Wednesday, February 29, 2012

Much ado about IPAB

Congressional Republicans and some Democrats have set their sights on eliminating the Independent Payment Advisory Board (IPAB) authorized by the Affordable Care Act.

Today, the House Energy and Commerce Committee voted 17-5 to repeal IPAB, with the support of Frank Pallone (D-NJ), the ranking Democrat on the committee. The House likely will take up and pass the IPAB repeal bill later this year. Prospects for IPAB repeal in the Senate are far less certain, but even if repeal were to pass the Senate, President Obama could veto it. So IPAB likely will remain on the books for now.

Even if IPAB survives, it is unlikely to do much of anything for at least another six years. The members of IPAB won’t even be named by the President until 2014—and they would have to first be confirmed by the Senate (where their nominations likely would be subject to a filibuster by IPAB opponents). Then, assuming the President is able to get IPAB members confirmed, the board will submit recommendations to Congress to reduce costs only if spending exceeds a target rate of growth set by the statute. That likely won’t happen until 2018, at the earliest, according to HHS Secretary Kathleen Sebelius. IPAB’s recommendations would then automatically go into effect unless a “Super Majority” of Congress voted to override it. Even so, IPAB is prohibited from making any recommendations to ration health care, raise revenues or Medicare beneficiary premiums, increase Medicare beneficiary cost sharing, or otherwise restrict benefits or modify eligibility criteria.

(You can learn more about how IPAB is supposed to work in “The Internist's Practical Guide to Health System Reform,” published by ACP’s governmental affairs division.)

So IPAB hardly is a clear and present danger to anyone, if it ever will be.

Yet you wouldn’t know that from the rhetoric being hurled at it—with some calling IPAB a “death panel” or “rationing board.”

And, as Don Taylor explains in the Incidental Economist blog, some prominent Republicans—who today are ardent foes of IPAB—proposed similar unelected cost control boards. The Patients’ Choice Act, introduced in 2009 by Rep. Paul Ryan (R-WI), now chair of the House Budget Committee, would have created an unelected quality commission with authority “to make recommendations to the Secretary to enforce compliance of health care providers with the guidelines, standards, performance measures, and review criteria adopted [by the commission]. Such recommendations may include the following, with respect to a health care provider who is not in compliance with such guidelines, standards, measures, and criteria: (1) Exclusion from participation in Federal health care programs . . . and (2) Imposition of a civil money penalty on such provider.”

The point is that many Republicans and Democrats used to agree that an independent board of health care experts and clinicians could help the country decide on the difficult tradeoffs involved in controlling health care costs, outside of the usual political process where powerful health care industry lobbies can effectively block any legislation that hurts their economic interests.

For its part, ACP “believes that an independent board of physicians and other healthcare experts would be more likely to achieve needed Medicare changes, and be less affected by undue special-interest influence,” than Congress. The College believes that the IPAB has the potential to serve this role, but requires some significant modification—including amending the law to allow Congress to reject IPAB’s recommendations with a simple majority vote.

Maybe a future Congress will be able to demonstrate that it can make tough cost control decisions on its own, even if this means going against the special health care interests that fund the lawmakers’ campaigns. Maybe it doesn’t need an independent group of experts who really understand health care to help it figure out the most effective policies—and provide political cover for the unpopular tradeoffs involved. Maybe…but why in the world would anyone believe that Congress is up to the task?

Today’s questions: Do you think an independent board of health care experts is needed to help Congress make decisions on controlling health care costs? What do you think about the argument that IPAB will lead to rationing and “death panels”?


Arvind said...

The best clinical and economic decisions are made between the patient and his/her physician. there should be no other agency that decides appropriateness of clinical decisions. The ACP leaders should acknowledge this first and foremost.

If you think IPAB is not a clear and present danger, all you need to do speak to a few Medicare beneficiaries to see how they are already being denied care by Medicare's refusal to pay for prescribed medications and investigations, by arbitrary ruling of "not medically necessary". How does any agency (whether filled with experts or not) understand each patient's medical necessity? The fact that the ACP is even entertaining such a preposterous idea shows that it has abdicated its responsibility to promote the physician-patient relationship. What a sorry state of affairs!

ryanjo said...

The position that the ACP leadership takes on these contentious and untried programs continues to astound and disappoint me.

