American Society of Dermatology
2721 Capital Ave.
Sacramento, CA 95816-6004
Phone: (916) 446-5054
Message: (561) 873-8335
Fax: (916) 446-0500 		American Society of Dermatology, Inc.
A Voice for Private Dermatologists Since 1992

April, 1998

ASD v. SHALALA

by Chester C. Danehower, MD
ASD Past President and Member of the Board of Directors

On June 24, 1997 the American Society of Dermatology (ASD) was informed that its request for an In Banc hearing by the Federal Court of Appeals in the District of Columbia had been denied. This denial meant from the ASD's standpoint that all of its legal remedies in ASD v. Shalala had been exhausted. The ASD found the decision to be unbelievable, and this finding led its board to carry out a thorough review of the case.

Before I begin the discussion of the court's findings, I feel that some background information is essential for the reader to understand why ASD v. Shalala was ever initiated. As almost everyone knows Donna Shalala is the current Secretary of Health and Human Services, but what is the ASD? The following discussion will clarify this matter.

Why was the ASD formed?

On Feb. 29, 1992 thirteen dermatologists from various parts of this country gathered to ponder the fate of not only dermatologists but also of our once proud profession. They had watched with disbelief as our profession, which was under unceasing attacks by big government, big business, the media, and elements within the legal profession, failed to mount any significant defense. These attacks were manifested by PRO activities, the Medicare price freeze of 1984, fines and sanctions by Medicare carriers, the National Practitioner Data Bank, and the Resource Based Relative Value Scale (RBRVS) just to mention a few. Behind all of these attacks was a growing left wing ideology within this country.
Out of this meeting evolved the ASD; an organization dedicated to protecting the interests of private practicing dermatologists and the interests of our patients. The board of the ASD was determined to fight back, since organized medicine appeared to be impotent in the defense of our profession and the physicians of this country.
The home office of the ASD is currently in Peoria, Illinois, and the organization has a current membership between 400 and 450. Because of its small size and conservative views, the ASD has been called a "splinter group" and a "rump group" by various elements in organized medicine.
Of all of the affronts to our profession, we found the RBRVS to be the most onerous and insulting. We explored the possibility of legal action to stop the RBRVS with our attorney Kent Masterson Brown. Initially we thought that we could attack the RBRVS on a constitutional basis through the Due Process Clause of the Fifth Amendment and through the separation of powers doctrine. However, with the success of Kent Masterson Brown in AAPS v. Clinton, we then decided that a better approach would be a procedural challenge primarily through the Federal Advisory Committee Act (FACA). It was our understanding that any committee that is utilized by the President or other federal agency or department for advice or recommendations was an advisory committee for the purpose of the FACA if these committees were not entirely composed of full time employees of the federal government. If they fulfill the preceding criteria then their meetings have to be open to the public, announced in a timely manner, and published in the Federal Register. In addition, they have to maintain appropriate minutes for their meetings. They also must have a charter that is filed with the Library of Congress.

Two ASD members file suit . . .

On July 5, 1995 the ASD along with two of its board members, John A. Kasch of Sacramento, California and Melissa Kline Clements of Oklahoma City, Oklahoma, filed a suit against Secretary of Health and Human Services Donna Shalala challenging her administration and development of the RBRVS. The suit was filed in the United States District Court for the District of Columbia and was based on the Federal Advisory Committee Act (FACA), the Administrative Procedure Act (APA), the Freedom of Information Act, and the Government in the Sunshine Act. The case was assigned to Judge Norma Holloway Johnson .
The ASD challenged five committees. It was our impression that the AMA CPT Editorial Panel, the AMA CPT Advisory Committee, the AMA/Speciality Society Relative Value Update Committee (RUC), the AMA/Speciality Society Relative Value Update Advisory Committee (RUC Advisory Committee), and the Multispeciality Physician Panels were all advisory committees for the purpose of the FACA. We also challenged Secretary Shalala's failure to develop a coding system as directed by Congress; instead she adopted the pre-existing AMA's CPT codes. Finally the ASD challenged that HCFA had violated the notice-and-comment rulemaking procedures of the APA. We argued that HCFA's handling of CPTcoding updates, their five year review of the physician's fee schedule, and the Multispeciality Physician Panels were in violation of the APA.

Judge Johnson renders her opinion . . .

