Tuesday, December 2, 2025

Senator Escalates Concerns about AMA "Monopoly" (Coding)

On December 2, 2026, Washington Post features a story on Sen. Cassidy's escalating tensions with AMA, regarding coding and the RVU payment system.  The Senator kicks off by asserting that AMA's response to an October 6 letter "was anything but open and transparent."

  • See our October 29 blog on this topic here.
  • See updatess, December 2 at Washington Post,here.
  • See the new 5-page Senate letter to the FDA, dated December 1, here.

AMA Summit on Digital Medicine

The exchanges come as AMA is on the brink of holding a major summit meeting in Chicago, December 8, on the future of new technologies coding and reimbursement, covering digital medicine, digital pathology, and AI.   More here.

CMS Innovative Work-arounds for Digital Reimbursement

And the letters, and that AMA meeting, come just as CMS announces its CMMI "ACCESS" model, under which some new, FDA-approved software-based or software-intensive interventions like remote monitoring will be reimbursed directly by Medicare as part of its new comprehensive approaches to chronic disease management, potentially outside the usual CPT coding channels.  Entry point here.



Summarizing the WaPo  [Chat GPT5]

Sen. Bill Cassidy (R-LA), chair of the Senate health committee, has intensified scrutiny of the American Medical Association (AMA) over its role in setting physician payment rates. Cassidy sent the AMA extensive questions about how it develops and licenses Current Procedural Terminology (CPT) billing codes, the fees it collects for that work, and how its process incorporates diverse stakeholder input. He argued that the coding system has become a “cash cow” generating roughly $500 million annually for the AMA, with licensing fees ultimately contributing to rising health care costs.

Cassidy’s inquiry reflects long-standing bipartisan criticism that the AMA’s influence over reimbursement is opaque and distorts incentives. For more than 30 years, the AMA has helped assign relative values for thousands of medical services, shaping Medicare and commercial payment. Critics argue this structure favors high-cost procedures over primary care and prevention, contributing to physician specialization and worse population health compared with other countries.

The Trump administration, simultaneously, has begun reforming Medicare reimbursement to shift payments away from surgeries and toward chronic disease management, cutting procedural payments by 2.5 percent. Surgeon groups have protested, warning of reduced access and financial harm, while primary care advocates praised the changes as long overdue. Cassidy said he is not coordinating with the administration but sees converging pressure to reconsider the AMA’s outsized role. He has not ruled out subpoenas if the AMA fails to respond by December 15.

Summarizing the New 5-Page Senate Letter

Sen. Bill Cassidy, chair of the Senate HELP Committee, writes to AMA President Bobby Mukkamala to express dissatisfaction with the AMA’s prior response to his earlier inquiry and to reiterate detailed questions about the organization’s financial practices, governance, and control over the Current Procedural Terminology (CPT) system. Cassidy says he seeks to determine whether AMA’s pricing and access framework for CPT delivers optimal outcomes for patients, but argues that current practices appear to “enrich the AMA at the expense of patients,” with revenue being used to advance political goals unrepresentative of most physicians.

The letter requests itemized financial data on revenue derived specifically from CPT sales, licensing, subscriptions, pricing methodology, and cost structure. It also seeks information about AMA’s governance of the CPT Editorial Panel, requirements for membership, the influence of “Interested Parties,” confidentiality rules, acceptance rates for code change applications, and the effects of nondisclosure agreements.

Cassidy demands granular data on user fees, royalty payments, definitions of “users,” pricing for different stakeholders, and software requirements for digital access.

He also asks for disclosures related to AMA’s advocacy, especially around DEI and gender-transition policies, and whether member fees fund advocacy activities. Cassidy sets a December 15 deadline and warns that the committee may use compulsory measures if the AMA does not comply.

Tone & Style?

The letter is formal, adversarial, and prosecutorial in style. It emphasizes transparency, accountability, and financial scrutiny, with a strong insinuation that the AMA is self-interested and politically motivated. Its structure reads like a cross-examination, demanding precise, itemized answers to dozens of sub-questions.

