10 ms·

The AMA is a tax-exempt hedge fund and licensing corporation

277 points by erentz 6y ago

erentz 6y ago
Note original title “AMA? BITFD!” is vague so chose another line from the article that better describes it.
- wbenhunt 6y ago
  Thank you!
yostrovs 6y ago
Author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA, rather than the supposed members of the organization. It seems to have strong political opinions that arise out of ether.
- JumpCrisscross 6y ago
  > author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA That would make the post look like infighting. By focussing on dereliction of fiduciary duty, possibly to an unlawful extent, the argument is rendered sharper.
  - wbenhunt 6y ago
    YES
deleted 6y ago
[deleted]
hpoe 6y ago
To me this seems to highlight the worry about "fake news" and "credible sources". To me it seems less like the quality of journalism and reporting has gone down hill and more like because we have so many new independent sources of news and information we are starting to realize that the originally "trusted" organizations were not as objective and honest as we originally thought. Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information.
- JumpCrisscross 6y ago
  > the originally "trusted" organizations were not as objective and honest as we originally thought Has AMA been plumped up by mainstream journalists? I can’t recall them being quoted as an authority.
  - ponker 6y ago
    The AMA decides who gets to call themselves a doctor. Can’t imagine a more pivotal arbiter of trust.
    - ghaff 6y ago
      AFAIK, it's technically state licensing boards. Of course, licensing, the AMA, and other medical organizations are pretty intertwined in various ways.
  - TuringNYC 6y ago
    Conveniently ignoring -- for decades -- major questions about national healthcare (e.g., who creates the artificial scarcity in medical specialists) is essentially fostering the status quo. I'm happy with the AMA being the authority on medical news, but that does not mean their business practices should be beyond scrutiny.
- eightysixfour 6y ago
  > Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information. Why not both...? > isn't that we have illegitimate news flooding the market of information This is absolutely a problem. Old media seems to be pretty content with narrative framing for the most part, this new brand of illegitimate media just makes shit up. They have no intent to engage in the public discourse, their only purpose is to reinforce alternate realities and to shift the Overton window.
  - 6y ago
JumpCrisscross 6y ago
If you are an Illinois-based AMA member, consider calling your Attorney General’s Charitable Trust Bureau to make a complaint citing this article [1]. AMA is registered in Illinois; your voice will be louder. As a paying member, you have standing to show harm. [1] https://ag.state.il.us/charities/rules_statutes.html https://ag.state.il.us/charities/rules_statutes.html
vmception 6y ago
As someone forming a private foundation, this is very inspirational, thank you! Albeit under 501(c)3 and not 501(c)6 like this organization.
- ghaff 6y ago
  The two categories are pretty different. A 501(c)6 exists for the benefit of its members. That doesn't mean it's bad or can't have a positive mission but it's a trade association at the end of the day. A 501(c)3, as you know, at least ostensibly has some sort of charitable/educational/etc. mission.
  - vmception 6y ago
    I'm aware, and I take issue with the "this is bad because I have an uncomfortable relationship with money" approach that the article took. The point of the author's digital sleuthing was not for inspiration, it was to find fault to reinforce a conclusion they had already made. I doubt there was any transparent and accurate reporting that would have satisfied their idea of acceptable. The primary difference with the 501(c)3 is that 5% of the assets has to be granted per year. It would for the most part have the exact same flexibility as this organization.
gen220 6y ago
The AMA was the first group to lobby against publicly-funded healthcare (1930s-40s). See here [1] for some examples of cartoons they commissioned, playing to base emotions to sink the healthcare components of Truman's Fair Deal. There's not a lot of content on wikipedia about the details of the opposition, but here's the summary of the context of the pre-WWII years [2]. Then after WWII, Truman proposed revisiting this problem. There's a really good account of what followed here [3]. Essentially, the AMA engaged in a mass-marketing scheme to paint universal healthcare as part of a communist agenda and therefore un-American. This advertising, coupled with the ironically-government-induced rise of employer-subsidized insurance, decimated what had been broad public support for universal healthcare. So, yeah. There's a pretty proximate alternate history where we've had universal healthcare since 1947. It'd be interesting to see what that world looks like today. [1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935669/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935669/ [2]: https://en.wikipedia.org/wiki/History_of_health_care_reform_in_the_United_States#1930s%E2%80%931950s https://en.wikipedia.org/wiki/History_of_health_care_reform_... [3]: https://www.pbs.org/newshour/health/november-19-1945-harry-truman-calls-national-health-insurance-program https://www.pbs.org/newshour/health/november-19-1945-harry-t...
tgbugs 6y ago
