Wednesday, January 16, 2019

Governance Reform: CMA envisions a new future for organized medicine

By Steven E. Larson, M.D., MPH, Chair of the CMA Governance Technical Advisory Committee


Change is never easy. But oftentimes is it necessary, and even invigorating. The California Medical Association (CMA) is about to embark on a journey of change that will position our association as a nimble, proactive organization ready to lead the practice of medicine into a brave new world. In 2013, the CMA House of Delegates (HOD) approved a plan to reform the way our association is governed. Will it be easy? No. Will it be worth it? There is not a doubt in my mind.


In a nutshell, the reforms will make CMA more relevant and effective by focusing the association on, and bolstering its resources to address, the critical issues of universal importance to physicians. By doing so, CMA will be better able to protect the interests of its physician members and, even more importantly, guide the future of our profession, not only in California but nationwide.


150 Years of Tradition

For 150 plus years, CMA has been guided by the HOD, which meets once a year to set policies and direct resource allocation. This has led to a sometimes unwieldy 581-member HOD, a Board of Trustees numbering more than 50, a seven-member Executive Committee and hundreds of other members serving as alternate delegates and in various capacities on dozens of councils, committees, sections and mode of practice forums.


Over the years, there have been several task forces assigned to this subject. It wasn't until this year, however, that the abstract discussions about "governance reform" began to produce concrete results.


These discussions resulted in big questions. Does the HOD foster a reactive culture rather than a proactive one? Does it inhibit CMA’s ability to take quick action in a rapidly evolving health care environment?


While these questions were being asked, the HOD was spending most of its time on a growing number of resolutions that struggled to be assigned or implemented because of resource limitations.


The CMA Board of Trustees, realizing that a floundering governing style prevented the organization from quickly acting on issues of universal import to the membership and their patients, created a committee—the Governance Technical Advisory Committee (GTAC)—to look at this issue.


The GTAC confirmed what the executive committee had feared —the association was unable to quickly address universal issues that arose faster than the once-a-year HOD meetings could handle. And, there were other inefficiencies in CMA’s governing bodies and processes.


And there was the cost. An independent study commissioned by CMA (an activity-based costing, or “ABC” study) found that CMA governance is far more resource-intensive than previously thought, accounting for almost one-third of CMA’s operating budget—an allocation that commensurately reduces resources available for advocacy and other member services.


The GTAC began its discussion of how to bring relevance, democracy and cost-effectiveness to governing the association. It became clear to us that the rank and file members want more advocacy, while the delegates and trustees are heavily invested in leadership.


Tackling the Big Issues

A proposal to reform CMA's governing structure, put before the 2013 CMA HOD by the GTAC this past October, proposed that instead of a diffuse focus on many issues, the HOD take on a limited number of big issues—the most important, most pressing matters facing physicians and the practice of medicine.


CMA’s long-standing traditions of democratic participation and representative governance would continue; the difference, as envisioned by the GTAC, is that specific issues that are of concern to a narrow spectrum of the membership would no longer command HOD’s limited time. Rather, the democratically elected Board of Trustees would act on those issues, as it already does on the increasing number of matters referred to the board for action by a House that is aware of its policy-making constraints.


The HOD would continue to set policy on major issues, and its decisions would be informed through a year-round process not constrained by 15-minute limits on debate of recommendations developed in a rushed overnight exercise, as is currently the case. More focused expertise would be brought to bear in a more careful development of recommendations for action. Policy on other issues would realize the same benefits of a more careful and expert deliberative process throughout the year.


We would like to improve the discussion at the House of Delegates to deal with the big issues of the day and to utilize the valuable resources of our delegates for the collective development and direction of important policy matters. We believe this proposal has real potential for a robust discussion around issues that will impact all physicians.


The reforms would also open the discussion to individual members who could continue to bring forth their ideas and proposals through a year-round resolution process provided for in the CMA bylaws. Such proposals would be studied, with recommendations acted on by the board.


A year-round dialog about timely issues should result in well-thought out policy pieces that could be brought to the floor during HOD.


Charting a Course for the Next 150 Years

This year’s discussion and debate at HOD on governance reform has set the stage for the GTAC to make proposals to modify the bylaws to begin the changes needed to set CMA’s course for the next 150 years.


I am optimistic that this will result in an improvement for our entire organization. It will make CMA more effective in reaching the average member and give them a direct voice in policy, bringing broader input into our more difficult decisions.



The full report of the CMA Governance Technical Advisory Committee, as amended by the House of Delegates at its October 2013 meeting in Anaheim, is available for download on the California Medical Association website. To access the report, available to members only, visit and click on the "documents" tab. The report begins on page 12 of the "Actions of the 2013 House of Delegates" document.

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