On September 5, 1996 , Judge Norma Holloway Johnson rendered her opinion. The ASD had lost at the Federal District Court level. Quite frankly we were in utter disbelief. However, let us look at some of Judge Johnson's reasons for her decision. She stated that the Medicare program would be thrown into chaos if our demands were granted, ignoring that the program was already in chaos, and functioned only because our government has resorted to Gestapo tactics. She then accepted the argument by Barton C. McCann, M.D. that "The CPT codes must be updated constantly to reflect changes in medical practice and technology." In the first place these codes do not have to be updated constantly. They are a burden to physicians, and do nothing to enhance patient care. With the recent "Sunbeam" debacle one can not help but wonder if there is a significant financial incentive for the AMA to make just enough changes to have to publish new CPT code books each year. Could this represent a huge windfall profit for the AMA; the very thing the FACA seeks to avoid? How many of these books are sold each year and at what profit?
Judge Johnson then went on to state "The court lacks subject matter jurisdiction to consider plaintiff's challenge to HCFA's determination of RVU's and establishment of the coding system. Congress plainly intended to give the Secretary the authority to develop and implement the RBRVS system without being subjected to judicial scrutiny." In making this decision she referred to Painter v. Shalala, 1995 WL 693224 (D. Colo. 1995), a case that related to the conversion factor in the RBRVS formula. Painter v. Shalala was a substantive challenge and not a procedural challenge as was ASD v. Shalala; therefore, the findings in Painter v. Shalala should not apply in the ASD's case. In any event, Judge Johnson ruled against judicial review. This decision of course raises the question of how the federal bureaucracy can be held accountable if not through judicial review. This decision also raises the constitutional issues of the Due Process Clause of the Fifth Amendment and the separation of powers doctrine.
We now come to the "woolly verb" scenario. In explaining why the CPT Editorial Panel, the CPT Advisory Committee, the RUC, and the RUC Advisory Committee were not FACA advisory committees, Judge Johnson called on Washington Legal Foundation v. United States Sentencing Comm'n, 17 f.3d 1446,1447 (D.C. Cir. 1994). In this case the word utilize is called a "woolly verb" and is given an additional meaning which can not be found in any dictionary; i.e. "actual management or control" of the advisory committee must exist before a committee can be considered an advisory committee for the purpose of the FACA. Even if one accepts this new definition as being valid, it is ridiculous for one to think that these committees were not under management or control of HCFA. The ASD can not accept that these committees were solely under the management or control of the AMA. In fact, the RUC and the RUC Advisory Committee were formed because of the statute establishing the RBRVS system. They would not exist if it were not for the statute. Besides almost every physician in this country is aware of the controlling nature of HCFA.
Finally with regard to the Multispeciality Physician Panels, Judge Johnson conceded that these panels are under actual management and control of HCFA. However, she then applied the continuum doctrine from AAPS v. Clinton, 997 F.2d 898 (D.C.Cir 1993). She used the following quote from the appellate court decision in this case. "The point, it seems to us , is that a group is a FACA advisory committee when it is asked to render advice or recommendations, as a group, and not as a collection of individuals." Despite testimony by Grant Bagley, M.D. of HCFA proving that these panels functioned as a group and not as a loose collection of individuals, Judge Johnson concluded that these panels function as a loose collection of individuals. She went on to state that no consensus was reached by these panels despite information provided in the Federal Register by Secretary Shalala proving that a consensus is reached. Since in Judge Johnson's opinion the Multispeciality Physician Panels were not a group and did not reach a consensus, they were not FACA committees. Her conclusion was unbelievable!
As far as our APA challenges were concerned she dismissed them as being without merit. To say the least, the ASD was most displeased with Judge Norma Holloway Johnson's decision. Therefore we appealed her decision.
Then at the appellate level, it appeared that there was no way for the ASD to lose the case.
There had been two recent decisions in the Federal District Court of the District of Columbia that were reversed by the appellate court. These cases were California Forestry Association v. Forest Service and Animal Legal Defense Fund, Inc. v. Shalala. Both cases closely mirrored ASD v. Shalala. In addition during the presentation of oral arguments, the opposing side's attorney was figuratively "roasted", and the three judges seemed to have a clear understanding of the case.
However, at the end of the hearing, three additional issues were addressed by Judges Sentelle, Randolph, and Rogers. First of all they asked how many members were in the ASD. As presented earlier in this paper, the ASD has between 400 and 450 members. In our opinion the number of members should not have mattered. After all we are a national organization with members in every state in this country. The question on the part of the judges should have been whether or not Secretary Shalala was in violation of the law in her administration and development of the RBRVS!
Then the second issue was raised. We were once again described as being a "splinter group." We could not help but wonder how the judges arrived at this term. The only time we had ever been called a "splinter group" was shortly after the ASD was formed. A certain entity in organized medicine had disparagingly used the term to describe the ASD.

