• 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?

    • Hello!

      I have a question that has less to do with Ryan’s crusade against IPAB and more to do with the program in general.

      I think as a cost containment mechanism for whatever government programs our country does decide to offer its citizens, some sort of IPAB makes good sense.

      What I’m worried about, however, is the proposal in the President’s budget whereby IPAB does have teeth, but that the process is not insulated from Congress (Congress must approve recommendations and if it takes no action then the HHS secretary must implement IPAB’s recommendations).

      My concern is that Congress is going to complicate the whole process. Can you imagine Congress micromanaging Medicare every year when growth (inevitably) exceeds the growth target? I cringe at the thought.

      My question to you is — do you think that IPAB in its form under the President’s budget will be effective at containing costs? I am inclined to believe such a board would need to be completely insulated from Congress in order to be effective, but I’m curious to hear your thoughts.

      Many thanks!

      PS. Huge fan of your blog — keep up the great work!

    • It became controversial when Obama and Democrats started pushing for it. Its their fault for politicizing it, and by “politicize” I mean by supporting it in a bipartisan way.

      It’s the same way that Obama politicized education, the individual mandate, and killing Bin Laden.

      Why can’t he stop making Republicans abandon their own policies in favor of scoring cheap political points? It’s truly shameful on his part.

      • Yep, this is what happened.

        Republicans have no policy beliefs. They just really hate Democrats.

        The health insurance mandate was a mainstream Republican policy for decades, supported by Bob Dole, Richard Lugar, Chuck Grassley, Orrin Hatch, Jesse Helms, Trent Lott, etc.

        In August, 2009, Grassley called for health care reform “through an individual mandate,” on the grounds that ”Republicans believe in individual responsibility.” A few months earlier, he told Fox that even though some might view them “as an infringement upon individual freedom,” there wasn’t ”anything wrong” with a health insurance mandate.

        Then Pres. Obama embraced the Republican idea.

        In response, Grassley didn’t say that it was poorly implemented, or that he’d changed his mind… no, he insisted that it violated the Constitution.

        All the GOP candidates are running in fear from anything sane & conservative they’ve ever done (eg, supported cap and trade, or health insurance mandates). There are no Republican leaders, and none in the rank and file, who want to discuss policy ideas. Republican politics is merely the continuation of psychology by other means. If Pres. Obama says something nice about a person or policy, the GOP will then repudiate it vehemently, regardless of what they said yesterday, or for the previous few decades.

        No policy, no philosophy, just tactics and resentment.

    • @Andrew
      I think the IPAB as passed is fairly weak, and needs to be strengthened in a variety of ways to be consequential, including insulation from Congress. The existence of the IPAB means that it could be tweaked and strengthened over time. The IPAB is no panacea, and undertaking the hard work of putting limits on what is paid for/how much is paid by Medicare will be hard and necessarily iterative. Mistakes will be made. It will take both political parties to do the very hard work of slow cost inflation, which I think should include IPAB.

      • I agree with Don on the strengthening of IPAB. I believe that it needs to be given control over Medicare coverage (and eventually over a national health insurance system designed along single-payer or managed competition lines). It should apply comparative effectiveness research and it should do so every year, based on long-term goals, not just one-year fixes when costs exceed targets.

        But, comparative effectiveness has always been politically controversial. Remember what happened to the Agency for Health Care Policy and Research in 1995? Or what about the National Center for Health Care Technology, which was killed in 1981?

        It is more likely that IPAB will have teeth now that it has been created (no easy task in itself), but still improbable.

        Given the history of Medicare policy in Washington, I see no reason to be optimistic (naive?) about the prospect of a bipartisan solution. This is where Don and I disagree.

        Love the blog, keep the debate going.

      • IPAB needs to be strengthened both in an obvious way (not having their scope of action be so limited as to be meaningless) and a less obvious way (eliminating the requirement that it be a full time job for a six year term). MedPAC has been able to engage top notch folks like Joe Newhouse BECAUSE they didn’t have to effectively end their careers to serve. I find it unlikely that anyone willing to serve given the limited authority and the long, full-time time term prohibiting any outside employment is going to be someone I’d want to have in that position.

    • @Richard Hirth
      I agree that the requirement for IPAB members to ‘give up their day job’ and only do IPAB for 6 years limits membership (because of who would be willing to do it) in ways that probably are bad. The two most surprising things to me about the ACA was that IPAB survived and that the tax on high cost insurance remained (though delayed). If we are serious about addressing costs, both will remain and/or be improved. Time will tell.

    • I think the short answer to your question is that Ryan has higher ambitions. I agree that the IPAB should be part of the Medicare solution, though if the Ryan plan passed, it would not be able to do anything.