Organized medicine has clout, but practicing physicians are more effective at the influence game.
Organized medicine has clout, but practicing physicians are more effective at the influence game.
Organized medicine spends more than $85,000 a day to speak on physicians' behalfto lobby Congress, the White House, and sundry federal agencies. What does the money buy, exactly? And how wisely is it spent? Those questions are nearly impossible to answer. Lobbying isn't like medicine, with well-defined outcomes. "Only on occasionwhen an organization gets this bill passed or that bill blockedis it easy to show success," explains Robert Doherty, senior vice president for governmental affairs and public policy at the American College of Physicians-American Society of Internal Medicine.
Even then, the payoff often isn't clear-cut. Take the recently passed Quality Health-Care Coalition Act of 2000 (better known as HR 1304, or simply the Campbell bill).
In March 1999, Rep. Tom Campbell (R-CA) introduced the bill, which gives physicians and other health care providers the right to bargain collectively with managed care organizations and insurance companies. Campbell had failed in an earlier attempt to get an antitrust exemption passed, and there was little reason to think he would succeed the second time around. On its face, HR 1304 looked mostly to be a bill that protected the financial interests of a group that hardly needs protection: doctors. The US Department of Justice and the Federal Trade Commission, not to mention the entire managed care lobby, opposed the legislation. Even some medical associations seemed wary of the bill's self-serving nature.
But the AMA, which for years has desperately wanted physicians to have the right to bargain collectively, appointed itself lead lobbyist for HR 1304. At times, you'd swear Campbell and the AMA were joined at the hip. They put a new spin on HR 1304: It became a patient-protection bill. Give doctors the power to negotiate collectively with HMOs, and they'll stop the horrors of managed care.
Over the course of a year, the AMAwith help from other lobbying organizations, such as the National Community Pharmacists Associationpulled out all the stops. It prodded and cajoled members of the House, testified before Congress, sent letters and memoranda to House leaders, and organized grassroots support. Momentum built, and by this spring HR 1304 had amassed 220 co-sponsors. For sure, it was going to pass.
Then, bam! Just as the House was preparing to vote in late May, the Rules Committeewhere Republicans outnumber Democrats by more than two to oneblocked the bill from reaching the House floor. HR 1304's future was in question.
The AMA went ballistic. "It's hard to imagine a more outrageous subversion of the American democratic process," said a livid D. Ted Lewers, chair of the AMA's board of trustees.
The American Association of Health Plans, which had denounced the bill the day it was introduced, chalked up the committee's decision to sudden enlightenment. The committee members took a hard look at the bill and didn't like what they saw, AAHP President and CEO Karen Ignagni explained gleefully.
Did the lawmakers really have an epiphany over a seven-page, 12-month-old bill that was the subject of a congressional hearing the previous year? Hardly. The committee's decision probably had more to do with money than demerit. Campbell told the Washington Post that some of his colleagues wanted the vote postponed so they could continue to collect campaign contributions from the managed care lobby and from organized medicine simultaneouslyto "milk both cows," he quoted a colleague.
Eventually, Speaker of the House Dennis Hastert (R-IL) promised Campbell that HR 1304 would get to the floor sometime in June. On the very last day of the month, the milking machines were unplugged and the House passed the bill, 276 to 136.
The AMA celebrated the vote as a "milestone victory." But a stepping-stone victory is more like it. Before doctors take managed care to the mat, collective bargaining proponents must persuade the Senate to pass a bill comparable to HR 1304 (no senator has even offered to draft legislation), then overcome a likely presidential veto. The antitrust exemption for physicians is still a long shot.
In the matter of HR 1304, how effective was the AMA? Depends on how you choose to answer a number of questions.
How much heavy lifting did the AMA really do? How much credit should go to the supporting cast of lobbyists? To Reps. Campbell, John Conyers Jr. (D-MI), Henry Hyde (R-IL), and other key sponsors?
Is the AMA to be lauded for its years of tenacity on the issue? Or faulted for wasting resources on a fight that in the end it's likely to lose?
