Doctors Lobby Uses Clout to Block Agency Reforms

When Assemblywoman Jackie Speier proposed establishing a toll-free hot line so consumers could easily file complaints against doctors with the state medical board, she figured the measure would pass without a ripple of debate.

She was wrong. The idea was killed in a legislative committee.

Speier had not counted on an opponent as formidable as the California Medical Assn.

Representing about half of California’s doctors, the association has used massive campaign contributions and a highly sophisticated lobbying apparatus to achieve a position of influence in state government that few interest groups rival. The CMA’s typical expenditure of about $3.5 million during a two-year legislative session outstrips that of any other lobbying group.

As a result, its legislative victories in recent years have been numerous, ranging from its ability to bottle up proposed reforms of the Medical Board of California to its success at scotching attempts to require doctors to post signs in their offices telling patients how to complain about physicians.

Critics charge that the association is so determined to shield doctors from bureaucratic intrusion that it has ladened the disciplinary process with a labyrinthine regulatory system. They accuse the association of causing the system to be weighed down with due process procedures that limit the medical board’s access to evidence and its ability to put bad doctors out of business.

“The medical industry has created outstanding protections and has helped create a system (of enforcement) that is totally ineffectual doing what it was commissioned to do,” said Speier, a San Francisco Democrat. “The due process argument is used over and over again by physicians who want to try and repudiate a particular measure and we tend to sit back and say, ‘Well, gosh, everyone deserves due process that’s fair.’ ”

CMA officials maintain that the enforcement system is good but could work better with minor reforms and greater efficiency on the part of the staff of the medical board, which licenses, regulates and disciplines physicians. CMA officials contend that the critics’ actual motive is to create a system dominated by lawyers instead of doctors, a system streamlined so that accused physicians would have few opportunities to defend themselves.

Even now, as a new movement to restructure the medical board gains momentum in the Legislature, the CMA is using the due process argument to fight key reforms proposed by Sen. Robert Presley (D-Riverside) and the University of San Diego’s Center for Public Interest Law, which prepared a stinging report last year on doctor discipline.

The 101-page report called California’s medical disciplinary system “effectively moribund” and unable to protect citizens from incompetent physicians.

Presley’s bill would give the medical board and its staff new powers to act more swiftly and decisively. A panel of medically trained administrative law judges would hear disciplinary cases. In egregious situations, they would be empowered to suspend a doctor’s license early in the disciplinary process. Also, a medical board lawyer would oversee the investigation and prosecution of cases, and appeals of board decisions would go directly to the appellate courts, bypassing the Superior Court.

The CMA is promoting its own reform proposal, which gives the board fewer additional enforcement powers. The legislation introduced by Assemblyman William J. Filante (R-Greenbrae) includes some of the Presley features but retains the right of appeal to the Superior Court.

The CMA has been adamant on the Superior Court issue, saying the elimination of that right would deny doctors an important element of due process. So far, it has gotten its way with lawmakers even though the medical board considers bypassing Superior Court a vital reform.

“We are a membership organization and we have an obligation to protect the rights of our members and that is where we are coming from on these issues,” Linda Ramsey, director of the CMA’s division of scientific and educational activities, said in a recent interview.

But she said the association also believes “a public responsibility to have a well-working disciplinary system. To have bad doctors out there hurts everybody and hurts our members most of all.”

As an example of their public responsibility, CMA officials cite their support of a recent license fee increase that helps pay for additional medical board investigators. The association also supported a 1989 bill empowering the board to investigate complaints of excess doctor fees, which was approved by the Legislature but vetoed by Gov. George Deukmejian.

However consumer activists who have battled the CMA on health care issues argue that when it comes to lobbying, the CMA’s desire for an effective disciplinary system is overshadowed by concern for protecting its members.

“The CMA is first and foremost the lobbying arm on behalf of the wallet of a minority but a wealthy minority of the doctors in this state . . . its agenda seems to be very focused on the financial interests of its members,” said Jim Shultz, a policy analyst for Consumers Union.

On the legislative battlefield, the CMA is an awesome force that derives its power from the large sums it pours into lawmakers’ political treasuries each year, the substantial professional lobbying force it employs and the influential position physicians hold in society.

In 1989 the CMA pumped more than $1 million into the political campaigns of legislators and state officeholders, then spent thousands of dollars on dinners, drinks, receptions and gifts for lawmakers, their staffs and in some cases even their spouses and children. In the last year, every legislator received a contribution of no less than $500 and often as much as $10,000 from the CMA.

For most of the last decade, California Common Cause, a public interest lobby that promotes campaign finance reform, has found that the medical association contributed more to state legislative candidates than any other interest group.

At a cost of $500,000 a year, the CMA employs six full-time lobbyists and contracts with outside lobbying firms to work on specific legislative issues. To back up the lobbyists, the association has an elaborate communications system that sends out “alerts” to members at critical times, encouraging them to contact their local legislator on a particular issue that the CMA opposes or supports.

“They know how to churn up enough anger so that three or four angry calls from influential doctors in a district can overwhelm several dozen calls from ordinary citizens,” said Steve Barrow, a lobbyist for the University of San Diego’s Center for Public Interest Law.

To oppose Speier’s proposal to establish a toll-free hot line, the assemblywoman recalled that the CMA “sent out a mailing to all its members statewide saying this bill must be killed.”

“Someone later told me it cost $13,000 just to send out that mailing,” she said.

Former CMA President William G. Plested said the bill needed to be defeated because patients would use the hot line to file frivolous complaints. “Every time you look cross-eyed at someone, they would call and start an investigation. It is crazy,” he said.

In March, two years after Speier failed to get the hot line mandated by the Legislature, the medical board went ahead and installed its own.