The rhetoric combines policy oversight language (“best outcomes for patients”) with culture-war signaling, particularly in its focus on DEI and gender-transition procedures. The repeated framing of the AMA as both financially self-serving and politically ideological gives the letter a sharply accusatory tone, more investigative than collaborative.

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What are the AMA's main options in responding?  Go short? Go long?  Go orthogonal?  Other?

Here are the main strategic options the AMA has in responding, based on the content, tone, and stakes implicit in Cassidy’s letter. These reflect not just length, but posture, narrative framing, and political calculus.

1. Go Long: Full, granular answers

Approach: Provide detailed, point-by-point responses with data, explanations, governance details, and legal justifications.

Pros

  • Signals transparency and confidence.

  • May preempt subpoenas or hearings.

  • Positions AMA as a cooperative, technically expert actor.

  • Could help shape the narrative around CPT’s value and complexity.

Cons

  • Risks exposing data that could be weaponized politically, by the press, or by CMS.

  • May open follow-up rounds of scrutiny and requests.

  • Could invite unintended consequences (e.g., rate-setting reforms, antitrust arguments).

Best use-case: If AMA believes it can win on facts, technical opacity, and complexity.

2. Go Short: Minimal, compliant, formal answers

Approach: Provide tightly phrased responses that formally answer questions but avoid elaboration.

Pros

  • Limits disclosure risk.

  • Reduces material that can be used against the AMA.

  • Creates less “thread to pull.”

Cons

  • Risks being deemed evasive.

  • Increases probability of Cassidy escalating (hearings, subpoena).

  • May allow opponents to fill in narrative gaps with negative assumptions.

Best use-case: If AMA believes Cassidy’s campaign is politically motivated but unlikely to sustain long-term momentum.

3. Go Orthogonal: Reframe the issue

Approach: Shift narrative away from AMA finances toward patient outcomes, federal mandates, and complexity of standard-setting.

Tactics

  • Emphasize CPT as a public good.

  • Frame licensing fees as cost-recovery for mandated work.

  • Highlight alignment with Congress’s original statutory intent.

  • Argue stability, interoperability, cybersecurity, and safety concerns.

Pros

  • Moves debate away from AMA profit and culture-war attacks.

  • Repositions AMA as a steward of a national infrastructure rather than a monopoly business.

  • Potentially resonates with bipartisan technocrats.

Cons

  • Might look like deflection if questions aren’t directly answered.

  • Risks further probing into underlying finances.

Best use-case: If AMA prefers political narrative management over technical rebuttal.

4. Go Aggressive: Counter-criticize

Approach: Push back on premise of letter and defend CPT system against political interference.

Tactics

  • Cite Congress’s delegation of authority.

  • Emphasize international consensus.

  • Argue GOP actions threaten coding stability and provider reimbursement.

Pros

  • Energizes supporters, especially specialties.

  • Potentially frames Cassidy as politicizing technical processes.

Cons

  • Very risky.

  • Could provoke hearings, subpoenas, or White House alignment with Cassidy.

Best use-case: If AMA believes political environment favors open confrontation (unlikely now).

5. Hybrid: Tactical long response on some points + strategic vagueness on others

Approach: Overanswer procedural/technical questions; underanswer political/advocacy questions.

Logic

  • Exploit technical complexity to bury critics in detail.

  • Provide less ammunition on sensitive areas (pricing, DEI).

Pros

  • Balances cooperation and risk management.

  • Creates "appearance of transparency" while reducing exposure.

  • Harder to criticize publicly.

Cons

  • Time-consuming.

  • Requires careful legal review.

Best use-case: If AMA wants to neutralize Cassidy without losing control of narrative.

6. Procedural Defense: Argue inability to disclose

Approach: Explain that confidentiality, contracts, or legal agreements limit disclosure.

Pros

  • Legitimate legal shield.

  • Justifies limited transparency.

Cons

  • Plays into accusations of opacity.

  • Might trigger calls for statutory reforms.

Best use-case: If AMA fears disclosures could materially damage business.

7. Delay & Defer

Approach: Request more time due to complexity, committee schedules, holidays, etc.

Pros

  • Buys time to strategize.

