• When did the IPAB become so controversial?

    Sometime after May 20, 2009, the day that Rep. Paul Ryan (R-WI) introduced The Patients’ Choice Act (PCA) into the 111th Congress (along with co-sponsors Devin Nunes, and Sens. Tom Coburn and Richard Burr). The PCA proposed changing the tax treatment of private health insurance and providing everyone with a refundable tax credit with which to purchase insurance in exchanges. However, it is less widely understood that the PCA also proposed two governmental bodies to broadly apply cost effectiveness research in order to develop guidelines to govern the practice of, and payment for, medical care. The bodies proposed in the PCA had more teeth, including provisions to allow for penalties for physicians who did not follow the guidelines, than does the Independent Payment Advisory Board (IPAB) that was passed as part of the Affordable Care Act.

    Rep. Ryan did not include such provisions in his budget plan unveiled earlier this Spring, and he has recently been a vocal critic of the IPAB. For example, on May 11, 2011, he tweeted from @RepPaulRyan the following:

    Repeal POTUS rationing board for current seniors, ensure NO CHANGES for those 55+, save Medicare for next generation: and included a link to this video (his comment about repealing the ‘rationing board’ or IPAB is at the 3:58 mark of the video).

    Rep. Ryan has undergone quite a change of heart from May 2009 to May 2011. Don’t take my word for it, lets look at the details of the PCA that he co-sponsored in May, 2009.

    Title VIII of the PCA created two boards: a Health Services Commission, and a Quality Forum. Following are key portions of the bill text with line numbers removed (but the full section is relatively short pp. 205-216, so you can read the entire section for yourself in just a few minutes):

    Purpose, sec. 801 (b), p. 207
    (b) PURPOSE.—The purpose of the Commission is to enhance the quality, appropriateness, and effectiveness of health care services, and access to such services, through the establishment of a broad base of scientific research and through the promotion of improvements in clinical practice and in the organization, financing, and delivery of health care services.Duties, sec. 802 (a), p. 207-08
    (a) IN GENERAL.—In carrying out section 801(b), the Commissioners shall conduct and support research, demonstration projects, evaluations, training, guideline development, and the dissemination of information, on health care services and on systems for the delivery of such services, including activities with respect to—(1) the effectiveness, efficiency, and quality of health care services; (2) the outcomes of health care services and procedures; (3) clinical practice, including primary care and practice-oriented research; (4) health care technologies, facilities, and equipment; (5) health care costs, productivity, and market forces; (6) health promotion and disease prevention; (7) health statistics and epidemiology; and (8) medical liability.

    The Act also proposed, under subtitle B, a sub-unit of the Health Services Commission, a 15 member Forum for Quality and Effectiveness in Health Care.

    Membership, sec. 812, p. 210-11
    (a) IN GENERAL.—The Office of the Forum for Quality and Effectiveness in Health Care shall be composed of 15 individuals nominated by private sector health care organizations and appointed by the Commission and shall include representation from at least the following: (1) Health insurance industry. (2) Health care provider groups. (3) Non-profit organizations. (4) Rural health organizations.

    Duties of the Forum, sec. 813, p. 211-12

    (a) ESTABLISHMENT OF FORUM PROGRAM.—The Commissioners, acting through the Director, shall establish a program to be known as the Forum for Quality and Effectiveness in Health Care. For the purpose of promoting transparency in price, quality, appropriateness, and effectiveness of health care, the Director, using the process set forth in section 814, shall arrange for the development and periodic review and updating of standards of quality, performance measures, and medical review criteria through which health care providers and other appropriate entities may assess or review the provision of healthcare and assure the quality of such care.

    When Boards will bring about guidelines, p. 213

    (e) DATE CERTAIN FOR INITIAL GUIDELINES AND  STANDARDS.—The Commissioners, by not later than January 1, 2012, shall assure the development of an initial set of guidelines, standards, performance measures, and review criteria under subsection (a).

    Enforcement Standards, sec. 814, p. 213-214

    (b) ENFORCEMENT AUTHORITY.—The Commissioners, in consultation with the Secretary of Health and Human Services, have the authority to make recommendations to the Secretary to enforce compliance of health care providers with the guidelines, standards, performance measures, and review criteria adopted under subsection(a). 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 (as defined in section 1128B(f) of the Social Security Act (42 U.S.C.1320a–7b(f))).(2) Imposition of a civil money penalty on such provider. [emphasis mine]

    I think the policy proposed by Rep. Ryan and his co-sponsors was quite good, as I wrote on July 24, 2009.

    The most intriguing aspect of the Act is the creation of a Health Services Commission….A systematic look at the Medicare program (treatment coverage decisions, payment approaches, quality improvement strategies) that was insulated from Congress in a manner similar to the military base-closing commission would be a good first step toward addressing cost inflation in Medicare in a comprehensive and reasoned manner. Lessons learned from Medicare could then be applied more broadly to the health system.

    Any such effort will undoubtedly be called rationing by those wanting to kill it, and quality improvement and cost-effectiveness by those arguing for it. Whatever we call it, we must begin to look at inflation in the health care system generally and in Medicare in particular.

    Obviously Rep. Ryan can change his mind, and seems to have done so. However, going from proposing what could be thought of as IPAB-on-steroids to deriding the general approach as rationing-that-is-harmful is quite a big change. What happened to change Rep. Ryan’s mind?

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