Among national medical organizations, ACP really is alone on supporting the IPAB. "In a letter sent Monday to members of the House Energy and Commerce Committee, the AMA supported a bill that would eliminate the Independent Payment Advisory Board (IPAB)—a serious threat to patients’ access to care...the IPAB is another arbitrary system that could make the same dangerous type of overall cuts (as the SGR)" (AMA Wire, February 29, 2012). The AMA, co-cheerleader with ACP for the PPACA "reforms", appreciates the "loose cannon" potential of an unelected board of experts of the Don Berwick type. Perhaps ACP will prepare another strongly worded letter of concern, after the IPAB convenes in the shadows after bypassing due process with recess appointments by Sibelius & Obama.

"Maybe a future Congress will be able to demonstrate that it can make tough cost control decisions on its own...but why in the world would anyone believe that Congress is up to the task?" Exactly my thought. Which is exactly why ACP should be advocating to remove government from any further toxic involvement in medicine. Instead of standing alone on Mt. Olympus.

Harrison said...

Arvind and Ryanjo seem to suggest that the government should have no role in health care decisions made between a patient and a physician.

Does that include paying for the procedures and referrals and services that come from the decisions?
Is the government supposed to step out completely?
Dissolve Medicare and Medicaid?
Or just write checks for whatever a doctor and a patient decide is medically necessary?

Can we all agree that the Medicare program and Medicaid program have been helpful at some level and that people who otherwise would not have had access to health care have been able to get it?

If we can reach a consensus on that point then I think we can next reach a consensus on the notion that there have to be controls over what is decided and what is paid for.

Then we just have to decide on how to do that.
And with that decision we either have to rely on an independent panel made up of health care providers and policy makers, or we rely on Congress -- with industry lobbyists strongly pushing for the latter.

Is there some other way of looking at this that I'm not seeing?


ryanjo said...

We are receiving the same information, and processing it differently.

Arvind & I are looking at the methods and results of government's mismanagement of the funding of senior and indigent healthcare, and their plans to restructure this for the alleged purpose of improving quality and efficiency (we all know it is only to save money). And at every turn we find blunders, waste, fraud and distorted priorities designed to please big Pharma and other contributors. And we judge the government of being incapable of doing better.

Harrison sees that government has a role in paying for this part of the healthcare system, and feels that this should allow it to set payments and priorities. But this ignores the record of government incompetence in healthcare.

There are government programs that are administered without undue interference in private matters. Millions of retirees pick up Social Security checks every month. Grocery stores, car dealerships, gas stations, movie theaters, restaurants (etc) are not told what to charge retirees, and retirees have many choices. Does anyone think that government price-setting and volume controls on the food industry or auto industry would make access better for consumers?

Oh yes, begin the hand-wringing: Health care is too complex. Consumers will be taken advantage of. Hmm, isn't that their physician's role? Just let me do it. Patients seem very capable of decisions in my experience. And they are not very happy now being treated as idiots by a "nanny government".

Harrison said...

A voucher system?

Maybe Bob could review in a bit more depth the pro's and con's of Paul Ryan's plan.

I trust patient decision making.
I am worried that it doesn't address the problem.
The two problems are health care costs and access.
A voucher system in my mind would help the federal budget but hurt the out of pocket costs from patients.
And therefore I think it would hurt the access problem.

And I don't think it would help the cost problem much at all.
Costs would continue to rise, the difference however would be picked up increasingly by out of pocket costs by patients.


Jay Larson MD said...

I had always hoped that the IPAB would be a way to get around the RVU system set up by the RUC. The RUC is a death panel. Death to general internists and other cognitive based specialists.

ryanjo said...

I am not sure that vouchers are the answer either. The programs proposed so far are not the answer. A complete change of direction is needed.

I am asking that the decisions and responsibility for costs be at least partially borne by the consumer, with their physician being totally committed to the patient, not hobbled by federal or insurance contracts or incentives. What I am seeing every day is gross profiteering by healthcare companies, with little input by patients, who don't have any responsibility for costs incurred. How many free diabetes test strips or meters can I get at sky high Medicare pricing (available online for a fraction of the cost for less fortunate consumers)? "Just give me a 90-day prescription, Doc -- it costs me the same as a week's worth." Pharmacies calling patients to "remind them" that their prescriptions are ready to be picked up, weeks before refills are due. Mail order PBMs charging patients $30 dollar co-pays or requiring preauths for meds costing a few dollars. Oxygen providers making extra visits for "free" oximetry tests (billed to Medicare). Home care nursing firms discovering "skin erosions" and recommending high tech mattresses at budget busting Medicare prices, which sit folded in the corner, since Medicare won't pay for patient teaching.