Don't forget that CPT is also a massive money maker and completely proprietary. Want to do open research to improve patient care and health and use CPT codes? Probably not going to happen [1]. 1. https://www.ama-assn.org/practice-management/cpt/ama-cpt-licensing-overview https://www.ama-assn.org/practice-management/cpt/ama-cpt-lic...
- ericd 6y ago
  Yeah, this was a big stumbling block for a project we wanted to work on. So completely bizarre that you essentially need to pay a toll to them to do public projects with medical billing data that uses standard codes. One of the more egregious examples of rent seeking I’ve seen recently.
  - tehlike 6y ago
    Another one is cusips in a similar fashion. Cusips are unique identifiers that identify a security. They are also proprietary with fairly expensive pricing for startups.
maxwell 6y ago
The AMA killed the single payer option in the ACA under Obama, and they'll do their damndest to keep it dead under Biden: https://www.nytimes.com/2009/06/11/us/politics/11health.html https://www.nytimes.com/2009/06/11/us/politics/11health.html https://www.modernhealthcare.com/physicians/ama-maintains-its-opposition-single-payer-systems https://www.modernhealthcare.com/physicians/ama-maintains-it...
- lumost 6y ago
  Single payer makes US healthcare a monopsony, a market with only one buyer. All sellers/providers inherently hate that as the single buyer can check each companies margin, and dictate a lower price in the future.
  - baryphonic 6y ago
    The problem with monopsony in theory is that it reduces the actual wage below the market-clearing wage, which results in a lower quantity of labor supplied. A better arrangement in such cases is usually a bilateral monopoly (think of how sports leagues negotiate with players' unions), which results in wages and labor supplied much closer to market clearing amounts (again, in theory). In many ways, the US already has a soft form of monopsony, given the total dominance of CMMS in determining everything from reimbursements to billing codes to proper medical procedures. We shouldn't be surprised by the already significant shortages within US medical professions given this situation. CMMS regulation has also resulted in large hospital groups absorbing private practices such that most physicians now work for some large hospital group, and most of the rest work for larger companies focused on one or a few specialities.
    - dredmorbius 6y ago
      Access, not quality, is the principle determinant of health outcomes. Since 1960, life expectancy advances have been greatest among minority, poor, and under-served populations. Not wealthy whites.
      - 6y ago
lekanwang 6y ago
The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine, has extremely strong pricing power over the entire healthcare system via the RUC (https://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...), advocates on behalf of doctors whether or not you agree, and much more, all under a guise of "non-profit advocacy for public health." They are a racket -- we would do well to have a rogue upstart competing licensing body.
- goatinaboat 6y ago
  They are a racket -- we would do well to have a rogue upstart competing licensing body. And programmers think that they are too intelligent and have too much variation in productivity to form any sort of professional organisation, or “union”, you could call it. Doctors don’t worry about ageism or offshoring or being stabbed in the back by their peers or managers.
  - H8crilA 6y ago
    Unions work, there's no question in my mind about that. Just look at macroeconomic stats from the 40s to 70s. All that inflation took pretty much all the wealth from capital owners and handed it over to workers. However, most software people are clearly in the capital owners category (despite still having salaries), so maybe it is justified to keep the status quo.
    - throwaway201103 6y ago
      You can be both a wage earner and a capital owner. 401K or just a standard discount brokerage account are easy paths to that. I don't know why this is always presented as two sides with no overlap.
      - H8crilA 6y ago
        The point is you can say goodbye to the S&P500 performance if unions become as popular as in the post-FDR era. You'll experience low to negative real performance for decades. Find old Warren Buffett shareholder letters or opinion pieces from those times if you want a capitalist's point of view, the guy has been around forever and has seen this particular story play out. Also, he's still for greater wealth redistribution, but that's just his personal political opinion.
AtlasBarfed 6y ago
There are four pigs at the trough of US healthcare: 1) drug/device companies 2) insurance companies 3) trial lawyers 4) doctors When asked what's wrong, they point at one of the other three. The AMA is guild that makes sure doctors stay rich, valued, and semi-scarce.
- terr-dav 6y ago
  What about for profit hospitals? It’s the marketization of health care that incentivizes suffering and death, not any particular group.
  - triceratops 6y ago
    Ok so 5 pigs at the trough.
  - kgwgk 6y ago
    For-profit hospitals are not that important (~20% of the hospital system). Edit: But if lawyers can make it to that list hospitals can as well (including not-for-profit hospitals paying huge salaries, just because they are not “for profit” it doesn’t mean they are not profit-driven).
  - pessimizer 6y ago
    Non-profit hospitals are responsible for the bulk of health care costs, they just extract the profits in salaries.
