Pressured by declining membership and eroding political clout, the American Medical Association took a first step last week toward the biggest organizational overhaul in its 155-year history.
Now, after overwhelmingly approving plans to revise its mission and revamp its membership structure, the once-hidebound AMA faces a more daunting task: corralling support from scores of autonomous specialty societies and translating the new structure to heightened influence on Capitol Hill.
"The real issue is the effect of declining membership on our advocacy," said Steven Hanks, M.D., an internist from Albion, N.Y., and a member of the AMA's 550-member House of Delegates.
"What this boils down to is that the AMA is anxious to do something-anything-to solve its membership problem," Hanks said. "But there are still a lot of very difficult questions that have to be addressed with this change. And the biggest is whether this is at all feasible."
AMA delegates, gathered in Chicago last week for their annual meeting, rejected a more conservative course charted by the AMA board and voted instead to create an umbrella organization that would oversee hundreds of specialty societies and state associations.
Under the plan, the membership-driven AMA would become the medical community's core organization, responsible primarily for overarching issues such as advocacy and ethics, and would have virtually no dues-paying members of its own.
Change was prompted largely by a 12% drop in membership last year, to about 278,000, including approximately 80,000 medical students and residents. The AMA now represents just 26% of America's licensed doctors, versus more than half in the mid-1970s.
Under the new structure, the AMA would derive its membership-and almost all of its dues revenue, which amounted to $54.3 million in 2001-from state medical organizations and specialty societies that would collect an as-yet undetermined portion of the annual dues of all members to the new core organization.
"We've been circling this issue for a decade," said Richard Roberts, M.D., chairman of the board of the American Academy of Family Physicians. "It looks to me like we're actually prepared to finally go forward. It's a little scary to a lot of us, but very exciting."
Some said the shrinking membership has made it harder for the AMA to get lawmakers' attention. By drawing its membership from affiliated organizations, proponents of the plan said the AMA can claim to represent a far greater proportion of America's medical community, perhaps as much as 75% of licensed doctors.
"Right now (officials in Congress) are just laughing at us," said Tom Garcia, M.D., an outspoken member of the Texas delegation who worked on the committee that called for dramatic change at the AMA. "But can you imagine what's going to happen when we represent 600,000 doctors? We'll get right in to see those congressmen."
To reach those lofty membership numbers, though, the AMA-which has an annual budget of about $250 million-faces a formidable task in winning the widespread support it needs from specialty societies. Based on the emerging plan, the AMA would receive a certain percentage of the dues paid by each member of specialty, state and local medical societies-from $50 to $100. It might involve an increase in dues across the board, some officials acknowledged.
William Hazel Jr., M.D., an orthopedic surgeon from Virginia, said his 8,000-member state society could not afford to pay that kind of money to an umbrella group.
"One hundred dollars a member to be in the AMA would cost us $800,000. We don't have that kind of money," he said. "And if we raise dues. . ."
Far from a political lightweight in Washington, the AMA has about 100 employees based in an office two blocks north of the White House, and spends about $18 million per year on advocacy. If the AMA can successfully negotiate the transition as the medical community's umbrella organization, a core group for the vast majority of every licensed doctor in the nation, it will greatly enhance those efforts, said Richard Wade, spokesman for the American Hospital Association.
"It's going to be a slow process-I think they've acknowledged that," Wade said. "It's a process of building stakeholders. But, still, there's nothing out there that's bigger or speaks for more doctors than the AMA. This is an effort to take what they have and bring it all together."
The AMA will establish a committee to develop a business plan and determine whether the specialty and state societies want to be a part of the federation, and if they'd fund it. There are concerns that societies might become disenchanted with AMA policies and decide to yank their memberships.
In addition, physicians who belong to other associations might not want to be forced into joining the AMA, even indirectly.
"I don't think we have the answers to those questions," said board member William Plested, M.D., a cardiothoracic surgeon from Los Angeles.
The reorganization as a "federation of medicine" is expected to result in a reduction of AMA services, as the association strives to avoid duplication with specialty societies and focus efforts on advocacy, ethics and standards, officials said.
Richard Corlin, M.D., a gastroenterologist from Santa Monica, Calif., whose one-year term as AMA president ended last week, said the creation of an umbrella organization will save money and benefit both physicians and patients.
"We're looking to deal with the specialty societies in the mode of convener," Corlin said, "and recognize that for all of us the time is long since past when we can afford to duplicate our efforts."