We simply wanted to open the committees . . .

The final issue that was raised was what did we hope to accomplish if we won. Our answer was that we simply wanted to open the committees in question to the public. We wanted to know what was being decided behind closed doors about our very future. Apparently this protection which the FACA is supposed to provide was not enough. The appellate court within ten days of the hearing confirmed the district court's findings, but did grant that the ASD had received judicial review. As stated earlier our request for an In Banc hearing was then denied.

We were in the battle to save our profession . . .

To say the least we were disheartened by the findings of the court. However, we must learn from this venture. I must admit that it was very satisfying for the ASD to be on the battlefield. At least we were in the battle to save our profession. Where was the rest of organized medicine? We also learned that the courts have determined that the CPT Editorial Panel, the CPT Advisory Committee, the RUC, and the RUC Advisory Committee are entirely under the control of the AMA. Therefore the AMA should no longer have an excuse for not opening these committees! Finally there is much information that the ASD obtained in the discovery phase of this case which will be of great value in the future to the ASD and other interested parties. Somehow, I do not think we have heard the end of this case.
It is my opinion that we did not lose on the merits of the case, but because the judges felt that we were a small insignificant "splinter group" that did not speak for the physicians of this country. The AMA is seen as speaking for the physicians of this country by the vast majority of American citizens and these judges must have felt the same. Unfortunately most of the citizens of this country are not aware that only approximately 40% of the physicians belong to the AMA, and of that 40% many do not agree with the direction the AMA is taking our profession. We were apparently seen as attacking our own representative, the AMA.
I have long felt that it is imperative that physicians with conservative views must be involved in organized medicine. ASD v. Shalala has confirmed this opinion. If the AMA is seen as representing the physicians of this country, then we must work to change the ideology of the AMA. We must be involved not only in our local medical societies but also in our state societies and the AMA. Only in this way can we have a positive impact on their thinking and their decisions. This process will take time and will be very frustrating for many of us. We must not become angry and quit; the stakes are just too great. Many physicians have already taken this latter course of action and in so doing they have left the door of the AMA open to a leftward leaning ideology and have allowed an institution seemingly more interested in its own financial security than in the interests of physicians to develop.

Note: I am the current Secretary and Treasurer of the Illinois State Medical Society. The views expressed in this article in no way should be construed to represent the views of the Illinois State Medical Society. Mr. Kent Masterson Brown's expert handling of and comments regarding this case were most helpful in my writing this article.

Successful Sixth Annual Meeting

The ASD Annual Meeting in San Antonio, Texas was a tremendous success. Those of you who attended know how informative and inspiring the presentations were. Take a look at the photos. If you weren't there, you missed a unique experience which is not rivaled by any other organization. Some of the most intriguing topics were:

  • What the government truly has in store for medicine - from U.S. Representative Ron Paul, MD, who is on the forefront of efforts to defend private practice.

  • How and why you are being profiled by Managed Care.

  • Why some doctors are forming unions and what unions have to offer physicians - from a union organizer who has been involved in the actual process.

  • Practical information concerning how each of us can effectively influence how our legislators vote on critical bills - presented by a lobbyist who has worked on both sides of the fence!

  • Plus the latest in software for your office, the newest applications of laser technology to your practice, professional use of the internet...and much, much more.

    • As successful as this meeting was, we at ASD will "top" this meeting and continue to provide our members with the most up-to-date, useable information to help each of us maintain excellence in caring for our patients. Audio and video tapes are now available.

