Doctor Prescribes Some Big Changes for AMA : Medicine: A progressive in the medical Establishment argues that physicians must put the patient first.

A doctor is telling physicians: “Get ready for a bumpy ride. Like it or not, we’re in for change.”

This realistic physician--Ray Scalettar, a rheumatologist here--says doctors must recognize that change in American medical care is inevitable and try to make it change for the better.

What makes his view newsworthy is that he is chairman of the board of trustees of the American Medical Assn., and, in AMA terms, he is a progressive. This means he is in combat often with the many doctors who say that the changes are mostly bad and that the AMA should battle for the old ways, when doctors were undisputed bosses of the medical world.

The Scalettar camp won a victory in early December, when the group’s House of Delegates declared it unethical, except in certain cases, for doctors to refer patients to facilities where they have a financial interest but don’t themselves give any care.

Studies have shown that most doctors with such interests tend to over-refer to them, reaping the profit. Scalettar, among others, argued for “putting the interest of our patients ahead of our own.”

“This has always been the AMA’s position: The patient comes first,” he contended in recent interviews.

Many Americans did not see the AMA in this light in the 1950s, when the organization opposed Medicare and argued about whether medical care is a basic “right.”

It took struggle after struggle for the AMA to change. One step forward was advocacy of a Medicare reform intended to pay family physicians and internists more and “procedure” doctors, like surgeons, less.

Another was the adoption of a 1990 plan called “Health Access America” saying that “the status quo is not acceptable,” that all Americans should have adequate health coverage and that the government should make employers insure employees and dependents. This brought the AMA position close to one held by many liberals, including AMA arch-foe Sen. Edward M. Kennedy (D-Mass.).

There was a day when the AMA called almost any kind of national health insurance program “socialized medicine.” Today its “Health Access America,” fully enacted, would hugely improve Americans’ care, however one may compare it to more extensive reform proposals.

“There has been great change in the AMA over the years,” Scalettar maintained, “a greater concern for public needs, social values and ethics.”

Scalettar, 54, talked of growing up on Brooklyn streets, part of a “frugal family” scarred by the Great Depression. “My father was a dentist,” he said; there was no such thing then as dental insurance, and “when there was no money, the patients’ teeth”--and the Scalettars’ income--”were first to go.”

Now, he said, “I believe in social commitment,” care for all and “the improvement of the practice of medicine,” putting patients first.

None of this puts the AMA--or Scalettar--on the political left. It, and he, oppose government fee-setting. They oppose a firm government lid on health spending. They oppose a health system like Canada’s, where government uses tax money rather than private insurance to pay for everyone’s care.

Instead, they want to see costs controlled by a competition in which groups of doctors, hospitals and health plans compete for patients by price and services.

Most advocates of such a system believe that virtually all Americans should be all but forced into organized plans by charging them substantially extra if they want to stay with their independent doctors.

“We differ,” he said. “We think the patient should always have a choice” of where to go for care. Yes, he agreed, the patient might have to pay a bit extra for a choice, but the extra amount should not be prohibitive. “The patient should be in the driver’s seat.”

On this and other issues, Scalettar is no quiet voice, unlike many predecessors. He argues strongly in AMA sessions. Traveling the country, he has joined James Todd, the AMA’s executive vice president, as one of the group’s two main public voices in today’s health-care debate.

“I’m not shy,” he said. And he is not shy about the fact he intends to run for the prestigious AMA presidency next June against AMA trustee Robert McAfee, who will probably be more favored by AMA conservatives.

With 292,000 members, the AMA represents 41% of physicians, drastically down from the early 1950s, when it represented 77%. Specialty societies--for surgeons, internists and many others--have grown at the AMA’s expense.

Politically too the AMA is no longer the awesome power it once was. Still, the American Medical Political Action Committee, its campaign arm, spent nearly $5 million on 1992 races, the kind of money that opens legislators’ doors.

Scalettar and many AMA members recognize that doctors can no longer call all the shots, in legislative bodies or their own offices. Yet no health-care reforms can be truly effective without willing doctors.