    - Spivak 6y ago
      Calling salaries extraction of profits is a weird way of spinning people being paid for their work. Even the most egregious executive and administrator salaries are small potatoes on a hospital’s balance sheet.
BurningFrog 6y ago
"The American Medical Association is perhaps the strongest trade union in the United States." --- Milton Friedman From https://www.fff.org/explore-freedom/article/freedom-daily-classic-reprint-medical-licensure/ https://www.fff.org/explore-freedom/article/freedom-daily-cl...
deleted 6y ago
[deleted]
JMTQp8lwXL 6y ago
You'd think Hospitals would want to strip the AMA of its power in order to lower worker wages. Health care wages are unusually high in America, though that's true of other fields as well. Compared to technology, however, the regulatory environment is mostly the same: yet SWE's in America are paid a premium (even without a group formalizing 'who' can be a SWE).
- nickff 6y ago
  Industry-wide unions like the AMA, UAW, and Longshoremen help to maintain a tacit price-fixing (as everyone is subject to the same price floor on their major expense), which can be very convenient for large, established players.
Areibman 6y ago
When we ask ourselves why healthcare is so expensive in the US, we never seem to point out that it's the health care that's so expensive. As many others have already said, the AMA puts an artificial cap on the number of medical school graduates each year at around 20,000. Anecdotally, I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I'm cynical, but there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers. I'm glad this article has the chutzpah to call the AMA what it really is-- a protectionist guild. These doctors make me sick.
- hhs 6y ago
  According to the AAMC, it seems like residency slots have also been an issue: https://www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace https://www.aamc.org/news-insights/medical-school-enrollment...
  - mimikatz 6y ago
    Do all doctors need residency or is it another barrier to having enough cheap doctors?
    - Spivak 6y ago
      I’m not sure most people would be comfortable with doctors that have zero on-the-job training. There are some places that don’t require it or only require it for a short period but I think most people are in the camp that residency programs are a good thing and not an artificial barrier.
      - walshemj 6y ago
        There's a joke in the NHS that when the new batch of doctors join in September - the risk on mistakes increases. I had a major operation just before 2017's intake it was interesting having a new doctor trying to cannulate me - I suspect the nurses where round the corner trying do to laugh.
hikerclimber 6y ago
I hope more people die in the us because of covid than in any other country. I also hope the virus evolves starting in these greedy ama office and they all die.
vernie 6y ago
Don't forget this gem: https://en.wikipedia.org/wiki/Ronald_Reagan_Speaks_Out_Against_Socialized_Medicine https://en.wikipedia.org/wiki/Ronald_Reagan_Speaks_Out_Again...
analogwzrd 6y ago
Russ Roberts did a good interview on EconTalk with Christy Ford Chapin, who wrote a book about the history of health insurance in the US and pointed several fingers at the AMA for preventing any progress or innovation in the healthcare industry. https://www.econtalk.org/christy-ford-chapin-on-the-evolution-of-the-american-health-care-system/ https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...
deleted 6y ago
[deleted]
tropdrop 6y ago
> The AMA has a Chief Strategy Officer who was paid $1,130,000 in 2018. > The AMA has a Chief Operating Officer who was paid $1,350,000 in 2018. > The AMA has a Chief Financial Officer who was paid … huh? … only $730,000 in 2018. Wow, that’s weird. I mean, she’s the only woman in the C-suite, but I’m sure that has nothing to do with it. I think we all know that being a CFO is nowhere near as rigorous or demanding a job as being a ((checks notes)) Chief Strategy Officer... > That’s Jim Madara... telling us that the core challenge for the medical profession in general and the AMA in particular will be finding ways to address health inequity – the disparate healthcare outcomes for Americans stemming from food and housing insecurity, limited access to transportation, and above all, income inequality. A great demonstration of what "diversity," "the triple bottom line," "social responsibility" and "addressing income inequality" really looks like at the corporate level.
deleted 6y ago
[deleted]
duffpkg 6y ago
... I wrote Hacking Healthcare, created ClearHealth & HealthCloud, many other credentials... I have negotiated with the AMA in several arenas. If they had anymore lawyers in a single place it would create a black hole. Everything in healthcare anything (procedure, test, sponge, scalpel, etc) that gets billed or reported to the federal government, that is roughly ~2.7 Trillion worth of transactions a year, roughly 160 billion line items, requires a CPT code (current procedure terminology). The federal government legally requires this. CPT is owned and licensed by the AMA, they spend incredible lobbying dollars to maintain that the CPT codes are used and required by the federal government. It is legally impossible to create an alternative. It is complete regulatory capture. That CPT revenue was 160 million a year as of 2018. A pure tax on healthcare, sadly one among many. Also a reason truly fully open source systems are impossible in healthcare.
- jl2718 6y ago