    Take Note! We may be "condoning" insanity!

    by Holly Fritch Kirby, MD
    President-Elect
    Take note... or you may be falsely accused of owing part of the $23.2 billion in Medicare fraud or improper payments reported last July by the HHS Office of Inspector General.
    The report clearly states that the $23.2 billion does not refer to outright fraud, such as phony records or kickbacks. Instead 47% is secondary to documentation and 37% to the lack of medical necessity. This 23.2 billion represents the work of America’s physicians on a daily basis as they try to cope with an exceedingly complex and confusing set of burdensome rules.
    A concerned Mary McKenzie, U.S. Congressional staff member on the House Health Care Working Group, had the following words of warning. A federal contractor had been asked by “higher ups” to find instances of billing errors so they could fine a designated provider. This contractor knew in her heart that the physician had tried to comply. So where do we stand?
    For the record, the Wall Street Journal reports that there are 42,000 pages of Medicare rules and regulations, whereas Senator Lott states there are 17,000 pages of IRS code. If it is true that most legislators do not fill out their own tax forms, despite having enacted the laws, then physicians might hope for some sympathy dealing with 2.5 times the regulations.
    Another part of the problem is the coding system and, in particular, the E&M codes brought about with the price fixing of the RBRVS legislation, as well as the pending implementation of a revised version. These codes were not devised for criminal prosecution but rather as guidelines. They were not implemented at the request of physicians who previously had used the market value of their service as the basis for payment.
    The revision has formally been rejected by the California Medical Association and the Pennsylvania Medical Society.
    From a preliminary study it would appear that physicians in general have rejected the E&M system. To have implemented the original guidelines, physicians would need to know the rules. However, when they were tested, the average score for generalists and specialists was four out of 100, and for a group of specialists was nine out of 100. (Furthermore, a recent California Medical Association survey revealed about 30% of physicians were not even aware of the guidelines on how to code for E & M visits.) Again, the conclusion is that physicians rejected this undue costly yoke. If analyzed further, this quiet rebellion/reaction was of uncommonly good sense, a general characteristic of physicians.
    When one masters a skill such as driving an automobile, learning a language, or becoming a physician, much of the knowledge is placed in the subconscious. To do each step consciously, such as documenting minutiae, would be very ineffective, not to say inefficient, wasteful, and costly. Furthermore, creating a record for the government distracts from the important issue at hand, namely taking care of the patient’s problem.
    If we consciously practice ineffective medicine, are we not at least somewhat practicing and condoning insanity? And, anyway, whose medical record is it .... the patient’s or the government’s?
    In contrast to the present state of affairs, where fraud and abuse have been redefined and physicians are threatened by Draconian penalties and imprisonment, the original (and unrepealed) Medicare law ensures that the government will not interfere with the practice of medicine.
    From Title 18 of the Social Security Act, signed into law by President Lyndon Baines Johnson on July 20, 1965:

  • * 1801. Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or, over the selection, tenure, or compensation of any officer or employee of any institution, agency or person providing health services; or to exercise any supervision or control over the administration or operation of any such institution, agency, or person.
  • * 1802. Any individual entitled to insurance benefits under this title may obtain health services from any institution or agency, or person qualified to participate under this title if such institution, agency, or person undertakes to provide him such services.
  • * 1803. Nothing contained in this title shall be construed to preclude any State from providing, or any individual from purchasing or otherwise securing, protection against the cost of any health services.

    Dermatology is part of any ongoing process to impact legislation and regulation. April 9, 1998 U.S. House of Representative member, Vince Snowbarger (R-KS), Vice Chairman of the House Government Reform and Oversight Subcommittee on Human Resources, along with Chairman, Chris Shays (R-CT) will hold a Congressional Field Hearing on Fraud in Kansas City at the Kansas University Medical Center. The hearing was prompted by the HHS OIG report presented by a dermatologist to a sympathetic Rep. Snowbarger, who understood the dismay of his local physicians.
    There are a number of actions that a physician can do to defend him/herself. These include taking a few minutes to call your congressional legislators. Explain the difficulty and cost of working with the immense amount of complex Medicare rules, and how it differs from the original law, as well as the ways these rules distract from patient care.
    Ask about the relevance of the paper reduction act and impact of these rules on small businesses. Ask for a moratorium on prosecutions relating to the E&M billing codes. Ask for their support of the Administrative Civil Rights Act while a new system is contemplated. Finally, encourage them not to enact legislation which would diminish a patient’s privacy. If this legislator supports MSAs, ask that MSAs play a role in a new system.
    Remember, “The only thing necessary for the triumph of evil is that good men do nothing.” - Edmund Burke.
    The telephone number of the Congressional Switchboard is: 202-224-3121.

