The AMA is in existential crisis — why the profession should be alarmed

The federal AMA is in trouble and its predicament is serious enough to affect the medical profession as a whole.

Its historic membership demise is accelerating, with a heavy impact on revenue. Financially, it is breaking and there are discussions about another round of cost cutting, including staff redundancies. 

The trigger for the latest crisis is the decision by AMA Queensland to walk out late last year. In terms of substance, the reasons were not much different from what happened with AMA WA’s yearlong departure before a stony rekindling of the relationship resulted in its return. 

The federal AMA’s share of the membership fees is out of whack, it is claimed. It takes too much, states cannot function. This is mixed with accusations of arrogance; that stuck in the Canberra fishbowl, it believes it is too important to fail. As a result it’s out of touch with the issues affecting doctors at the grassroots.

The immediate impact of the Queensland walkout is the loss of some 5500 doctors to the federal AMA along with their membership fees. The expectation was that these doctors would be happy to remain with the federal AMA.

The sales pitch was simple. They would join “Australia’s most trusted and powerful medical peak body voice in federal politics on matters of funding, regulation and access”, along with a free subscription to its Fees List and The Medical Journal of Australia.

But very few have bothered to hand over the $800 membership fee the federal AMA was asking for [*]. 

So far, only some 370 Queensland doctors have made the blood pledge. You can do the calculations yourself, but the low take up has left a $2 million revenue hole in the accounts. 

AusDoc has heard rumours that the federal AMA veering towards insolvency. We have been assured by those who should know that this is definitely not the case.  

But the management in Canberra has to balance the books. No decision on staff cuts yet, but there is a block on travelling to meetings now, with a rule that everything is done via Zoom/Teams where possible.

This sudden conflagration has occurred during a long, slow burn when it comes to membership. Doctor numbers in Australia have increased rapidly over the last 20 years as governments try to fill the medical workforce hole. Some 150,000 doctors are on the medical register.

But federal AMA numbers have flatlined. It seems good at attracting the new blood, particularly the doctors-in-training, but the rest of the membership is an ageing specialist cohort. What is missing is the middle — the huge contingent of mid-career doctors who make up the backbone of the health system.

According to numbers seen by AusDoc, the federal AMA has roughly 19,000 members, down from 25,000 in 2023. A federal AMA source says it is not so bleak; the current number is closer to 23,000.

But that is still not great. The financial woes have also been around for a while. In 2018, it sold its HQ, AMA House in Canberra, and turned to the rental market for its accommodation.

That sale raised $15.6 million. It sits in the reserves, but it could have a finite life cycle.

If Queensland has gone and another state walks — say NSW or Victoria, or suddenly there is a second divorce with AMA WA — the risk is the Federal AMA shrivelling into some sort of representative organisation for the marginalised minority, the smaller states like Tasmania along with the territories.

The plight of the AMA, or say the medical colleges, is usually background noise for most doctors, even the never-ending technicolour pantomime nightmare of the RACP. But the demise of the AMA as a political force in Canberra, should that awaken the profession from its slumbers?

Those happy to let the current logic unfold need to offer a coherent account of how the interests of the medical profession will be served.

What reason would any GP have for remaining with a state AMA given federal control over the basics of the specialty: Medicare funding, funding for vocational training and funding incentives for the workforce as well as control over the regulatory machinery hanging over their heads?

Queensland has suggested it has the necessary federal contacts but that seems ludicrous.

We end up with the spectacle of half a dozen AMA representatives sat outside Mark Butler’s office, each one with their wish list and discussion points?

They get six minutes each, the Yes Minister version of McMedicine?

That is not happening. Every politician asks themselves the same questions that every lobbyist asks of a politician.

Who is this person? Who do they represent? What powers do they have to help me, what powers to harm me. Why is it in my interest to speak to them?

It is noticeable that with the Pharmacy Guild of Australia, once an afterthought for most health ministers, each question now has a clear and definite answer. 

Apart from the occasional public temper tantrum by its current president, the guild’s lobbying happens behind closed doors; it can offer a fix of some sort to issues that can disturb a minister’s job prospects and it tends to speak with one voice with a degree of superficial coherence that allows some of its dumber ideas to become reality.

The AMA has already witnessed firsthand what happens when it vacates space, with the RACGP a decade ago using its easy access to its own members’ money to become a lobbying force for GPs. 

This too was the result a (perceived) failure by the AMA to stand up for the specialty.

Nothing captured the changed dynamics better than Dr Karen Price, who, as college president, was urging GPs to ditch bulk-billing where possible because the funding was so crippled doctors were struggling to providing the care they had been trained for.

That was fighting talk and it resonated loudly.

The college has also energised grassroots GPs in ways the AMA rarely has. I am thinking of experienced, politically engaged female doctors that AMA has for too long struggled to attract.

But the college has material conflicts of interests; too much government cash flows through its coffers, the most blatant being its $750 million contract with the Federal Government to train GPs. 

It is first and foremost about education and standards. This means while it is vocal about GP red tape for instance, it speaks less loudly about the heavy toll of practice accreditation. 

Recently, it was also having to defend clauses in the government training contract that attempt to prioritise registrar placement with bulk-billing practices.

The college insists the clause is no big deal, but it is not a good look and makes explicit the power dynamics that exist in all medical colleges with their trainees. Their interests are not the same.

So when it comes to the AMA, the profession should be alarmed at what is happening.

This is at a time when the medical colleges are being unpicked by ministers who continue to see them as monopolisers of the specialist workforce. 

Specialists themselves are now the target of an orchestrated political campaign over their fees which is engineered to deflect the Federal Government from blame over the failure of Medicare.

The ultimate idea seems to be to strip high-charging specialists from accessing Medicare rebates. 

What role do the state AMAs have in that battle?

And then comes the rise of independent allied health prescribers.

The guild’s success in expanding pharmacist scope of practice into diagnosing and prescribing of S4 drug is now being furnished, remarkably, with taxpayer dollars, both state and federal.

Unthinkable, even ten years ago. It did this by targeting the soft underbelly of the states’ control of the poisons legislation allowing pharmacists to bypass the TGA powers on who prescribes what in Australia. 

Given the lack of angst at a federal level at the unravelling of a key mechanism to protect patients from harm, the guild’s strategy demanded influence at both the state and federal level. 

The AMA is meant to prevent these incursions into medicine give the fragmented chaos that typically ensues. But it has to have the capacity to touch the same pressure points as the guild. Allowing a thousand flowers to bloom across the organisation doesn’t work.

AusDoc has been told there are no ongoing conversations between AMA Queensland and the federal AMA on reconciliation, just one of those public declarations that should anyone want to talk, the door is open.

The internal ructions have a long history. But they are being driven by personalities, where the scar tissue accumulates alongside the resentments and the anger. That is a world that can rapidly mutate into distorted perceptions of malign intent. In extremis, you end up with the basket case of the RACP.

Those involved in the federal AMA do need to take a cold, hard look at themselves into the reasons why they are continuing to suffer these break-ups. Something is not working. 

But all those embroiled in this mess needs to start asking themselves the fundamental question: What is the AMA meant to look like once this fighting stops? 

There is only one hard end point and that is an organisation that can do the job its members want done.

The current wreckage bodes ill for everyone, everyone apart from the many players who would prefer the medical profession enfeebled.

[*] AusDoc has been told that Queensland membership fees for doctors have not changed despite the loss of federal membership. The typical fee for a specialist is usually around $1,800, with some $800 covering the membership of the Federal AMA. It may explain why so few doctors have paid to join the Federal AMA since the split.