  You need to pay somebody to use a lookup table? I just realized I forgot to pay my language license to Webster’s. If they haven’t licensed the human anatomical nomenclature and all known DNA sequences yet, they are missing out.
haltingproblem 6y ago
Similarly the American Heart Association is a licensing and fundraising organization which rakes in around $750 million in revenues and gave out $150 in grants. The rest of the program spend of $595 million which was $445 million (!!) goes on salaries and fund raising. The AHA has around 4,000 employees. They have an endowment of $1.2B. [1] Amongst the most dubious of AHA recommendations are dietary sodium around 1.5-2.5g/day [2] which flouts established research which shows all-cause mortality doubling from 4-6 g/day to 1.5-2.5g/day to those who do not have salt specific hypertension. But they dgaf as their primary focus is not the heart and cardiovascular health of Americans but licensing the "Good Heart" license to cereal companies so they can use it to sell more obesity causing products like Honey Nut Cheerios. [1] https://paddockpost.com/2016/02/09/where-does-1-to-the-american-heart-association-go/ https://paddockpost.com/2016/02/09/where-does-1-to-the-ameri... [2] https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/shaking-the-salt-habit-to-lower-high-blood-pressure https://www.heart.org/en/health-topics/high-blood-pressure/c... [3] https://www.nejm.org/doi/full/10.1056/nejmoa1311889 https://www.nejm.org/doi/full/10.1056/nejmoa1311889
javajosh 6y ago
One thing they could fund with all that money is an independent, regularly televised frank discussion between patients, doctors, and administrators about their issues with the healthcare system, and each other, from a moral and ethical perspective. It seems to me that if you want to represent some sort of "halo of authority" then you better earn it by hosting some frank and real dialectic!
jl2718 6y ago
The doctor-centric medical system is rapidly becoming technologically obsolete. It’s now cheaper to get an MRI with radiology report than a primary care office visit. Lab tests for most common ailments are less than gas to get to the hospital (GSA schedule pricing). Doctors don’t have any more information than the diagnostics tell them. Office visits are a functionally useless exercise. Innovations in private elective procedures have dramatically reduced costs and increased safety compared to procedures controlled by hospitals and paid by insurance. The government pays for drug development and then the FDA grants monopolies charging several orders of magnitude markups and giving kickbacks for prescriptions. Although there is little technological need for most doctors, the administrative demand is greater than any other industry, but don’t expect many H1Bs granted for physicians. Limiting access to the profession through high standards is actually great for innovation, if innovation is allowed, but protecting obsolete functions is probably bad for everybody. I’d like to do some angel funding of new concepts in private consumer healthcare that go around the system. Medical hacker stuff. For instance, you can buy an imaging ultrasound system from China for roughly the cost of a single ultrasound appointment. I think micro-MRI is achievable under $10k, mostly a problem of data analysis. X-rays of course could be very cheap if people could be trusted not to abuse them. DIY blood and urine testing could be nearly free. I don’t want to sound like Elizabeth Holmes here; I’m mostly talking about known existing simple procedures with huge unnecessary overheads, replaced by DIY, community, or AI business models that are aligned with users.
- derbOac 6y ago
  The worst problem with the AMA is that it's worked to completely distort our expectations about what is possible in a healthcare system. A lot of the comments here are focused on artificial restrictions in supply of physicians and so forth, which are important issues, but the more insidious problem is the way in which licensing and practice laws distort alternative structurings of healthcare delivery. As you point out, healthcare should be more consumer-driven, with providers acting more as consultants, akin to how tax accountants and lawyers work. The problem isn't necessarily that we need more physicians, it's that we need consumers to get more of their healthcare directly, and/or through alternate providers like pharmacists, psychologists, dentists, optometrists, or some other classes of providers we haven't even dreamed up yet because the healthcare system is so centralized and rigid. The discussion of healthcare in the US has focused so much on who pays, with such little attention to how the care is structured, when it seems to me that's a much bigger problem. To me the payment issue is almost an entirely different issue. I have lots of family in healthcare, including physicians in administration, and they're terrified of single-payer not because they don't want universal care, but because they already see the healthcare system overburdened by regulation and red tape, and don't really see how having single payer (as opposed to something like the ACA) will really help a lot. In their minds the only thing worse than what existed 10 years ago, is what existed 10 years ago plus a monolithic government agency controlling payment as well. I see an important role for physicians, but there needs to be a lot more flexibility and deregulation in healthcare. There's so much that could be written about this it's absurd.