    The Phony Baloney Theory

    by Chester C. Danehower, MD
    Many physicians are watching in utter disbelief as their plight goes rapidly from bad to worse. After all, the vast majority of the physicians in this country are well trained, and are dedicated to their patients. They are honest, and sincerely feel that they are trying their best to comply with the incremental changes in health care that are being foisted upon them by our government and big business. They feel that they deserve a better fate, and in all candor they really do. However, until we who are physicians understand why we are in our current predicament, our situation will continue to worsen.
    Who is to blame? Well, we obviously have many enemies. Physicians blame our government, big business, the media, the legal profession, society in general, and even organized medicine. I will grant that we are certainly under attack; however, it is my opinion that we are our own greatest enemy. We must first put our own house in order before we can make any significant positive changes in our predicament. In this process we must ask ourselves why physicians and the medical profession have enemies.
    Could some physicians' pomposity and lack of caring for their patients have a bearing on our current plight? Could it be that the public in general finds it abhorrent when a young, new physician moves to town and very shortly after his or her arrival purchases a new Mercedes and one of the finest homes in the area? You can bet that these activities have a profound negative influence! We could begin by educating those who are entering the medical profession that overt displays of wealth are not wise for members of our profession, and especially when they first move to a community. However, it does seem strange that a member of any other profession exhibiting the same behavior would almost certainly be extolled for his or her hard work and business acumen. It indeed does seem ridiculous, but this is the view of our society. Unfortunately the actions of a few are attributed to all physicians.
    Obviously our actions in our everyday lives and in our practice of medicine are very important in our developing a positive image for our profession; however, in my opinion, the greatest weakness of physicians and organized medicine is their application of the "baloney theory." For one to understand this theory one must first visualize an individual who possesses a stick of baloney. Whenever another individual demands some of the baloney, the possessor just gives away a few slices; after all, he has more than enough, and by giving away a few slices he can avoid any bad publicity and ill feelings. He goes along to get along. Because of repeated demands by others, the stick of baloney is eventually exhausted. We currently find ourselves in the predicament of almost giving away our whole stick of baloney; that is our profession! The physicians of this country along with its representatives in organized medicine have the habit of going along to get along in order to avoid confrontation and bad publicity. We must stop fearing bad publicity, and we must stop avoiding confrontation when it is in the best interest of our patients, our profession, and the physicians of this country! We must inform those who wrongfully attack our profession and the physicians of this country, that we will no longer tolerate their attacks, and that we will no longer tolerate their attempts to destroy our profession. We must stand on principle, and state our positions to them in clear terms. We must not concern ourselves with the attacks that are sure to follow. We are already under attack. How could it be any worse?
    Let us look at the American Medical Association (AMA). Under their representation, our profession has been gradually decimated. One of their greatest fears is bad publicity, and this fear causes them to rarely state their positions in clear terms. They appear to be much more concerned about bad publicity, than in protecting the interests of the physicians whom they represent. For example, the AMA House of Delegates several years ago established the policy that the AMA would abolish the National Practitioner Data Bank. Well it still exists, and "evil" physicians along with the most wanted by the FBI and sex offenders are in national data banks. How absurd! The AMA is even using a physician's not being listed in the data bank for a positive point for that physician in its new AMAP accreditation program. Quite frankly it appears to me that they are prepared to go along with incremental change until our whole profession is given away, and every physician in this country is totally under the control of our government and/or big business. The recent E & M coding fiasco is another example of the "baloney theory." However, in this case the AMA appears to be responding, but only because of the recent "Sunbeam debacle" and the fact that physicians expressed outrage over the attempted implementation of these codes. However, all that is likely to happen, is that some minor modifications of the new E & M coding guidelines will be made. The AMA will then declare victory, and in a few years through incremental change these minor modifications will, as if by magic, just disappear. The only way to avoid this result is for physicians to awaken and to persistently express their outrage.
    Physicians and organized medicine must speak out immediately when others infringe upon their freedom and their rights. They must not be intimidated by fear, and they must stand on principle. In addition if physicians and organized medicine improve their image, and if they stop employing the "phony baloney theory," the plight of physicians and organized medicine might well improve.

    Dr. Don Printz, who is the current president of the ASD, introduced me to the concept of the baloney theory.

    It's Not the Sex; It's the Tyranny

    by Holly Fritch Kirby, MD and reprinted with permission from Kansas City Star

    It would appear from the various legal maneuvers and very carefully crafted responses, that the President committed one or all of the following felonies: Perjury, suborning perjury, and obstruction of justice.
    If this is the case and the President is above the law, then we are not living under a constitutional government. In other words, if the President is not subject to the rules of law, then we are ruled by a tyranny.
    Therefore, Congress and the American people must act to restore a constitutional government.

