Epsilon Theory PDF Download (paid subscribers only): AMA? BITFD!

If you’re a medical doctor, you probably received an email like this in recent days from the American Medical Association, a tax-exempt not-for-profit corporation organized under section 501(c)(6) of the US tax code:

Subject: Dr. XYZ, don’t wait to get the PPE you need from the AMA

Dear Dr. XYZ,

Since the start of the pandemic, physicians across the country have gone above and beyond to keep patients safe. Yet after eight months, many are still unable to get enough PPE for their practices. We’ve urged the federal government to act, and now, we’re stepping in.

The American Medical Association is collaborating with Project N95, a not-for-profit organization, to reserve quality-certified PPE for AMA members to purchase with no minimum.

If you’re interested in ordering PPE, go here to learn more and view the available equipment, and then activate your AMA membership to get started. The deadline to place an order is 3 p.m. Central time on Monday, Nov. 23.

This PPE shortage has placed physicians in jeopardy for far too long. I hope this collaboration with Project N95 provides some immediate support as we continue to advocate for a long-term resolution.

Activate your AMA membership

Silly me. Did I say that if you were a medical doctor you would probably have received this email? What I meant to say is that if you were a medical doctor who is not currently a member of the AMA, or if your membership has lapsed … THEN you would probably have received this particular email. It’s tailored just for you.

That will be $420 for your annual membership.

And once you pay that – and no, you can’t see our great PPE bargains until you do, in fact, pay that – well, NOW take a look at these great PPE bargains.

Are they a bargain? I dunno. Honestly I have some significant qualms about the PPE pricing through this channel. But I’ll say this – I don’t think any of the parties involved in this effort (other than the manufacturers) are trying to profit in the technical sense of the word from some margin or mark-up on the PPE items themselves.

But the AMA is absolutely trying to profit here.

The AMA is absolutely NOT doing what it should be doing – giving away or heavily subsidizing PPE to ALL healthcare professionals.

What is this email and offer of PPE “support” to doctors all about?

It’s a freakin’ membership drive for the AMA.

But hey, maybe I’m too quick to judge the AMA here and how they are “stepping in to help”. Maybe they’re kinda new to the licensing and product sales world. Maybe they’re spending every dime on educational programs and grants to improve the medical profession and the delivery of healthcare to all Americans. Maybe they don’t have the resources to purchase and distribute PPE for their members – much less ANY healthcare worker – in urgent need of said PPE.

I mean, sure, the organization that Rusty and I helped start – Frontline Heroes – has been able to distribute 170,000 medical respirators to more than 1,400 clinics and hospitals across the United States at absolutely no charge to the recipients, funded by the awe-inspiring generosity of hundreds of donors who know exactly what “stepping in to help” truly means. Sure, every penny we raised has gone exclusively to the purchase and distribution of that PPE, with no one taking any compensation ever. Sure, we’ve done all that with a handful of incredible human beings and working out of my garage. But it is, admittedly, a nice garage. Maybe the AMA doesn’t have the wherewithal to find a couple of volunteers and a nice garage. Maybe they’re stretched terribly thin in “these unprecedented times”.

So I decided to look up the AMA’s tax filings.

All of the information I’m about to share is on the AMA’s public IRS filings (EIN: 36-0727175). I’ve stored and made available for download their most recent filing here: AMA 2018 Form 990.

In 2018, the American Medical Association had total revenues of $332 million. That’s not a typo or an extra zero or two in there. That’s three hundred and thirty two million American dollars in revenue. In one year.

I figured membership dues would be the biggest revenue line item, but no, not even close. Membership dues from all you doctors comes to just over 10% of revenues – $36.8 million. The AMA got almost as much in revenue from direct sales of merch – $29.7 million – and with a COGS of $5 million you really gotta admire their margins. Subscription revenues of $39.7 million were a bit higher than membership dues, but still not the biggest revenue item. Nor was the advertising revenue of $15.7 million, nor the dividend income of $12.4 million on an investment portfolio of publicly traded securities valued at $643 million, nor the profit on securities sold of $14.0 million, nor the “credentialing” revenue of $14.0 million, nor the “reprints and permissions” revenue of $7.4 million, nor all the other odds and ends categories.

No, by far the primary annual revenue engine for the AMA is … royalties.

In 2018, the American Medical Association made $158.6 million in 100% gross margin revenues by licensing its name and logo and membership lists to everyone from its own insurance brokerage subsidiary – the AMA Insurance Agency – to every pharma co or medical device co or whatever co that was willing to pay for that stamp of approval and halo of authority.

