Thursday, July 21, 2011

Who is trying to kill Grandma now?

I came across this provocative commentary about why the “death panel” myth lives on, and how it continues to poison debate on changing the status quo. You will recall that the “death panel” charge was originally leveled at a proposed provision in the health reform law that would have reimbursed doctors for end-of-life care, leading to the provision being dropped from the Affordable Care Act (ACA). Now, the charge is being leveled at the Independent Payment Advisory Board (IPAB) authorized by the ACA. Some critics outrageously equate IPAB to the Soviet Union’s politiburo, as if IPAB had gulags in Siberia to enforce its recommendations!

Actually, IPAB is a 15 member advisory committee (not yet appointed) that will propose to Congress ways to reform payment policies to reduce Medicare spending, but only if overall spending exceeds an allowable rate of growth. It is specifically prohibited from “rationing” care or denying benefits the Secretary of Health & Human Services (HHS) would be required to implement the provisions included in the IPAB proposal, unless Congress, under “fast track” rules, passes an alternative proposal with an equivalent amount of budgetary savings or “supersedes” the IPAB recommendations with a supermajority vote of three-fifths of the Senate.

ACP agrees with critics who say that IPAB gives too much authority to an unelected board and too little authority for Congress to reject its recommendations, but those problems could be easily be fixed. In a statement submitted to a congressional hearing on IPAB, ACP had this to say:

“Current discussions within Congress and the healthcare community focus on the dichotomous options of maintaining IPAB as defined in the legislation or repealing it. The College offers an alternative position---one that maintains the provision’s positive elements that both informs Congress on means to effectively control the unsustainable growth of Medicare healthcare expenditures and provides an increased requirement for Congress to address this important issue, but amends the provision to maintain Congress’ authority to control Medicare expenditures and be appropriately accountable to the public.”

Specifically, ACP proposed that Congress be able to over-ride IPAB’s recommendations with a simple majority vote of the House and Senate, instead of a “super-majority” of Senators. This would ensure that IPAB was accountable to the democratic legislative process, while still recognizing the value of having an independent expert board, with sufficient oversight and accountability, being able to propose policies that would be less affected by undue special-interest influence than Congress. (Just look at how poorly Congress has handled the Medicare Sustainable Growth Rate (SGR) . . . or for that matter, the debt ceiling debate! )

I understand that some people—and it isn’t just conservative critics, since some liberal Democrats also are calling for IPAB’s repeal—would say that it can’t (or shouldn’t) be fixed as ACP proposes, that it needs to be repealed in its entirety. And some supporters of IPAB will argue that subjecting its recommendations to a simple majority vote, as ACP proposes, would make it ineffective by making it too easy for Congress to override it. These are reasonable points of view that should be debated. But the debate is not helped by comparing IPAB to a Soviet dictatorship and claiming that it will put seniors to death.

I feel the same about liberals’ claims that Paul Ryan’s Medicare contribution (voucher) proposal will “kill seniors.” ACP is concerned that the voucher proposal would shift too many costs to beneficiaries, especially since the value of the voucher would not keep pace with health care costs. And there are reasons to question the logic that private insurance companies would run the program better and more efficiently than the current government-administered programs, when that has not been the case with the Medicare Advantage program. These too are reasonable issues to be debate, but I don’t think that the issues are illuminated by telling seniors that House Republicans want to kill them.

The problem with hyperbole is that the only way to reduce the federal deficit and debt is to explore ways to reduce Medicare spending without hurting seniors. IPAB or the Ryan voucher plan may not be the best approaches, but if so, critics who really care about seniors –and about the public debt—need to offer constructive alternatives or ways to improve them, as ACP is trying to do. Otherwise, we will be left with an unsustainable status quo.

Today’s question: What do you think about the scare tactics on IPAB and the Ryan voucher plan?


Steve Lucas said...

This will be an uphill battle as everyone from the drug/device companies down to the medical supply companies do not want any changes in the status quo. They have made fortunes working a system with unlimited reimbursement.

As noted, people at both extremes need to look at the system and understand we will not have meaningful cost reduction without some type of outside guidance.

Steve Lucas

American Journal of Medicine said...

We have received several phone calls and e-mails about a pro-healthcare reform editorial we recently published. The people who contacted us-- all physicians-- were up in arms about rationing and death panels.

One caller used "rationing" in practically every sentence when we spoke on the phone. Finally, I ask, "Wouldn't you agree that there is much unnecessary diagnostic testing now?"

He ignored the question and continued spouting soundbites. Sigh.

Steve Lucas said...

I find this type of reaction unfortunate given the ongoing list of questionable therapies and test being employed in American medicine. We can look at this link and the billions spent on an ineffective heart drug Natrecor only to find it will remain on the market:

Or we find this posting that despite the evidence to the contrary we see a call for more mammograms in this post:

Even the general circulation International version of L’EXPRESS headlines issue #3132 with this headline: Les psys Sauveurs ou Imposteurs, even with my poor French the title of the article is obvious.

On a personal note if I were able to move to England I would deal with NICE and could expect to find lower cost and live a longer life.

When you read that many radiologists are not aware of the radiation levels of CT scans. When you are subject to repeated test with no or little value or test are demanded that you do not want, then you are looking for an outside voice to both speak to the relevance of the test and its cost effectiveness.

Medicine has moved from being dysfunctional to being dangerous.

Steve Lucas

ryanjo said...

The issue is not that our present dysfunctional medical system is wasteful and inefficient -- all agree. In my mind, it is the naive assumption that the "reforms" enacted recently will have any positive impact. Most of these measures have never been tested (i.e.: ACOs), and even the few pilot programs of others (PCMH) have been able to show improved patient satisfaction only with large outlays of money and human resources. Hardy the fulfillment of promises that were made. In addition, nothing meaningful and sustainable is being done to address primary care shortages, tort reform, paperwork reduction or physician payment.

All this is not surprising, given our present even more dysfunction system of government, with the pernicious influence of money and the privileged access it enables. Can anyone say that the political leaders in power are the best agents of reform? Many of us feel that the entire system needs to cut ties with Washington, and allow a direct relationship between custom and provider, with direct responsibility as well. This seems to be working in the more functional aspects of our national life that are not poisoned by the influence of government.

The drama of "killing Grandma" in attracting readers to this column is obvious, as are the responses citing statements by more extreme members of the right wing. However, there is an innate dishonesty in setting up a straw-man argument and disposing of the whole opposition as crackpots.