Is the milestone victory solid or hollow? Would 276 lawmakers have voted in favor of HR 1304 if the bill had had a serious chance of becoming law? Would it have gotten anywhere if the country hadn't been in the midst of a managed care backlash?
Is the public image of physicians strengthened or weakened? Do patients think doctors want the right to bargain as a group so they can be heroic? Or greedy?
In most instances, big questions aren't askedbecause most outcomes aren't as clear-cut as the HR 1304 vote. More often, the end result of a lobbying binge is the underappreciated "tweaking" of a provision in a bill or a regulation, explains Doherty. "The final bill may be something physicians don't like, but they would have liked it even less if we hadn't been on the Hill," he says.
In Washington, perception is nine-tenths of lawmaking. Logically, one way to evaluate the effectiveness of a lobbyist organization is to find out what others in the nation's capital think of it.
Three years ago, Fortune magazine began an annual survey of Congressmen, their staffers, senior White House aides, hired lobbyists, and lobbying organizations' executives to determine which lobbyists wield the most power.
Looking at the Fortune surveys, it's tempting to conclude that the formidable influence of organized medicineparticularly of the AMAis slipping. At the same time, the power of the managed care industry and other likely political opponents appears to be rising.
In 1997, the AMA ranked eighth among the 120 top lobbying groups. Two other physician associations were listed: the American Academy of Family Physicians at 117th and the American Academy of Ophthalmology at 119th. The American Association of Retired Persons ranked first (a position it hasn't relinquished); the National Federation of Independent Business, a staunch opponent of a patient-protection act, was fourth; and AAHP was 108th.
In 1998, Fortune listed only the top 25 lobbyists. The AMA was the sole physician organization cited, but it had dropped to No. 10. AAHP didn't make the cut, but the association was praised in the magazine as a "newly beefed-up trade group" that "put together a multi-tiered campaign worthy of a presidential election bid" to block legislation backed by organized medicine.
Last year, Fortune offered up the 114 most influential organizations. The AMA, the only lobby for doctors in the top 50 (the American Society of Anesthesiologists ranked 110th), fell three more notches, to 13th. Several of organized medicine's adversaries rose, however. AAHP climbed to 48th. NFIB tied for second with the National Rifle Association, the Health Insurance Association of America ranked 25th (up from 30th in 1997), and the Blue Cross and Blue Shield Association moved to 29th (from 32nd in 1997).
Except for the rise of AAHP, however, the shifts aren't very significant, according to Bill McInturff of Public Opinion Strategies, one of the two firms that conducts Fortune's annual survey. "Among those near the top, the difference in scores is pretty modest," he says.
The AMA's slight decline may reflect its standing with the GOP. "At one time," observes a seasoned Washington lobbyist, "Republicans thought they had the AMA in their back pocket." And no doubt the AMA thought that's where they had a lot of Republicans.
But now, many Republicans are down on the AMA. Rep. Tom Bliley (R-VA), for example, is so irked over the AMA's support of a patient-protection act that he's intensified his efforts to have the National Practitioner Data Bank opened to the public. And after the AMA's public dress-down of Sen. Bill Frist (R-TN) at its annual meeting in June, the Senate's only practicing physician is feeling a bit hostile, too.
AMA officers castigated Frist for his position on patients' rights legislation. "Physicians across the country need to send a strong message to Senators Frist and [Don] Nickles [a Republican from Oklahoma and frontline opponent of a patient-protection bill]. We are tired of the foot-dragging, smoke screens, and posturing," said the AMA's Lewers, sounding like a coach with a troublesome star player he'd love to trade.
By any measureincluding Fortune's surveythe AMA is a bruiser. Its Washington office has an annual lobbying budget of more than $18 million and a staff of about 60. Fifteen registered lobbyists routinely stalk Congress and the executive branch. Despite recent rifts with the GOP, the AMA is well connected with members of both parties, and it knows all the lobbying tricks, from old-fashioned arm-twisting to mobilizing constituents in legislators' home districts.