Lawmakers say CMA membership pressure is often exerted in subtle ways that allow the organization to capitalize on a doctor’s personal relationship with a legislator. Several legislators said it was apparent the CMA had assigned a doctor from their district to maintain frequent personal contact and plug for the association’s position on issues.

“I know there is one in my district that has been assigned to me,” said Presley. “He and I have been good friends for years. He was not my private physician but he is someone who has been involved in a lot of issues over the years and I’ve known him and politically we’re very close. And so they picked him. “

To consumer lobbyists who battle the CMA on issues, the association’s highly organized lobbying operation coupled with its ability to make generous campaign contributions permit it to develop a rapport with lawmakers that they cannot hope to match. And it virtually assures that the Legislature will defeat--particularly in the health care area--bills that the CMA opposes.

At the end of the 1985-86 session, the CMA boasted to its membership in its monthly magazine that its “score card” for that two-year legislative cycle showed that none of the 155 bills it opposed had been enacted.

“If X legislator is being lobbied it’s one thing for me to go in there to lobby him and quite another for the CMA--someone who’s given thousands, who talks to him over an expensive lunch or who may have attended his campaign dinner the night before,” said Shultz.

Consumer advocate Maryann O’Sullivan ran headlong into the CMA lobby when she tried to persuade the Legislature to adopt a tougher “anti-dumping” law to stop hospitals from rejecting emergency patients without insurance.

“You would sit down and talk to a legislator and you would know that he knew patient dumping was wrong but yet you wouldn’t get a promise of his vote,” she said. “You would see votes swing the wrong way and you would know that was because of the money.”

Unable to match the power of the CMA purse, O’Sullivan fought back by staging dramatic presentations in legislative hearings that were sure to attract the attention of television cameras. She brought in witnesses to tell stories of loved ones who had died or suffered permanent disabilities because hospitals had turned them away.

“You would know some legislators came in ready to vote for the CMA and wouldn’t be able to do it in front of the television cameras,” she said. The patient dumping bill finally won legislative approval in 1987 after the CMA reversed its position and agreed to support it.

Speier said she experienced another example of CMA power when she was trying to push her hot line bill through a Senate committee chaired by then-Sen. Joseph B. Montoya (D-Whittier). As she was proposing a change that she hoped would win committee votes, a CMA lobbyist was vigorously shaking his head “no” in the back of the room out of her range of vision.

“Well, the CMA doesn’t support this,” Montoya said as he fixed his sights on the CMA lobbyist, according to witnesses at the hearing.

“I looked at him (Montoya) and all the other members of the committee and said, ‘well who is running this Legislature, the CMA or the members?’ ” Speier recalled.

The committee threw the hot line proposal out of the bill and passed a watered-down measure that merely required that a study be made of how the medical board could be more accessible to the public.

The CMA wields power more subtly with the regulatory bureaucracy, where its most potent asset is the mutual interest it shares with the medical board.

Board officials, sensitive about suggestions of CMA clout, deny that the doctors’ trade group holds sway with them or with the agency’s staff, particularly in individual discipline cases.

“I don’t think they have any influence with the board,” said Dr. J. Alfred Rider, the board’s president. “I think we listen politely to any propositions they have but as far as doing something because they propose it, absolutely not.”

But the CMA’s power is felt in indirect ways. Board officials acknowledge that they need to take into account the CMA’s special relationship with legislators when formulating various policies. As a result, they seek CMA opinion on major issues and maintain regular staff contact. Top officers of both organizations meet formally about once a year.

Rider said: “I think the CMA is a formidable force. It’s nice if they’re with you. It is tough if they’re against you.”

Board Executive Director Kenneth J. Wagstaff said that because the CMA’s clout with the Legislature is “stronger” than his panel’s, he works to “anticipate” and “avoid” legislative collisions.

CMA officials claim little influence with the board. Our influence is “a lot less than with the Legislature, you don’t give money to political campaigns for who is elected to the board,” the CMA’s Ramsey said.

“We feel that the board has a special obligation to listen to us. They don’t. But we think that when you represent the biggest doctor organization in the state of California . . . it would be very foolish of them not to take advantage of the organized input that we can give them about their policies.”

Ramsey added: “If we have cooperation, we can do a heckuva lot more than we can if we have an adversarial position. We have an enormous mutual interest in a lot of these issues.”

The board is made up of 12 physicians and seven members of the public. All are appointed by the governor except two public members who are picked by the Legislature.

Only one physician on the board is not a CMA member, according to the association.

About half of the 70,000 physicians based in California belong to the CMA. Doctors are not required to be members of a professional association as a condition of being licensed. CMA statistics show that a typical member is male and is older, wealthier and more likely to be in private practice than a non-member.

CMA campaign finance records show six of the 12 physician members are recent contributors to the CMA political action committee, which finances the political donations to legislators.

Several board members said CMA membership and political action contributions had no influence on their votes.

Five of the board’s seven public members also have ties to the medical community. They include a lawyer who represents doctors on business and tax matters, a hospital administrator, a licensed psychotherapist, a member of a hospital board of trustees and a former medical social worker who is the former wife of a physician and the mother of a physician.

Both Presley and Speier said such appointments violate the original intent of the Legislature’s decision to require that a certain percentage of the members of regulatory boards be public members responsible for representing consumer interests.

“They (public members) shouldn’t be linked to the industry,” Speier said. “I guess you have to decide, are all these boards in existence to license and protect the industry which they are regulating or are they there to provide rules and regulations for discipline, to provide the licensing function and to make sure that the consumer is not getting ripped off?”

But Tom Beermann, a spokesman for Deukmejian, said the governor believes that it is necessary for public members to have some prior knowledge of the medical profession in order to make the kinds of decisions board members are required to make.