Advocacy is built by forming coalitions among various groups of like-minded individuals
The American Medical Association (AMA), in its purest form, is a deliberative body where all state societies and national specialty societies come together to craft policy for the education and practice of medicine in the United States. Potential policies are made and voted on by the delegates. Although the AMA's influence has declined, it is still an important avenue for establishing healthcare policy within the halls of government.

The Academy's representation in the AMA consists of eight delegates. Twice a year, they meet with 530 members from all branches of medicine. They convene to help craft a cohesive message from the individual priorities of member organizations. In addition to the AAOS delegates, a few orthopaedic subspecialty societies have individual representation, including the American Orthopaedic Foot and Ankle Society and American Society for Surgery of the Hand. Individual orthopaedists, representing their state organizations, also participate in this biannual process.

These delegates work together under the Orthopaedic Section Council. This council convenes during the biannual AMA House of Delegates meeting to discuss the issues that affect orthopaedic practice. These meetings also provide an opportunity for the Council to disseminate the orthopaedic perspective to nonorthopaedist delegates. It is also where we offer our support to issues or initiatives that may be important to certain states.

Advocacy is built by forming coalitions among various groups of like-minded individuals so that the message carries more weight. To form a stronger message within the AMA, AAOS delegates are forming a coalition with the representatives of the Rheumatology and Physical Medicine groups to better disseminate a common, musculoskeletal perspective to all voting members. In this deliberative body, votes count. Bigger coalitions wield more influence in guiding AMA policy. Active AAOS participation to help block harmful ideas from becoming policy and to assist in the development of beneficial policy proposals is necessary.

As an example, the House of Delegates recently discussed the -25 modifier. This modifier is used extensively by orthopaedists when the patient undergoes a procedure on the same day as a legitimate evaluation and management service (E&M). The Current Procedural Terminology (CPT) coding handbook has clear rules on when it can be used and when it is appropriate to be billed as a separate service paid in full. There is a recent push by some insurance companies to reduce or disallow payments attached to a modifier -25 in clear defiance to the coding guidelines. Once every group who routinely does injections or other services for their patients realized the impact, there was a resounding call for the AMA (which develops CPT codes) to demand "by any legal means possible" that insurers are held to the rules outlined by the CPT book.

Medicine, as a profession, is facing practice encroachment from many sides. In scope of practice discussions, the AMA is a strong advocate for the clear delineation of privileges based on education. Through legal and political efforts, the AMA is working to establish a consistent national strategy to address state legislative efforts affecting who can provide patient care.

In the end, advancing the practice of orthopaedic surgery is about gaining access to those individuals and groups who help make final policy on the practice of medicine. And while we, as the Academy, are very effective as a small group at getting our message to legislators, it can be much more effective if we have a larger coalition advocating for the same goals. There are two ways to build coalitions. One is to wait to see what other groups think and try to work out the differences. The other is to be at the meetings where other groups' decisions are made to bring your issues to discussion before final decisions are made. Although we may not all agree with the end result, it is always better to understand how it came about sooner rather than later so that we can build a more effective strategy.

The AMA offers us a place to help mold our message so that it becomes the message of medicine in general. Numerically, our representation is based solely on the number of AAOS members who are also in the AMA. The more AMA members, the more delegates. The more delegate votes, the more influence. Think of AMA membership as more than just belonging to another society, but rather as an advocacy effort. AMA membership is the price of admission to the larger debate on the future of medical practice. Although advocating to the policy makers is important, advocating to our medical colleagues is vital to getting our message heard and understood.

John Early, MD, is in private practice in Dallas. He is a past president of the Texas Orthopedic Association and was a representative from Texas to the AAOS Board of Councilors. He presently serves as an AMA delegate for the AAOS.