277 points by erentz 6y ago

erentz 6y ago

Note original title “AMA? BITFD!” is vague so chose another line from the article that better describes it.

wbenhunt 6y ago
Thank you!

yostrovs 6y ago

Author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA, rather than the supposed members of the organization. It seems to have strong political opinions that arise out of ether.

JumpCrisscross 6y ago
> author forgot to note that the AMA is also a political advocacy organization that seems to speak on behalf of some insider committee of the AMA That would make the post look like infighting. By focussing on dereliction of fiduciary duty, possibly to an unlawful extent, the argument is rendered sharper.
- wbenhunt 6y ago
  YES

deleted 6y ago

[deleted]

hpoe 6y ago

To me this seems to highlight the worry about "fake news" and "credible sources". To me it seems less like the quality of journalism and reporting has gone down hill and more like because we have so many new independent sources of news and information we are starting to realize that the originally "trusted" organizations were not as objective and honest as we originally thought. Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information.

JumpCrisscross 6y ago
> the originally "trusted" organizations were not as objective and honest as we originally thought Has AMA been plumped up by mainstream journalists? I can’t recall them being quoted as an authority.
- ponker 6y ago
  The AMA decides who gets to call themselves a doctor. Can’t imagine a more pivotal arbiter of trust.
  - ghaff 6y ago
    AFAIK, it's technically state licensing boards. Of course, licensing, the AMA, and other medical organizations are pretty intertwined in various ways.
- TuringNYC 6y ago
  Conveniently ignoring -- for decades -- major questions about national healthcare (e.g., who creates the artificial scarcity in medical specialists) is essentially fostering the status quo. I'm happy with the AMA being the authority on medical news, but that does not mean their business practices should be beyond scrutiny.
eightysixfour 6y ago
> Ultimately the problem is that it isn't that we have illegitimate news flooding the market of information it's that we are finally starting to realize almost all of our information was biased to one degree or another and we are slow to adjust the way we consume information. Why not both...? > isn't that we have illegitimate news flooding the market of information This is absolutely a problem. Old media seems to be pretty content with narrative framing for the most part, this new brand of illegitimate media just makes shit up. They have no intent to engage in the public discourse, their only purpose is to reinforce alternate realities and to shift the Overton window.
- 6y ago

JumpCrisscross 6y ago

If you are an Illinois-based AMA member, consider calling your Attorney General’s Charitable Trust Bureau to make a complaint citing this article [1]. AMA is registered in Illinois; your voice will be louder. As a paying member, you have standing to show harm. [1] https://ag.state.il.us/charities/rules_statutes.html https://ag.state.il.us/charities/rules_statutes.html

vmception 6y ago

As someone forming a private foundation, this is very inspirational, thank you! Albeit under 501(c)3 and not 501(c)6 like this organization.

ghaff 6y ago
The two categories are pretty different. A 501(c)6 exists for the benefit of its members. That doesn't mean it's bad or can't have a positive mission but it's a trade association at the end of the day. A 501(c)3, as you know, at least ostensibly has some sort of charitable/educational/etc. mission.
- vmception 6y ago
  I'm aware, and I take issue with the "this is bad because I have an uncomfortable relationship with money" approach that the article took. The point of the author's digital sleuthing was not for inspiration, it was to find fault to reinforce a conclusion they had already made. I doubt there was any transparent and accurate reporting that would have satisfied their idea of acceptable. The primary difference with the 501(c)3 is that 5% of the assets has to be granted per year. It would for the most part have the exact same flexibility as this organization.

gen220 6y ago

The AMA was the first group to lobby against publicly-funded healthcare (1930s-40s). See here [1] for some examples of cartoons they commissioned, playing to base emotions to sink the healthcare components of Truman's Fair Deal. There's not a lot of content on wikipedia about the details of the opposition, but here's the summary of the context of the pre-WWII years [2]. Then after WWII, Truman proposed revisiting this problem. There's a really good account of what followed here [3]. Essentially, the AMA engaged in a mass-marketing scheme to paint universal healthcare as part of a communist agenda and therefore un-American. This advertising, coupled with the ironically-government-induced rise of employer-subsidized insurance, decimated what had been broad public support for universal healthcare. So, yeah. There's a pretty proximate alternate history where we've had universal healthcare since 1947. It'd be interesting to see what that world looks like today. [1]: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935669/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935669/ [2]: https://en.wikipedia.org/wiki/History_of_health_care_reform_in_the_United_States#1930s%E2%80%931950s https://en.wikipedia.org/wiki/History_of_health_care_reform_... [3]: https://www.pbs.org/newshour/health/november-19-1945-harry-truman-calls-national-health-insurance-program https://www.pbs.org/newshour/health/november-19-1945-harry-t...

tgbugs 6y ago

Don't forget that CPT is also a massive money maker and completely proprietary. Want to do open research to improve patient care and health and use CPT codes? Probably not going to happen [1]. 1. https://www.ama-assn.org/practice-management/cpt/ama-cpt-licensing-overview https://www.ama-assn.org/practice-management/cpt/ama-cpt-lic...