Moreover, it's not bashful. "The AMA is willing to get in anybody's face," says a lobbyist who has been both an ally and an opponent on health care issues. "I say this in a complimentary way. It doesn't just write a few letters, then brag about what it did for its members."
Many specialty societies and other health care organizations also have Washington offices that, among other things, engage in lobbying activities. ACP-ASIM, for instance, has five lobbyists and spends more than $2 million a year on lobbying activities. AAFP has five staff members engaged at least part time in lobbying and spends $1.5 million a year. The Medical Group Management Association spends roughly $240,000 and has three staff members involved in lobbying.
Dollar for dollar, the smaller organizations can be as effective as the AMAmaybe even more so. "Unlike the AMA, we don't have to dedicate staff and other resources to a broad range of issues," explains Patrick Smith Jr., MGMA's vice president for government affairs and a former AMA lobbyist. "So we pick and choose what's most important."
MGMA, according to Smith, tends to concentrate on bottom-line issues, and for some time it has been the go-to organization on Stark self-referral legislation and regulation. ACP-ASIM often gets charged up over reimbursement issues; it has, for instance, led the fight for the resource-basing of practice expenses in the Medicare physician payment formula. AAFP often focuses on broader issues, such as health care for the uninsured, patients' rights, equitable insurance coverage for mental illnesses, and graduate medical education. "We're sort of a white-hat group," explains Jeff Human, who directs AAFP's Division of Government Relations in Washington, DC.
Mean or lean, rich or poor, a lobbying organization has to do certain thingsand do them rightif it's to be persuasive in Washington. Here's a list of basics.
Policy. Obviously, an organization's political positions have to reflect the opinions of its members. But those opinions can't be "off the wall," to use ACP-ASIM executive Doherty's description. "A lot of doctors may want Congress to pass a law that gets rid of Medicare's documentation requirement," he explains. "But if it were repealed, how would HCFA make sure the services it pays for are the services that were delivered?"
To develop a sound, sellable policy, most medical associations have a system that collects physicians' opinions and packages them to fit real-world politics. For example, AAFP has a nine-physician commission that tracks the progress of bills in Congress and the state legislatures, and analyzes upcoming issues. "The ultimate policy is set by the academy's board of directors," says Mary Frank, the commission's chair. "But its decisions are based on the commission's advice."
Connections. Jawboning a lawmaker as he walks down the hall doesn't get you far these days. But communicating in a civilized manner to a congressman's personal staff or to a congressional committee staff may. "We try to develop strong, trusting relationships with staff members," explains Doherty. "That allows us to influence a committee's agenda, and also to hear back as it makes decisions." To facilitate relationships, ACP-ASIM assigns it lobbyists to committees rather than to issues, as is more common. One ACP-ASIM lobbyist covers all the issues before the House Ways and Means Committee, for example, while another deals with those in the Committee on Appropriations. "Our lobbyists have to be jacks-of-all-trades," says Doherty.
Working with Congress is but part of lobbying, however. A smart organization has solid connections to the administration and to regulatory agencies such as the Health Care Financing Administration and HHS' Office of Inspector General. A third of the AMA's lobbyists are assigned to the White House and federal agencies, though their work generally doesn't get the notoriety that the push for a bill, such as the patient-protection act, does. "We worked two years with HCFA to have the errors in the Medicare sustainable growth rate formula changed," says Thomas Reardon, the AMA's immediate past president. "But who knows about that?"
"A law is just the beginning," adds MGMA's Smith. "Writing and implementing the law's regulations also have great impact. We represent our members throughout the process."
Straight talk. Lawmakers' knowledge regarding health care is tenuous, at best. Even they seem to realize it. Why else would Washington politicos say that delivering unadulterated facts is the most effective lobbying technique?
