By James R. Missett, M.D., Ph.D.

Every  year half of the dues paid by SMCMA members is directed to the California Medical Association (CMA). With a certain regularity, questions arise concerning the extent to which such mandated contributions to CMA influence and improve the practices of its member physicians.

At the annual meeting of the CMA in Sacramento earlier this month, CMA CEO Jack C. Lewin, M.D., reviewed the progress CMA has made to date in implementing the Strategic Plan approved by the CMA Board of Trustees in January 2003.

Dr. Lewin remarked that the CMA Board of Trustees had charged him with increasing CMA membership and attracting 2000 new physician members in 2003. He pointed out that during the course of the year, CMA brought in 1800 new members. Because of attrition, retirements, and relocation, the final net increase in new members for 2003 was about 500, a significant 2 percent gain in total membership. This year, Dr. Lewin observed, CMA has grown by 1700 physicians over the total membership last year at this time, adding that the data appear to show that the increase is primarily related to better retention of members rather than to new physicians signing on. This suggests a higher level of satisfaction among CMA members, which is a hopeful sign.

Dr. Lewin reported that another priority of the Board of Trustees was winning the RICO lawsuits initiated by CMA. He noted that these lawsuits had grown eventually to include 700,000 physician plaintiffs from around the country and 19 state association plaintiffs, making these the largest health care class action lawsuits in the history of the United States. Thus far, Aetna and CIGNA have settled their lawsuits at an estimated cost of more than $1 billion each in prospective damages. This is the type of class action lawsuit that can be pursued on a national scale only by an organization, such as CMA, which is numerically large, politically savvy, and sufficiently representative to make a difference

The Strategic Plan of the Board of Trustees also called for helping to secure the passage of Senate Bill 2 (SB2), a CMA-sponsored expansion of employer-based health insurance to cover an additional 1.5 million people. This bill was not a universally popular bill with doctors, but it ultimately became law within the state of California. This was a formidable task that appears to have been accomplished in large part because CMA was able to focus its considerable legislative acumen and its lobbying expertise in explaining to the Legislature what physicians and others felt were in their best interests and the best interests of their patients. Since the passage of SB2, more and more physicians have become increasingly disillusioned with discounted reimbursements and hassles related to employer-based insurance coverage. It may turn out that the Legislature or California voters eventually substitute another mechanism for insurance coverage of patients within the state of California from one that is employer based. Still, the fact remains that CMA demonstrated it is able to bring its lobbying abilities and its skills in representing the view of physicians and patients to the Legislature and the governor in Sacramento. This is the kind of action that is far more effectively carried out by a single organization that speaks with one voice representing physicians and their patients.

In early 2003 the CMA Board of Trustees had as one of the organization’s priorities compelling the Department of Managed Health Care (DMHC) and the Legislature to address inappropriate payment practices regarding physician reimbursement. Subsequently, the CMA was instrumental in securing a legal injunction against DMHC with respect to its overreaching position requiring financial disclosure from various physician groups. In addition, the CMA was instrumental in securing the passage of AB1455 for fair payment regulations that eventually were implemented even in the face of significant opposition from huge health plans. The CMA also has been at the forefront of resisting the efforts of DMHC to prohibit balanced billing. On the legislative front, the CMA sponsored and supported the eventual passage of AB175 that made health plan “rent-a-network” scams illegal. It also supported the eventual passage of AB432, a two-year bill that should fix the secondary-payer issue in the state of California for at least the years 2004 and 2005.

Another priority of the CMA Board of Trustees in 2003 was the prevention of further cuts in Medi-Cal, with CMA having been instrumental in organizing a massive coalition of various organizations against such cuts and then having taken successful legal action to block the reimbursement cuts. Again, the fact that the CMA speaks with a unified voice and represents the professional and practice needs and desires of all physicians, regardless of practice structure or specialty orientation, makes it particularly effective in pursuing goals that serve the welfare of the state’s patients and those physicians who care for them.