ericd 6y ago
Yeah, this was a big stumbling block for a project we wanted to work on. So completely bizarre that you essentially need to pay a toll to them to do public projects with medical billing data that uses standard codes. One of the more egregious examples of rent seeking I’ve seen recently.
- tehlike 6y ago
  Another one is cusips in a similar fashion. Cusips are unique identifiers that identify a security. They are also proprietary with fairly expensive pricing for startups.

maxwell 6y ago

The AMA killed the single payer option in the ACA under Obama, and they'll do their damndest to keep it dead under Biden: https://www.nytimes.com/2009/06/11/us/politics/11health.html https://www.nytimes.com/2009/06/11/us/politics/11health.html https://www.modernhealthcare.com/physicians/ama-maintains-its-opposition-single-payer-systems https://www.modernhealthcare.com/physicians/ama-maintains-it...

lumost 6y ago
Single payer makes US healthcare a monopsony, a market with only one buyer. All sellers/providers inherently hate that as the single buyer can check each companies margin, and dictate a lower price in the future.
- baryphonic 6y ago
  The problem with monopsony in theory is that it reduces the actual wage below the market-clearing wage, which results in a lower quantity of labor supplied. A better arrangement in such cases is usually a bilateral monopoly (think of how sports leagues negotiate with players' unions), which results in wages and labor supplied much closer to market clearing amounts (again, in theory). In many ways, the US already has a soft form of monopsony, given the total dominance of CMMS in determining everything from reimbursements to billing codes to proper medical procedures. We shouldn't be surprised by the already significant shortages within US medical professions given this situation. CMMS regulation has also resulted in large hospital groups absorbing private practices such that most physicians now work for some large hospital group, and most of the rest work for larger companies focused on one or a few specialities.
  - dredmorbius 6y ago
    Access, not quality, is the principle determinant of health outcomes. Since 1960, life expectancy advances have been greatest among minority, poor, and under-served populations. Not wealthy whites.
    - 6y ago

lekanwang 6y ago

The AMA chooses who can be a doctor, who can train doctors, who can practice any kind of medicine, has extremely strong pricing power over the entire healthcare system via the RUC (https://en.wikipedia.org/wiki/Specialty_Society_Relative_Value_Scale_Update_Committee https://en.wikipedia.org/wiki/Specialty_Society_Relative_Val...), advocates on behalf of doctors whether or not you agree, and much more, all under a guise of "non-profit advocacy for public health." They are a racket -- we would do well to have a rogue upstart competing licensing body.

goatinaboat 6y ago
They are a racket -- we would do well to have a rogue upstart competing licensing body. And programmers think that they are too intelligent and have too much variation in productivity to form any sort of professional organisation, or “union”, you could call it. Doctors don’t worry about ageism or offshoring or being stabbed in the back by their peers or managers.
- H8crilA 6y ago
  Unions work, there's no question in my mind about that. Just look at macroeconomic stats from the 40s to 70s. All that inflation took pretty much all the wealth from capital owners and handed it over to workers. However, most software people are clearly in the capital owners category (despite still having salaries), so maybe it is justified to keep the status quo.
  - throwaway201103 6y ago
    You can be both a wage earner and a capital owner. 401K or just a standard discount brokerage account are easy paths to that. I don't know why this is always presented as two sides with no overlap.
    - H8crilA 6y ago
      The point is you can say goodbye to the S&P500 performance if unions become as popular as in the post-FDR era. You'll experience low to negative real performance for decades. Find old Warren Buffett shareholder letters or opinion pieces from those times if you want a capitalist's point of view, the guy has been around forever and has seen this particular story play out. Also, he's still for greater wealth redistribution, but that's just his personal political opinion.

AtlasBarfed 6y ago

There are four pigs at the trough of US healthcare: 1) drug/device companies 2) insurance companies 3) trial lawyers 4) doctors When asked what's wrong, they point at one of the other three. The AMA is guild that makes sure doctors stay rich, valued, and semi-scarce.

terr-dav 6y ago
What about for profit hospitals? It’s the marketization of health care that incentivizes suffering and death, not any particular group.
- triceratops 6y ago
  Ok so 5 pigs at the trough.
- kgwgk 6y ago
  For-profit hospitals are not that important (~20% of the hospital system). Edit: But if lawyers can make it to that list hospitals can as well (including not-for-profit hospitals paying huge salaries, just because they are not “for profit” it doesn’t mean they are not profit-driven).
- pessimizer 6y ago
  Non-profit hospitals are responsible for the bulk of health care costs, they just extract the profits in salaries.
  - Spivak 6y ago
    Calling salaries extraction of profits is a weird way of spinning people being paid for their work. Even the most egregious executive and administrator salaries are small potatoes on a hospital’s balance sheet.