Two years ago, Sen. Nickles and Rep. Hyde were promoting a bill, the Lethal Drug Abuse Protection Act of 1998, to restrict the use of controlled substances for patients' pain relief. Many doctors and medical associations were up in arms over the legislation. "Our staff sat down with Nickles' and Hyde's staffs to explain the problems in the bill," says Reardon. "We were able to have changes made." The revised and retitled legislation, the Pain Relief Promotion Act of 1999, was endorsed by the AMA and seems to be more palatable to the organization's members.
Communicating the facts comes in many formsfrom drafting model legislation that members of Congress adapt and sponsor, to supplying basic research they can use in drafting their own. In an effort to beef up its Washington office over the past three years, MGMA has tried to become a reservoir of information for Congress. "We provide data about the impact of legislation on health care delivery," says Smith. "The more we do, the more the Hill looks to us."
Most important, when lobbyists deliver the facts, they must avoid seeming self-serving. No one wants to listen to an organization that "comes across as dollars for doctors," explains AAFP's Jeff Human.
Friends, not enemies. It's hard to imagine a Washington where disagreements are kept civil and nonpartisan. But that's the order of the dayfor lobbyists at least. Washington insiders say getting along with members of Congress and their staffs is among the most important functions of a lobbyist.
Making enemies does no good; tomorrow you may want them on your side. "A member of Congress who is your worst opponent on the patients' bill of rights may be your best ally on tort reform," says Doherty. "Republicans are good at cutting budgetsincluding budgets that benefit doctorsbut they also try to get rid of HCFA rules. Democrats often want to over-regulate health care, yet they generally support adequate funding of Medicare and controls on guns and tobacco."
Even the AMA is trying to be evenhanded these days (and is offending thin-skinned GOP stalwarts in the process). In 1997 and 1998, the AMA's political action committee gave nearly three times more money to Republicans than Democrats; since then the contributions have been almost 50-50. "We'll work with whoever will work with us," says Reardon. "Republicans and Democrats."
The friendship rule applies to the treatment of other lobbyists, as well. Trial lawyers and doctors, for example, may well be on opposite sides of the fence when it comes to tort reform, but they stand shoulder to shoulder in favor of legislation that gives patients the right to sue their HMOs.
Collaboration. For smaller organizations, combining forces is a necessity. "We rely a lot on coalitions," says AAFP's Human. His group, ACP-ASIM, and a handful of other medical organizations have banded together, for instance, to lobby for Medicare's resource-basing of practice expenses.
The AMA, too, is into collaborating (though some of its collaborators complain that the AMA hogs the limelight and retains vestiges of the arrogance for which it was once famous). "We're more effective if we have a unified voice," says Reardon. "And if we're not in agreement, at least we should work closely enough that we don't surprise each other."
Physicians probably have never been better represented than they are today. The medical associations, large and small, have developed sophisticated lobbying machines. Their budgets and staffs are growing. The AMA's lobbying expenditures increased by $1.4 million between 1998 and 1999, and Reardon says it has allocated extra funds this year to advance the patient-protection act. MGMA, which had a one-person Washington office three years ago, now has seven professionals plus support staff. The American Medical Group Association is making staff changes and "redesigning its public sector arm to be more effective," according to Donald W. Fisher, its CEO.
As it turns out, the most potent lobbyist isn't Richard Deem or Lee Stillwell, who head the AMA's Washington operation. Nor is it one of the savvy lobbyists from AAFP or ACP-ASIM, MGMA, or another medical organization. The most effective lobbyist is a physician in Tennessee, say, or Connecticut, or Iowa, or Arizona, or Oregonthe folks known as grassroots lobbyists.
According to a survey of politicians and Washington insiders, two of the four best lobbying practices are "having active allies in a congressman's district" and "mobilizing grassroots action." These notions aren't lost on organized medicine, which sees to it that practicing physicians express their opinions to lawmakers.
One of lobbying groups' most popular grassroots rituals is the annual legislative conference. Physicians from across the country are brought to Washington, briefed on issues and the ways of Congress, bused to meetings on Capitol Hill, debriefed, then sent back home. The conferences may disappoint some physicians. Typically, they get face time with congressional staff members only, and perhaps a grip and a grin from the legislator.