  • May reduce political urgency after news cycle moves on.

Cons

  • Cassidy explicitly signaled impatience.

  • Could escalate his response.

Best use-case: If AMA expects presidential or CMS actions to eclipse the issue soon.

8. Early Outreach & Backchannel Diplomacy

Approach: Engage committee staff privately to negotiate data scope and tone.

Pros

  • Deescalates without public disclosure.

  • Allows AMA to frame issues in context.

  • Could head off subpoenas.

Cons

  • May be seen as insider dealing.

  • Requires trust-building.

Best use-case: If AMA believes Cassidy’s goal is leverage rather than transparency.

High-Level Strategic Choice

AMA must choose between:

  • Legal defensiveness

  • Narrative offensiveness

  • Technical obfuscation

  • Political accommodation

Each path has different risk/benefit dynamics depending on AMA’s goals.

Likely Best-in-Class Strategy

The most rational option is a Hybrid + Orthogonal response:

  • Provide exhaustive details on procedural and technical governance (bury enemy in complexity)

  • Offer partial, carefully crafted financial data framed as cost recovery

  • Reframe CPT as a public infrastructure essential to healthcare interoperability

  • Downplay (not debate) ideological policy aspects

  • Signal openness to collaboration on modernization

This:

  1. Reduces Cassidy’s ability to claim obstruction

  2. Satisfies procedural legitimacy

  3. Prevents a political spectacle

  4. Protects revenue streams

  5. Avoids cultural flashpoints

One-Sentence Bottom Line

The AMA’s best move is to appear maximally transparent on technical matters while strategically minimizing exposure on financial and political issues—essentially, “cooperate loudly, disclose selectively.”

If you'd like, I can outline how Cassidy is likely to react to each strategy, or draft a hypothetical AMA response based on one of these options


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How could the December 1 letter have been written to be more effective or compelling?

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Below is a structured assessment of how Senator Cassidy’s December 1 letter could have been written to be more effective and impactful, given his apparent goals, political environment, and rhetorical style. The suggestions assume knowledge of his stated complaints and aims in both letters (Oct 6 and Dec 1).

1. Clarify Objectives Up Front (Mission > Accusation)

The December 1 letter begins with disappointment in the AMA response and reiteration of fears that AMA “enriches itself at the expense of patients,” but it does not clearly state what Cassidy hopes to achieve policy-wise.

A more effective letter would open with:

  • A clear statement of public and legislative purpose (oversight, competition, transparency, pricing reform)

  • Outcome goals, not just grievances

This frames the inquiry as part of a legitimate, proactive policy agenda, rather than a punitive demand for paperwork.

2. Use Strategic Threats, Not Implicit Threats

The December 1 letter relies heavily on implied escalation (“other options”) but does not name any. That may read as weak or unfocused.

To increase impact, he could have explicitly invoked:

  • Subpoena power

  • Hearings with industry witnesses

  • GAO investigation into monopoly pricing

  • FTC referral on monopoly rents

A single sentence like:

“The Committee is prepared to use compulsory process if necessary,”
is more effective and less wordy than a vague statement about “other options.”

Right now, the letter signals irritation rather than leverage.

3. Better Use the Bipartisan Context

Cassidy has bipartisan cover: Warren, Laugesen, general Congressional frustration, and CMS reform.

2025 WAPO 1202 Cassidy Letters …

But the letter does not leverage this coalition.

More impactful framing would:

  • Cite bipartisan concern about CPT monopoly

  • Cite systemic distortions favoring specialties

  • Connect AMA’s “business practices” to health system dysfunction

This would reposition Cassidy as a leader of a cross-party reform moment, not just a lone critic with a partisan axe.

4. Avoid Culture-War Distractions

The December 1 letter introduces DEI and gender transition questions in detail.

Politically, this has obvious partisan appeal.

But tactically:

  • It undercuts the high-minded economic reform argument

  • It gives AMA an easy escape: “this is ideological harassment”

  • It risks diluting the central antitrust/monopoly message

A more impactful letter would:

  • Briefly reference controversial advocacy only as an example of opaque spending

  • Avoid a long list of culture-war interrogatories

By foregrounding these issues, the letter looks less like antitrust reform and more like Right-wing grievance fishing.

