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Emory’s Center for Ethics, Tom Price, and AMA &AAMC 990’s: An Imagined Senior Seminar Class

Posted on | January 22, 2017 | No Comments

Mike Magee

The recent endorsements by the AMA and AAMC of Tom Price to head HHS should provide a remarkable future senior seminar in situational ethics for Emory’s Center for Ethics and their much lauded “Health, Science & Ethics Pillar”. The case study’s syllabus will most likely include the recent AMA endorsement, the AAMC press release, and the congratulatory and laudatory pronouncements of the CEO of Emory Healthcare, Dr. Price’s original home base.

These will contrast with a range of other documents, including the recent critical NEJM article penned by two HHS directors which stated, Price’s record demonstrates less concern for the sick, the poor, and the health of the public and much greater concern for the economic well-being of their physician caregivers.” Recommended readings will also include the 2014 990 IRS filings of the AMA and the AAMC, a collections of comments under #NotMyAMA, and an ever growing list of names on an online petition titled “The AMA Does Not Speak for Us”.

In Part I, question 1 of those 990’s, required of all non-profit organizations, students will find instructions stating “Briefly describe the organization’s mission or most significant activities. The AMA stated, “To further the interests of the medical profession by promoting the art and science of Medicine and the betterment of Public Health.” The AAMC wrote, “AAMC leads the Academic Medicine Community and strengthens the world’s most advanced medical care by supporting education, research, and patient care activities conducted by our member institutions.”

A careful reading will reveal that the two organizations combined assets exceeded $1.1 billion, and they employed just under 3000 individuals whose compensation exceeded $218 million that year. 546 of those employees received compensation of greater than $100,000. Combined, the programs and services offered that year generated $475 million in revenue. Almost half of the revenue generated by the AMA came from royalties and sales associated with their exclusive control of the nation’s CPT codes and the Physician Masterfile Database that fuels physician prescription profiling. Just under 2/3 of the AAMC revenue derived from three data driven and monopolistic product sales – ERAS (Electronic Residency Application Service – The Match: $69.2M), MCAT (Medical College Admission Test: $33.2M), and AMCAS (American Medical College Application Service: $30.4M).

Students will surmise from these two organization’s strong and immediate public support for HHS candidate Tom Price that  both organizations also support political action, but in two different forms. They will find that the AAMC is a non-profit 501(c)3. These organizations are “absolutely prohibited from engaging in political campaign activities…ie. election or defeat of a candidate.” “Insubstantial lobbying” however is allowed. The IRS doesn’t use the word “lobby” but rather the phrases “carrying out of propaganda” and “attempting to influence legislation”.

The AMA, in contrast is a 501(c)6, as are the National Football League, the American Bar Association, and the Independent Insurance Agents of America. Student research will reveal that these non-profits are permitted to engage in unlimited lobbying, and may engage in political activity, but are required to pay a 35% excise tax on their total political expenses. However, these activities may not be “the organization’s primary activity”.

The AAMC 990 will reveal 2014 listed expenditures of $3.9 million under the title “Influencing public opinion or legislation”. The report will further explain that “The other activities include meeting with or calling government officials or legislators, placing advertisements and issuing press releases to direct the organizations efforts to influence public opinion on legislative matters”.

Students querying Maplight and Open Secrets will report to the class that AMA lobbying expenditures for 2014 were in the area of $20 million. That funded close to 50 lobbyists (including 24 registered AMA employees) generating over 100 reports, many to effect the outcome of 81 different pieces of legislation. Those lobbyists made 43 visits to the House, 42 to the Senate, 17 to HHS, 15 to CMS, 11 to the White House plus 5 to the Executive Office Building, and 8 to the FDA.

In an interview with one of those future students who will reach out to me for comment, I will report that, “In a conversation with the then CEO of the AMA some years back, he expressed his desire to move the AMA headquarters to Washington since this was the organization’s primary focus. He was just being honest.” The student however will not be able to validate this in the public record. However, she will surmise that these inconsistencies may, in part, explain why only 17% of the nation’s doctors are AMA members. But she will also wonder out loud whether that matters with the AMA Federation of state and specialties in its hip pocket, and non-member revenues from CPT and Physician Masterfiles a monopolistic lock.

The students in general will not express surprise at the AMA’s full-throated endorsement of Tom Price. Their spread sheets will reveal that some Federation members went along (ACS, AAFP, a spattering of medical and surgical sub-specialties), and others went mute (AAP, ACOG, ACP-ASIM). One student, in open class discussion, will wryly remark that ”Apparently, for these organization members, you are part of the Federation, except when you’re not. What’s not to like?” Others with public health aspirations and “generalism” in their bones will wonder aloud why Family Medicine doctors at the time tolerated an endorsement of such a socially compromised legislator as Tom Price without a huge human outcry from AAFP members.

One student, an aspiring physician scientist, will sternly proclaim that “the halo around the head of the AAMC is undeserved.” He will explain to the others that the organization is governed by giant academic hospital enterprises, detached entrepreneurial medical school deans, and the vaulted “thought leaders” of medical research in America, now nearly indistinguishable from their industry counterparts. He will explain that he is deeply conflicted since support of the organization and its entities is all but essential to his own career advancement including access to NIH grants, publications, and placement on government and industry advisory committees in the future.

He’ll say he feels “ethically trapped”, supporting as he does the AAMCs highly publicized focus on new medical school curriculum, advances in physician empathy, and concerns for hospital safety and the rights of human research subjects, but dismayed by his own course work which reveals “conflict of interest in publications, patient advocacy organizations and in Twitter postings for God’s sake”. He’s especially dismayed that his own school’s top health care officer openly and enthusiastically supported the successful nomination of Emory’s former orthopedist Tom Price, who went on (after his confirmation) “to lead the nation’s survival curve, not just for the vulnerable but for everyone, due south.”

In the final week of this high level seminar class, the professor will assign her 12 students to provide four concrete recommendations that might address their concerns and begin to re-establish appropriate checks and balances. The following week, they will return with these recommendations, provided in writing on a piece of Emory stationary. It will read:

1. In this trumpian era, every single doctor in America needs to make a list of all the organizations of which each is a member or a provider, including medical associations, hospitals and health systems.

2. Each must then ask, “Are any of these associated with, represented by, or a collaborator with the AMA or AAMC?”

3. If the answer is yes, you must consider yourself a member as well, because you are!

4. Now you must determine what you are going to do about it.

More next week.

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