    Remember the Alamo!

    reprinted from the January,February 1998 AAPS Medical Sentinel

    "The Sixth Annual Meeting of the American Society of Dermatology (ASD), held at the beautiful La Mansion del Rio Hotel in San Antonio, Texas, from October 3-5, 1997 was extremely well attended - a resounding success" reported Jane M. Orient, MD, Executive Director, AAPS.
    Topics ranged from laser surgery for dermatological lesions to socioeconomics, politics, and medical ethics. All dermatologists owe it to themselves to belong to this organization dedicated to the ideals of the private, independent practice of medicine.
    The ASD is the only organization founded exclusively on the political and socioeconomic interests of dermatologists in private practice.

    When is Enough, Enough?

    Editorial Comment, by Chester C. Danehower, MD, Peoria, Illinois

    The following article was written somewhat over a year ago for FrontLine, but was not published because of a desire on the part of the ASD not to be disrespectful to the AMA. However, with the recent advent of the Sunbeam debacle and the AMA's push to implement its new AMAP program, the question of "when is enough, enough ?" looms more ominous than ever. Unfortunately the AMA appears to be more interested in money than in the interests of physicians. I fear that the following article was, unfortunately, right on target.
    I recently received a flyer from the AMA describing the AMA's 1997 CPT and RBRVS symposia to be held in Chicago from November 13-15,1996. The cost for both symposia is only $345 for AMA members and $395 for nonmembers. Of course expenses for travel, lodging, and meals are additional. Either symposium can be attended to the exclusion of the other at a reduced rate, and those attending the CPT symposium will receive a copy of CPT 1997 and a complimentary issue of the CPT Assistant which is an "authoritative newsletter on correct coding" according to the AMA.
    At first this sounded like a pretty good deal to me. After all I have certainly had problems keeping up with the changes in CPT coding, and I certainly did not want to go to jail or get fined for incorrect coding; a punishment that was recently contemplated by our federal government in order to discipline "evil" physicians. And then I began to think ! Why do the CPT codes keep changing every year? Why do I have to buy a new CPT code book every year? Why do we need CPT codes anyway? Does CPT coding enhance patient care? How many CPT code books does the AMA sell each year? How much profit does the AMA make on each CPT code book they sell? The more I thought, the more angry I became.
    Not only is the AMA probably selling several hundred thousand copies of the CPT code books each year at a huge profit on each book, could the AMA be further exploiting the physicians of this country by putting on symposia to make even more money? How much is enough money for the AMA? Even though I think the AMA means well, my answers to these questions were not favorable to the AMA. My answers merely reinforced a sickening feeling that I have about the entire coding process. To quote another dermatologist to whom I recently spoke, perhaps we need another Boston Tea Party, but, instead of tea, CPT code books should be used!
    As far as the RBRVS is concerned, it was flawed from its inception. In my opinion it has simply been a mechanism used by our government to control physicians and their fees; it was never intended to be fair by most of those who devised it. Quite frankly I wonder why physicians and the public have not had adequate input into the process of development and refinement of the RBRVS. CPT coding is also being used to control physicians, and is getting in the way of good medical care. Physicians spend far too much time worrying about coding; time that would be better spent studying real medicine and caring for patients.
    If indeed the AMA is making several million dollars each year ,as has been rumored, because of their exclusive copywright on CPT coding, could just money explain the frequent changes in CPT coding by the AMA? There must be a better explanation. Could the AMA be trying to adjust to what they consider to be the new economic reality? Could they ultimately be trying to become a dues free organization or at least an organization requiring very low dues? If the AMA requires minimal or no dues, could the AMA become even less responsive to the needs of physicians than it now is?
    I feel that those in charge of the AMA are honorable people, and for this reason I am dismayed that the AMA could have any part in any process that could be used to control physicians and to ultimately ration care for our patients. In the name of the new public-private partnership between the federal government and medicine, I fear that our profession is unwittingly being given away by organized medicine. The AMA must not only consider the welfare of our patients, but it must give equal consideration to the welfare of the physicians of this country. When the AMA is percieved by physicians as truly standing up for them, then the AMA will no longer have to worry about its membership. Then and only then will the AMA membership grow significantly.
    I for one will not attend the coding and the RBRVS symposia. Quite frankly I feel that coding and the RBRVS are getting in the way of good medical care!