Still, some long-term relationships between physician/constituents and members of Congress develop during these meetings. "Typically, a visit is 10 to 15 minutes. People take a relaxed posture. They talk, and they listen," explains the AAFP's Mary Frank. "It's very productive, though hard to measure. The feedback from Hill staffers is that the visits are very helpful."
The associations also have procedures for gathering the grassroots troops in Washington at critical timesto testify at a congressional hearing, say, or to make the rounds on Capitol Hill during the mark-up of an important bill or before a significant vote. They hold seminars to make physicians politically savvy. They publish model letters on their Web sites to make it easy for doctors to write or e-mail their members of Congress.
More recently, the AMA, AAFP, and others have tried to move the battleground to where the grassroots are grown: the congressman's home district. This year, the AMA has been traipsing through various states under the banner "National House Call" to publicize health care issues and raise their profile in the November election.
In June, when the AMA concluded that a one-vote change in the Senate would result in the passage of a hard-nosed patient-protection act, it began campaigns in Michigan, Missouri, and Washington, where incumbent Republican senators are facing tough opponents. In Missouri, the AMA placed newspaper advertisements that said, "With Sen. John Ashcroft's vote, the US Senate could pass the real patients' bill of rights that the people of Missouri want." Either scare the senator into switching his vote or help him pack his bags, seems to be the theory behind the AMA campaign.
The AAFP's Jeff Human likes to tell a story that epitomizes the power of grassroots lobbying. "In 1997, Rep. Greg Ganske [a plastic and reconstructive surgeon from Iowa] was sponsoring an amendment that pretty much would have destroyed the movement toward resource-basing of practice expenses in the Medicare fee schedule," says Human. "AAFP sent out a grassroots alert to all family physicians in Iowa. The physicians responded by writing and calling Ganske's office to voice their opposition to the amendment, and Ganske pulled his amendment so another one, more palatable to family physicians, could be presented. Later, one of Ganske's staff members said to me, 'I had no idea there were that many family physicians in the country, let alone in the state of Iowa.' "
Perhaps it's not the thousands of dollars organized medicine spends each day that makes its lobbying effective. Instead, it may be the thousands of grassroots doctors it can mobilize.
Most people think money buys votes in Washington. Slather a member of Congress with enough cash, and you'll be able to slide him into your hip pocket.
Investigative journalists regularly report on the connection between money and power. Recently, for example, three reporters working for the watchdog Public Citizen concluded that there was a "strong body of evidence linking pro-managed care industry campaign contributions with Senators [Trent] Lott [R-MS] and [Don] Nickles' [R-OK] strenuous efforts to defeat popular patients' rights legislation."
Lawmakers themselves acknowledge the persuasive power of the purse. "Interest groups funnel money to political incumbents who have jurisdiction over issues that affect them most," writes Cecil Heftel, a five-term congressman from Hawaii, who left the House in 1986 and is now crusading for campaign finance reform. "In return for that money, which pays for the glossy, high-profile campaigns that win votes, members of Congress promote and pass legislation that benefits their big donors instead of their constituents."
Human nature is what it is.
Still, some seemingly sane people contend that money doesn't buy votes. In his book Interest Groups and Congress, George Washington University's John R. Wright argues that political action committee contributions don't grease wheels the way many people think. "There's no compelling evidence that PAC contributions have any direct and independent influence on the legislative behavior of members of Congress," he says.
Fortune magazine also takes issue with the conventional thinking on political contributions. Last year in its annual search for the most influential Washington lobbyists, the magazine tried to uncover a connection between campaign contributions and clout. "We couldn't find any direct relationship," concluded the magazine, which for the past three years has rated the American Association of Retired Persons as the most powerful lobbying group. AARP doesn't have a PAC.
The granddaddy of physician-based PACs is the AMA's, which is augmented by the PACs of state medical societies. The AMA set a precedent in 1961, when it became the first trade or business group to establish a national PAC. "In the 1962 and 1964 elections, AMPAC spent about $700,000," according to journalists Howard Wolinsky and Tom Brune, well-known critics of the AMA. "Although it was too little and too late to stop Medicare, it helped the AMA shape the program to benefit doctors."