BurningFrog 6y ago

"The American Medical Association is perhaps the strongest trade union in the United States." --- Milton Friedman From https://www.fff.org/explore-freedom/article/freedom-daily-classic-reprint-medical-licensure/ https://www.fff.org/explore-freedom/article/freedom-daily-cl...

deleted 6y ago

[deleted]

JMTQp8lwXL 6y ago

You'd think Hospitals would want to strip the AMA of its power in order to lower worker wages. Health care wages are unusually high in America, though that's true of other fields as well. Compared to technology, however, the regulatory environment is mostly the same: yet SWE's in America are paid a premium (even without a group formalizing 'who' can be a SWE).

nickff 6y ago
Industry-wide unions like the AMA, UAW, and Longshoremen help to maintain a tacit price-fixing (as everyone is subject to the same price floor on their major expense), which can be very convenient for large, established players.

Areibman 6y ago

When we ask ourselves why healthcare is so expensive in the US, we never seem to point out that it's the health care that's so expensive. As many others have already said, the AMA puts an artificial cap on the number of medical school graduates each year at around 20,000. Anecdotally, I know several bright minds who either pursued a DO or dropped out of medicine entirely because they couldn't pass the med schools' opaque admissions procedures. I'm cynical, but there's something disturbing about the fact that GPs and family doctors have to invest so much time and undertake so much debt just to become professional symptom Googlers. I'm glad this article has the chutzpah to call the AMA what it really is-- a protectionist guild. These doctors make me sick.

hhs 6y ago
According to the AAMC, it seems like residency slots have also been an issue: https://www.aamc.org/news-insights/medical-school-enrollments-grow-residency-slots-haven-t-kept-pace https://www.aamc.org/news-insights/medical-school-enrollment...
- mimikatz 6y ago
  Do all doctors need residency or is it another barrier to having enough cheap doctors?
  - Spivak 6y ago
    I’m not sure most people would be comfortable with doctors that have zero on-the-job training. There are some places that don’t require it or only require it for a short period but I think most people are in the camp that residency programs are a good thing and not an artificial barrier.
    - walshemj 6y ago
      There's a joke in the NHS that when the new batch of doctors join in September - the risk on mistakes increases. I had a major operation just before 2017's intake it was interesting having a new doctor trying to cannulate me - I suspect the nurses where round the corner trying do to laugh.

hikerclimber 6y ago

I hope more people die in the us because of covid than in any other country. I also hope the virus evolves starting in these greedy ama office and they all die.

vernie 6y ago

Don't forget this gem: https://en.wikipedia.org/wiki/Ronald_Reagan_Speaks_Out_Against_Socialized_Medicine https://en.wikipedia.org/wiki/Ronald_Reagan_Speaks_Out_Again...

analogwzrd 6y ago

Russ Roberts did a good interview on EconTalk with Christy Ford Chapin, who wrote a book about the history of health insurance in the US and pointed several fingers at the AMA for preventing any progress or innovation in the healthcare industry. https://www.econtalk.org/christy-ford-chapin-on-the-evolution-of-the-american-health-care-system/ https://www.econtalk.org/christy-ford-chapin-on-the-evolutio...

deleted 6y ago

[deleted]

tropdrop 6y ago

> The AMA has a Chief Strategy Officer who was paid $1,130,000 in 2018. > The AMA has a Chief Operating Officer who was paid $1,350,000 in 2018. > The AMA has a Chief Financial Officer who was paid … huh? … only $730,000 in 2018. Wow, that’s weird. I mean, she’s the only woman in the C-suite, but I’m sure that has nothing to do with it. I think we all know that being a CFO is nowhere near as rigorous or demanding a job as being a ((checks notes)) Chief Strategy Officer... > That’s Jim Madara... telling us that the core challenge for the medical profession in general and the AMA in particular will be finding ways to address health inequity – the disparate healthcare outcomes for Americans stemming from food and housing insecurity, limited access to transportation, and above all, income inequality. A great demonstration of what "diversity," "the triple bottom line," "social responsibility" and "addressing income inequality" really looks like at the corporate level.

deleted 6y ago

[deleted]

duffpkg 6y ago

... I wrote Hacking Healthcare, created ClearHealth & HealthCloud, many other credentials... I have negotiated with the AMA in several arenas. If they had anymore lawyers in a single place it would create a black hole. Everything in healthcare anything (procedure, test, sponge, scalpel, etc) that gets billed or reported to the federal government, that is roughly ~2.7 Trillion worth of transactions a year, roughly 160 billion line items, requires a CPT code (current procedure terminology). The federal government legally requires this. CPT is owned and licensed by the AMA, they spend incredible lobbying dollars to maintain that the CPT codes are used and required by the federal government. It is legally impossible to create an alternative. It is complete regulatory capture. That CPT revenue was 160 million a year as of 2018. A pure tax on healthcare, sadly one among many. Also a reason truly fully open source systems are impossible in healthcare.

