the goals of the entire federation.
"I think this is the one area where we can have some real optimism," Flaherty said.
The board may have backed off from the new membership plan because of fears that some members of specialty societies who are not members of the AMA might object to being forced to join the national umbrella group, perhaps paying additional fees in the process. Garcia and other sources have said no serious discussions were held on how the dues would have been distributed under the membership model proposed by the special advisory committee.
"I'm sure we have some members who would be vehemently opposed to being members of the AMA," Johnson of the national anesthesiology society said.
In the end, the board appeared to favor an approach opposite to the one recommended by its own committee, calling for the AMA to preserve the status quo and "focus on strengthening the voluntary individual membership model."
Garcia said he finds that notion foolhardy, a past failure with no prospects for positive change in the future.
"Individual membership?" he said. "What value does the AMA have to the average working doctor? Nothing. Absolutely nothing. If it did, they would join."