That’s how the AMA makes its money. Not so much by selling TO you – the doctors of America – with membership dues and overpriced PPE and merch, but by selling YOU – the doctors of America – to anyone who wants to buy your name and your reputation.

Okay, okay, but I’m sure it’s all for a good cause! Tell me about all the outreach programs and charitable grants that the AMA administers, Ben!

Yeah, well, about that …

In 2018, the AMA made $4.9 million in grants to 82 separate 501(c)(3) organizations. Almost all were quite small and for specific programs, except for a $1.8 million grant for “general support” to the PCPI Foundation, a Chicago-based medical consortium that is very closely linked to the – golly, can this be right – Chicago-based AMA. So really it was $3.1 million to 81 recipients, and yes, you can do that math as easily as I can: in 2018, the AMA handed out less than 1% of its revenues in grants and awards to independent medical charities and research programs.

The AMA spent more money on office equipment ($3.9 million) than on grants and awards. The AMA spent as much money on market research and telemarketing sales ($3.0 million) than on grants and awards. The AMA spent twice as much on advertising and promotion ($6.1 million) than on grants and awards. The AMA spent more than twice as much on membership solicitation ($7.8 million) than on grants and awards.

Of course you see where this is going.

In 2018, the American Medical Association spent $168.7 million on employee salaries and benefits.

The AMA had twenty-four Trustees in 2018, each paid an annual stipend ranging from $70,000 to $290,000. Four former Trustees, who had no apparent ongoing connection with the AMA, still collected $10,000 to $25,000 that year.

The AMA has five Senior Vice Presidents paid between $880,000 and $1,050,000 in 2018.

The AMA has a Chief Strategy Officer who was paid $1,130,000 in 2018.

The AMA has a Chief Operating Officer who was paid $1,350,000 in 2018.

The AMA has a Chief Financial Officer who was paid … huh? … only $730,000 in 2018. Wow, that’s weird. I mean, she’s the only woman in the C-suite, but I’m sure that has nothing to do with it. I think we all know that being a CFO is nowhere near as rigorous or demanding a job as being a ((checks notes)) Chief Strategy Officer, especially one who was the CEO’s best bud when they were both working at the University of Chicago Medical Center, a best bud who replaced the CEO and made sure he got his $2.7 million severance payment when the CEO was forced to resign.

Which brings us to Jim.

That’s Jim Madara, American Medical Association CEO and EVP since 2011, shaking his finger at us in a 2019 speech and telling us that the core challenge for the medical profession in general and the AMA in particular will be finding ways to address health inequity – the disparate healthcare outcomes for Americans stemming from food and housing insecurity, limited access to transportation, and above all, income inequality.

Jim announced that the AMA would be taking a “leadership role” in this important cause by acting on the AMA Health Equity Task Force recommendations to hire senior executives and staff to build out the AMA Center for Health Equity, a think tank that would be charged with making further programmatic recommendations to advance the AMA’s … leadership role.

To be sure, Jim’s bold vision for addressing health equity issues might surprise some, given that he was forced to resign from his prior position as CEO of the University of Chicago’s Medical Center over accusations of systematically redirecting low-income or uninsured patients to nearby hospitals and clinics for treatment, to the point where 190 U of C Med Center docs signed a letter to Trustees protesting Madara’s policy.

Speaking of income inequality, Jim Madara was paid $2.3 million in cash compensation by the AMA in 2018. That does not include deferred compensation, pension contributions and other benefits, which is reported at another $200k. Nor does it include his compensation from all of his other advisory side gigs, like the Aspen Leadership Group or the Chicago-based healthcare incubator Matter. But that’s not the big play for Jim.

In 2016, the AMA funded the creation of a private “tech accelerator” in Silicon Valley – Health2047 – with an initial $15 million investment, plus a follow-on $27 million investment in 2018. Did I mention that the AMA has an investment portfolio of $642 million in publicly traded securities and $111 million in private securities?

Health2047’s chairman of the board is – you guessed it – Jim Madara, and he hired his friend and self-described protege, Doug Given, as the company’s CEO. Health2047 has funded and “accelerated” four portfolio companies today, including Akiri (building healthcare data networks “on the blockchain”) and First Mile Care (described by Jim as “uber but for diabetes”). But this is only part of the big play for Jim.