Would patients tolerate these abuses if they were being cheated in the same way Medicare allows? Would they and their families abuse & threaten doctors for refusing to sanction this fraud if they shared the costs?

PPACA expands the same wasteful boondoggle to more patients, while asking physicians to cover the waste and fraud by "risk sharing" with no real control over costs. Even worse, ACA destroys private practice & forces physicians to work as employees, essentially joining the healthcare Mafia. There are already consulting firms running seminars on gaming Patient Centered Homes & ACOs to maximize profits. And patients & physicians are to be further marginalized as widgets in the assembly line.

PCP said...

Ryanjo makes an excellent critique of the status quo in medicine today.
Politicians are bought and paid for by the very corporate interests referred to therein. I do not expect them to wise up before the eventual bankruptcy of this nation, their political interests are short term and these issues are now perhaps medium term, but even that is too far distant for them, witness the largesse of greek politicians as their countryship was hewded for the iceberg. The depth of the hole they lie in lays bare the extent of the denial. When a haircut of over 50% of the nations debt can't guarantee solvency by the year 2025 barring an economic boom it says quite something. When we as a nation are being asked by our central bankers and politicians to collectively delude ourselves that 0% interest rates are a given and that currency debasement is the right approach to our economic woes created by woeful fiscal policy and out of control entitlement programs, why should a rational person not believe in a greek tragedy in our future?

Even worse is the fact that these programs have fostered a permanent change to an entitlement mindset amongst the public and created an even bigger problem to eventually solve in a democracy.
I am not surprised by corporate interests acting to expand or protect their interests, politicians acting in their short term political interests nor patients behaviour in the face of "freeness".
What astonishes me is the ignorance of our professional leadership to these ground level realities. When some of us speak of ivory towers, it is this indifference we are referring to. As long as we do not advocate for more fundamental change, we will not get anywhere.
The choice to ignore these issues as pressing as they are will not leave the profession, nation or ironically the patients better of in the end. Alas everyone just cares about their interets and now. Pitiful actually.
The dollars spent on healthcare in this country are more than adequate to pay every doctor very fairly and even generously for their time and cognition and skill, if the correct environment is fostered to unleash that potential within each doctor for sensible cost containment. When doctors and patient unite on a common objective of lower costs with quality, and the providers of other goods and services are made to compete in a transparent free market, then and only then will we make a real dent in health care inflation. That will not happen until doctors are released from the rbrvu system and allowed to bill for their time at rates commensurate with their education, risk, skill, effort and overhead and patients get more skin in the game.
Until then this raketeering and profiteering will continue and doctors, patients and eventually the nation will be the ultimate losers.

Steve Lucas said...

Working from memory I believe the ACP's cost containment measures include evidence based treatments that would in some way eliminate ryanjo's excesses.

I do not know a person that has not been sold some piece of over priced unnecessary equipment or treatment.

There was also the announcement last week of a $111B increase in the ACA insurance cost bringing the new total to nearly half a billion dollars.

We need to let doctors practice but we also have to find a viable way to control cost and remove incentives for over treatment.

Steve Lucas

BDoherty said...

Washington Post editorial makes the case for keeping IPAB, and pointing out politicians' hypocrisy for claiming to be concerned about the deficit and debt, but then opposing reforms (including IPAB) to lower costs, Washington Post editorial: keep, strengthen Independent Payment Advisory Board:

marcsf said...

IPAB cannot shift costs or ration care, so in effect, it can only recommend provider cuts. This is not something to help the current miserable state of internal medicine. Too bad provider cuts seem to be the only solution to cutting Medicare. While the Washington Post and New York Times seem to think physicians' salaries are outrageous, in reality if they are cut any more, physicians will not be able to afford the ridiculous charges of MOC. More provider cuts are only likely to continue to decimate the ranks of internists.