That was only the beginning for the AMA. "During the 1970s, AMPAC quickly moved up among the ranks of all PACs to dominate the field," report Wolinsky and Brune. "By 1976, AMPAC had risen to the top, becoming only the second PAC to contribute more than $1 million to federal candidates in an election cycle. AMPAC contributions have never dipped below the $1 million level since."
Not all physician associations have jumped on the PAC bandwagon. The Medical Group Management Association has never had a PAC. Neither has the American College of Physicians. When ACP merged with the American Society of Internal Medicine a few years ago, it insisted that ASIM dissolve its political action committee. The American Academy of Family Physicians doesn't have a PAC, though a few of its state chapters do. AAFP, however, may join with those chapters in the near future; it's hired a consultant to evaluate the pros and cons of creating a national PAC. "The Texas chapter believes its PAC has made it more effective," says Mary Frank, a physician from California, who chairs AAFP's commission on legislation and government affairs. "Other chapters think having a PAC dirties your hands." The consultant's report is due this month.
As of Aug. 3 in the 1999-2000 election cycle, the PACs of health professionals (mostly doctors, dentists, and nurses) contributed more than $6 million to federal candidates. In contrast, the PACs of insurance companies and their associations coughed up $7.8 million, and labor unions $31.7 million.
By the beginning of August, AMPAC had delivered a total of more than $800,000 to 20 senators and 274 members of the House. Those opposed to organized medicine's political positions also have been busy dispensing money to lawmakers. The Blue Cross and Blue Shield Association gave about $224,000 to 37 senators and 122 House members, and the National Federation of Independent Business handed out roughly $630,000 to 22 senators and 155 House members.
In some instances, a legislator has benefited from the largesse of both the AMA and its lobbyist opponents. Sen. Bill Frist (R-TN), whom the AMA recently badmouthed for his opposition to a strong patient-protection act, got $5,000 from AMPAC and $2,000 from BluePAC. Rep. Bill Thomas (R-CA), chairman of the House Ways and Means' health subcommittee, got $5,000 from AMPAC, $3,000 from BluePAC, and $1,000 from the NFIB's PAC. Senate Majority Leader Trent Lott, who said late in June that the AMA's tactics over the patients' bill of rights could cause a "permanent rupture" with the GOP, got $1,000 from AMPAC, $5,000 from BluePAC, and $9,000 from NFIB.
And so it goes. But to what end, nobody knows.
There's a "modest" correlation between lobbying expenditures and the ability to influence members of Congress, according to Fortune magazine. But among the lobbyists fighting over health care issues, it's hard to find even a small money-to-power relationship.
Last year, the AMA spent nearly eight times more than the National Federation of Independent Business, a staunch opponent of the patient-protection act, yet the AMA was ranked 11 places lower on Fortune's scale of political clout. The Blue Cross and Blue Shield Association spent two times more than the Health Insurance Association of America but was ranked four notches lower by Fortune. The American Hospital Association spent twice as much as the Pharmaceutical Research and Manufacturers of America, yet its influence was rated roughly the same.
Below is a list of organizations frequently involved in federal health care issues, ranked by how much they spend on lobbying. Note that the expenditure numbers provide an approximatenot apples-to-applescomparison. Lobbyists are required by law to report their expenses to the federal government, but they have a choice of filing methodone based on the Internal Revenue Service definition of lobbying, the other based on the definition in the Lobbying Disclosure Act of 1995.
The IRS method, which the AMA, ACP-ASIM, AAFP, and MGMA use, and the LDA method, which the NFIB, the Blues, the trial lawyers, and AAHP use, don't include all the same expense items. Plus, there's plenty of wiggle room in the reporting. An organization that liberally interprets the rules ends up submitting greater expenditures than one that takes a conservative approach.
Michael Pretzer. What have medical lobbyists done for you lately?. Medical Economics 2000;18:46.