A tech accelerator can make good money, sure, but it’s not nearly as lucrative as being the general partner in a private investment fund where you can charge a management fee and take a 20% carried interest in any realizations. So in 2018, Doug Given stepped down as CEO of Health2047 (don’t worry, he’s still on the board with Jim) so that he and Jim could start Health2047 Capital Partners, a good old-fashioned venture capital fund. Doug is the Managing Member of the General Partner for Health2047 Capital Partners, and Jim is chairman of the board.

SEC filings show that Health2047 Capital Partners recently closed on a $47 million investment as part of their $250 million initial fund. There are no public disclosures for investments in a private fund, but if I were a betting man – and I am – I would wager a substantial sum that the limited partner making that $47 million investment is the AMA. Hey, maybe I’m wrong. If Doug or Jim want to give me a shout and make a credible representation that the American Medical Association isn’t an LP in this venture fund where Jim is affiliated with the GP … I’ll be happy to post their denial statement directly in this note. LOL.

You know, I feel like I’ve been around the block a few times. I feel like I’ve seen more than just garden variety self-dealing and chicanery in my years around Wall Street. I feel like I’ve seen more than my fair share of corporate perversions of narrative and the tax code alike, more than my fair share of outright corporate betrayals of the public good.

But I’ve never seen anything like this.

The AMA is not a charitable organization.

The AMA is not an educational organization.

The AMA is a tax-exempt hedge fund and licensing corporation.

The American Medical Association is designed from the ground up to enrich its executives.

Publicly, it espouses a doubleplusgood narrative of social justice and health equity. Privately, the only interests it serves are its own bureaucratic imperatives and the self-aggrandizement of its “leaders”.

There is no “fixing” the AMA. There is no “reforming” the AMA. This is … this is an abomination.

Burn. It. The. Fuck. Down.

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  1. Thanks for digging into this Ben. My physician wife paid many years of dues to AMA before we figured out it was just a front for selling insurance, etc. Who knew all this? Not the average AMA member/victim. BTW, she’s been retired for 12 years, but that doesn’t discourage them from continuing to solicit her “membership”.

  2. Avatar for bhunt bhunt says:

    I thought I was immune to being shocked by corporate mendacity and greed. Then I started digging into the AMA …

  3. Great research Ben! Too bad, as usual, this will fall on dear ears. Our fine representatives at the federal and state level are too busy focusing on their own survival (and probably getting a few handouts from our friends at the AMA) to do more than perhaps shake an angry stick at the issue for a quick second. Gotta love it! The American Dream come true!**

    **if you’re lucky enough to catch on as a CEO at a non-profit or large publicly traded company.

  4. Ben, when I started working with healthcare IT companies 20 years ago, the real shocker was learning that the AMA owns the CPT billing codes and generates significant revenue from licensing them. The AMA is happy to complain about insurance companies claims practices but they’re just as much part of the problem. Best book I’ve read to understand the misalignment among the AMA, physician expectations and medical economics is The Social Transformation of American Medicine by Paul Starr. Docs helped build our beast of a system and the AMA is one of many manifestations of its problems.

  5. I would be very interested to see the fee structure (and frankly the annualized return) of that venture fund. I’d also be interested in their public security ownership and how they’ve managed to make under 2% in dividends (equivalent to a 2yr Treasury in 2018).

  6. …and the scales fell from his eyes…geez! Thank you for the enlightenment. This just pisses me off! I feel compelled to tell every doctor I know to beware of the AMA. I know I’m making a big leap when I say that this just another (albeit in the medical field) example of how so many organizations, companies, brands, government agencies (yes, I said it),etc. in this country in particular have been hollowed out to fit the “insiders” in to either drain it of life or fashion a cloak of invisibility over it while the rest of us live with our fond impressions of what it was, what it meant to us and to others and patronize them in ignorance. You just fed the skeptic in me and I’m still hungry. Thank you!

  7. Avatar for mckett mckett says:

    thinking just how many professional associations there are, it is comforting to know that this is such a rare outlier…as a charter holder of a certain 501(c)3 with 400M revenues I can rest easy, knowing I would find nothing of the kind if I examined their financials…

  8. Avatar for rguinn rguinn says:

    Pop over to the note thread in the new forums, where we beat on, boats against the current, etc. to uncover any other possible such organizations…but like you, I’m sure we’ve exhausted them. :slight_smile:

  9. American Medical Association is treated as a Business League under 501(c) (6) and not all donations are tax-deductible. AMA Foundation is a 501(c)(3) and gets 1 star rating from Charity Navigator. Link to their 990 55% of spending is on Administrative and Fundraising expenses. 4.43 spent to raise $1 AARP? Nope; It’s a 501(c)(4) entity. Social Welfare Organization. Most recent 990 here. Nice reporting.