jl2718 6y ago
You need to pay somebody to use a lookup table? I just realized I forgot to pay my language license to Webster’s. If they haven’t licensed the human anatomical nomenclature and all known DNA sequences yet, they are missing out.

haltingproblem 6y ago

Similarly the American Heart Association is a licensing and fundraising organization which rakes in around $750 million in revenues and gave out $150 in grants. The rest of the program spend of $595 million which was $445 million (!!) goes on salaries and fund raising. The AHA has around 4,000 employees. They have an endowment of $1.2B. [1] Amongst the most dubious of AHA recommendations are dietary sodium around 1.5-2.5g/day [2] which flouts established research which shows all-cause mortality doubling from 4-6 g/day to 1.5-2.5g/day to those who do not have salt specific hypertension. But they dgaf as their primary focus is not the heart and cardiovascular health of Americans but licensing the "Good Heart" license to cereal companies so they can use it to sell more obesity causing products like Honey Nut Cheerios. [1] https://paddockpost.com/2016/02/09/where-does-1-to-the-american-heart-association-go/ https://paddockpost.com/2016/02/09/where-does-1-to-the-ameri... [2] https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/shaking-the-salt-habit-to-lower-high-blood-pressure https://www.heart.org/en/health-topics/high-blood-pressure/c... [3] https://www.nejm.org/doi/full/10.1056/nejmoa1311889 https://www.nejm.org/doi/full/10.1056/nejmoa1311889

javajosh 6y ago

One thing they could fund with all that money is an independent, regularly televised frank discussion between patients, doctors, and administrators about their issues with the healthcare system, and each other, from a moral and ethical perspective. It seems to me that if you want to represent some sort of "halo of authority" then you better earn it by hosting some frank and real dialectic!

jl2718 6y ago

The doctor-centric medical system is rapidly becoming technologically obsolete. It’s now cheaper to get an MRI with radiology report than a primary care office visit. Lab tests for most common ailments are less than gas to get to the hospital (GSA schedule pricing). Doctors don’t have any more information than the diagnostics tell them. Office visits are a functionally useless exercise. Innovations in private elective procedures have dramatically reduced costs and increased safety compared to procedures controlled by hospitals and paid by insurance. The government pays for drug development and then the FDA grants monopolies charging several orders of magnitude markups and giving kickbacks for prescriptions. Although there is little technological need for most doctors, the administrative demand is greater than any other industry, but don’t expect many H1Bs granted for physicians. Limiting access to the profession through high standards is actually great for innovation, if innovation is allowed, but protecting obsolete functions is probably bad for everybody. I’d like to do some angel funding of new concepts in private consumer healthcare that go around the system. Medical hacker stuff. For instance, you can buy an imaging ultrasound system from China for roughly the cost of a single ultrasound appointment. I think micro-MRI is achievable under $10k, mostly a problem of data analysis. X-rays of course could be very cheap if people could be trusted not to abuse them. DIY blood and urine testing could be nearly free. I don’t want to sound like Elizabeth Holmes here; I’m mostly talking about known existing simple procedures with huge unnecessary overheads, replaced by DIY, community, or AI business models that are aligned with users.

derbOac 6y ago
The worst problem with the AMA is that it's worked to completely distort our expectations about what is possible in a healthcare system. A lot of the comments here are focused on artificial restrictions in supply of physicians and so forth, which are important issues, but the more insidious problem is the way in which licensing and practice laws distort alternative structurings of healthcare delivery. As you point out, healthcare should be more consumer-driven, with providers acting more as consultants, akin to how tax accountants and lawyers work. The problem isn't necessarily that we need more physicians, it's that we need consumers to get more of their healthcare directly, and/or through alternate providers like pharmacists, psychologists, dentists, optometrists, or some other classes of providers we haven't even dreamed up yet because the healthcare system is so centralized and rigid. The discussion of healthcare in the US has focused so much on who pays, with such little attention to how the care is structured, when it seems to me that's a much bigger problem. To me the payment issue is almost an entirely different issue. I have lots of family in healthcare, including physicians in administration, and they're terrified of single-payer not because they don't want universal care, but because they already see the healthcare system overburdened by regulation and red tape, and don't really see how having single payer (as opposed to something like the ACA) will really help a lot. In their minds the only thing worse than what existed 10 years ago, is what existed 10 years ago plus a monolithic government agency controlling payment as well. I see an important role for physicians, but there needs to be a lot more flexibility and deregulation in healthcare. There's so much that could be written about this it's absurd.