5. More Narrative, Less Interrogatory Dump

The letter is dominated by highly detailed, atomized questions, many of which sound like discovery requests.

This is “more legal than legislative.”

It does not build a public story.

A more effective rhetorical design would:

  • Explain why the monopoly matters for patients, physicians, spending, competition

  • Use concrete examples (price of CPT data to a rural clinic, etc.)

  • Show causal pathways from CPT fees to higher premiums, Medicare spend, bankruptcies, etc.

Right now, there is no storyline — only suspicion + data demand.

6. Frame AMA as Derelict in Its Public Duty

Cassidy argues AMA hoards monopoly rents, but does not explicitly say AMA has:

  • Failed in its public stewardship role

  • Betrayed the spirit of the federal delegation

  • Harmed the public interest by exploiting a federal mandate

More effective wording might be:

“Congress delegated a public function to the AMA; you have transformed that delegation into a private revenue stream.”

That frames AMA’s behavior as a violation of trust, not just a business model he dislikes.

7. Name Concrete Policy Outcomes He Is Considering

If Cassidy wants the AMA to take him seriously, he should signal he might pursue:

  • Statutory reform of coding authority

  • Federalization of CPT

  • Mandatory open licensing

  • Price caps or cost-based pricing

  • Sunset of monopoly privileges

Even vague signals would increase leverage because each of these is existential to AMA.

Right now, the AMA can read the letter and say:
“Worst case: we have to answer questions. No imminent threat.”

8. Rhetorical Tone: Too Emotional, Not Strategic Enough

Phrases like “enriching the AMA at the expense of patients” and “not representative of the majority of the medical community” are emotionally satisfying but do not build a credible policy argument.

A more effective tone would be:

  • Cold

  • Institutional

  • Data-driven

  • Focused on system outcomes

Less “AMA is bad,” more “The system you manage is distorting the market.”

9. Political Psychology

AMA is a powerful stakeholder with defensive instincts.

The letter reads like:

  • “You’re guilty, admit it.”

A more effective persuasion architecture might take the form:

  • “We are examining systemic barriers to innovation, access, and cost control, and want AMA in dialogue on constructive reform.”

Carrot + stick > stick only.

Right now, it’s 95% stick, 5% stick-with-a-nice-salutation.

Optional Variants of Tone (Toward AMA)

A. More Threatening

  • Shorter

  • Clinical

  • Explicit about subpoenas and hearings

  • Focused on structural reform, not ideology

B. More Reconciliatory

  • Acknowledge AMA expertise

  • Ask for collaborative reform ideas

  • Position AMA as partner in modernizing payment rather than defendant

C. More Technocratic

  • Cite economic research

  • Cite OECD comparisons

  • Use numbers to show distortions and inequity

This would signal:
“Reform is coming, because evidence demands it,”
not because “I’m mad at AMA.”

10. Overall Diagnosis

The December 1 letter is:

  • Legally aggressive

  • Politically partisan

  • Rhetorically punitive

  • Technically unfocused

  • Strategically weaker than it could be

It is designed to punish the AMA, not to catalyze a credible legislative or regulatory reform agenda.

This makes it:

  • A good media artifact

  • A weaker policy instrument

11. Optimal Strategy for Maximum Impact

If Cassidy’s true goals are:

  • Policy reform

  • Public credibility

  • Bipartisan momentum

  • Corporate accountability

He should have written a letter that:

  1. Narrows scope

  2. Elevates stakes

  3. Clarifies threats

  4. Uses bipartisan framing

  5. Lowers culture-war distractions

  6. Signals policy alternatives

  7. Allows AMA an honorable pathway to cooperation

That would be scarier, more strategic, harder to dismiss, and more likely to mobilize allies.

One-Sentence Summary

Cassidy’s December 1 letter is hard-hitting in tone but weak as a strategic instrument; a more effective version would be less emotional, more bipartisan, clearer on policy goals and consequences, and more structurally threatening rather than ideologically provocative.