The CMA Board of Trustees also charged CMA with seeking a physician resolution regarding reform principles for Workers’ Compensation and with working to protect physician reimbursement in Workers’ Compensation. The efforts and actions of CMA subsequently led to reducing a 15 percent across-the-board cut in physician reimbursement for Workers’ Compensation services to a 5 percent cut without any reduction in E&M codes whatsoever. The CMA is at present supporting the bill introduced by Senator Jackie Speier of San Mateo that has the potential of creating $2 billion in savings over what is currently spent on Workers’ Compensation claims each year in the state of California. Senator Speier’s bill protects the disability rights of injured workers and the reimbursement rights of those physicians who attend to them.

In response to the insistence of the Board of Trustees that the CMA seek to protect emergency room and on-call services statewide through the introduction of a nickel-a-drink bill, the CMA worked to support the introduction of SB108, which the beverage industry eventually held in committee. In response the CMA joined with such other statewide organizations as the California Hospital Association, the California ACEP, and the fire fighters to support an emergency room ballot initiative.

The CMA Board of Trustees also enjoined the CMA to work diligently to protect the scope of practice of all physicians within the state of California. CMA vigorously opposed legislation licensing neuropathic doctors, a measure that was eventually passed by the Legislature over CMA objections, but with the inclusion of CMA-proposed amendments. In addition, the CMA was at the forefront of efforts to protect scope of practice, belonging uniquely to physicians, by opposing practice expansion legislation proposed for physical therapists, acupuncturists, clinical social workers, and podiatrists.

The CMA also was enjoined to work diligently to protect the independence of hospital medical staffs. As a result, the CMA undertook to support an organized, ultimately nationwide, campaign to assist physicians of Community Memorial Hospital in Ventura, California, in resisting the efforts of their hospital administration to rob them of their autonomy and independence. At the same time, CMA has assumed a major role in a significant struggle with hospitals and the Joint Commission on the Accreditation of Hospital Organization (JCAHO) to protect physicians with respect to accreditation and licensure.

Over the past year CMA has been the only statewide organization working vigorously to protect and defend MICRA. To this end a $50 MICRA special dues campaign was successfully launched in 16 counties, which proved that such a campaign can work to the benefit of all patients and physicians within the state of California.

Thus far, CMA gives every indication of having forged a positive relationship with the new Schwarzenegger administration in protecting the patient-physician relationship, while working to assist physicians in the economic aspects of their various practices. In this process the CMA represents the interests of all county medical societies and helps physicians serve as the unfettered advocates of ethics in medical practice. It wants to retain physicians as the principal agents in the setting and maintenance of professional standards in medical care, in the development and implementation of quality care standards, and in the development and maintenance of a strong patient-physician relationship.

It is clear that discounted physician reimbursement by commercial and government insurance interests serves as one of the biggest threats to the patient-physician relationship by requiring that doctors compensate for their reduced reimbursement by increasing the volume of their practice, by seeing more patients, and by spending less time and giving less personalized and individualized attention to each patient that they see.

Such short-sighted reimbursement policies by commercial and government insurance plans serve as a source of frustration to both physicians and patients and reduces the time available for physicians to provide their patients with preventative care, with good and sustained chronic disease care, and with optimal communication. Ultimately, lower reimbursements and the attendant public and private discounting can be expected to result in fewer medical students choosing primary care residency, a trend that already is reflected in the loss of 50 primary care residency slots in the state of California this year alone.

What is clear is that the California Medical Association stands as a bulwark against those forces that would undermine the relationship between patient and physician. It is the one statewide organization on which physicians should always be able to count, where their professional and economic interests are represented. This is the reason why membership in the CMA is regarded as mandatory for members of the San Mateo County Medical Association, as it is for members of every other county medical association in the state. This is why the dues notice for membership in SMCMA is accompanied by a dues notice for membership in CMA.