  10. Avatar for bhunt bhunt says:

    Great point.

  11. Geez! You have good reason to be Angry Ben on this one. I have crossed swords with the AMA for over three decades and it is difficult to find virtue in much of what they do.

  12. I’d love to see something like “60 Minutes” interview you and your work on this

  13. Avatar for Greg_S Greg_S says:

    You can learn a lot about a “charitable” organization from those easy to obtain IRS form 990s.

  14. Thank you. The sentence that grabbed me was, “But I’ve never seen anything like this.” Do you keep that sentence in … do you remove it … AMA should shake anyone to the core. I’m sitting at the kitchen table right now angry and sad, capital “A” and “S”. I’m not a historian, but haven’t AMA’s existed since the beginning of time? Do we go through periods of less AMA’s and then more AMA’s? Maybe a topic for a future ET Live and the Forum. Thank you both for all your writings. I think you’ve done this in the past, but have you run all the ET writings through the Narrative Machine?

  15. Avatar for bhunt bhunt says:

    We have a thread running on the Forum covering exactly this, Brian! Would love to get your input.

    On putting ET itself through the Narrative Machine, we usually do this once per year in January.

  16. Sticking to the theme, this is a great article for BITFD because it’s an incredible case study of the behavior the system permits, and by permitting, incentivizes. This one is bad but BITFD becomes the only answer as we begin to realize that if we peel back the layers on ANY legacy institution we will find a spectrum of this same behavior.

  17. The corruption never ends, because it’s non-linear. It’s a Mobius Strip of self-dealing and graft, all signed off on by legislators and the unknowing members.

  18. The self serving avarice of the AMA is reprehensible and these revelations provoke a negative visceral response. But in another sense the other side of the discussion is the cult of self-serving doctors who belong to, promote, and try to coerce membership in the organization. To be sure they represent the right wing (not conservative but parochial and populist wing) of physicians who like to gather in conclaves to support their petulant positions. When I entered the medical field this organization promoted specialists to the detriment of primary care physicians and the liaison with Congress and government agencies was alarming enough that I quickly chose to leave (as I did other stodgy medical associations though not as egregious). My experience with young doctors today encourages me that their social allegiance does not support membership in the AMA which on my last google search reveals only 15% of US doctors belong to the AMA. At the least the term “medical” should be deleted from its name.

  19. There is a notable connection between Milton Friedman and the AMA that may complement Ben’s point.
    Friedman wrote his PhD dissertation in Columbia in the mid-1930s. However, his dissertation was so controversial that Columbia refused to grant him a PhD. He left academia and joined the federal government as a statistician. During WWII, one of his contributions was the invention of a statistical technique known as sequential sampling. It revolutionized how factories measured the quality of the output from their production lines, and significantly increased the rate at which factories were able to produce armaments. I think it’s fair to say this innovation had a real impact on the outcome of the war.
    After the war, Friedman was a hero within the statistics and economic professions, and Columbia decided it could no longer deny him a PhD. He received his degree, and went on with his academic career.

    Regarding Columbia’s initial decision, what could be so controversial as to cause it to deny him a PhD in the first place? Friedman’s dissertation argued the AMA was a rent-seeking institution that did not serve he public interest, and he suggested social welfare would materially increase if it was abolished.
    A key difference between Friedman’s and Ben’s observations is that the AMA was once a rent-seeker on behalf of doctors, generally. Now it’s a rent-seeker on behalf of its management. Regardless, this time around, let’s hope no one has to invent statistical techniques that help win wars in order for this argument to be taken seriously.

  20. Thanks for another great article, Ben! At first I thought the title meant “Ask Me Anything…”. I am not in the medical field so I never really paid any attention to this AMA. After reading this, I went to Wikipedia:
    I wonder if updating Wikipedia with well researched information will at least give a little push in the right direction?

  21. Avatar for bhunt bhunt says:

    I knew that Friedman was an outspoken critic of the AMA, but didn’t know the dissertation connection. That’s a GREAT story! Thank you, Mike.

  22. Avatar for bhunt bhunt says:

    I thought about a title of “BITFD the AMA. AMA.” but figured it was too cute! I have an aversion to using Wikipedia for highly pointed criticism (which mine surely is), but I dunno. The AMA is truly an abomination.

  23. The only thing the state and federal representatives are going to say “wow what a great construct, how can we do that and get away with it”?

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