OPINION: making the tough health care calls

Introduction

For decades, the American Medical Association and other health care special interests have pretty much had their way with Congress when it comes to Medicare. Even though the program is run by the Centers for Medicare and Medicaid Services, members of Congress frequently exert their influence over that agency to protect or enhance the fiscal well being of physicians, drug makers and others who help finance their campaigns.

It is because of this meddling by members of Congress that Medicare pays for procedures, medications and medical devices that have not been proven to be cost-effective and in some cases could actually do more harm than good.

This is not a secret. Health policy experts have long contended that one of the key reasons the Medicare program will eventually run out of money is because of the outsized influence lobbyists for health special interests have in Washington.

As the Center for Public Integrity’s Joe Eaton pointed out in an excellent piece last week, one of the reasons CMS has failed to implement cost-cutting measures over the years is the frequent interference from Capitol Hill.

Eaton contrasted what is not happening in Washington, D.C. to improve the solvency of the Medicare program with what is happening in Washington State to reduce unnecessary public spending on health care.

Seven years ago, Washington state lawmakers created a Health Technology Assessment program to evaluate medical procedures and devices paid for by taxpayers to cover state workers, Medicaid recipients and the people receiving benefits through the state’s workers’ compensation program.

Since then, the committee running the program — composed of doctors, nurses and other health professionals — has cut coverage for 21 medical procedures and devices, many of which are still covered by Medicare, and established conditions for covering others. The procedures cut or limited include arthroscopic knee surgery, back pain injections, CT heart scans and lumbar fusion. State officials estimate that the committee has saved taxpayers more than $40 million a year. If Medicare took the same actions, the savings would be in the billions.

What Washington state is doing resembles what many private insurance companies do, including Cigna, where I used to work. Insurers have their own departments that make decisions on whether a new medication, procedure or device is safe and cost-effective. Insurers, for example, do not immediately begin covering a newly FDA-approved drug. They often wait at least a year after FDA approval, during which time they evaluate the drug’s performance.

During the health care reform debate, some members of Congress, Sen. Jay Rockefeller, D-W.Va, in particular, felt something comparable to what Washington state and private insurers have put in place should be established for Medicare. They succeeded in inserting in the Affordable Care Act a provision establishing the Independent Payment Advisory Board. Ever since, other members of Congress — encouraged by the AMA and other special interests — have done their best to try to get rid of the board, which, like in Washington State, would be composed of health care professionals. Lobbyists and members of Congress would not have a seat on the board.

Although the provision establishing IPAB clearly prohibits it from rationing care in any way, that is exactly what opponents have said it would do. It would not, but that is simply an inconvenient truth that those who want to get rid of the board not only ignore but, frankly, lie about.

Consider this. In a Wall Street Journal op-ed last week, former Vermont Gov. Howard Dean, also a former doctor, wrote that the IPAB “is essentially a health-care rationing board.” Not true, wrote former Office of Management and Budget Director Peter Orszag in his own Bloomberg op-ed the next day. Orszag pointed out that the Affordable Care Act “specifically states that the board is not allowed to make any recommendations that would ration care.”

Other critics have even gone so far as to call the IPAB “a death panel,” as did lawyers Elizabeth Foley and David Rivkin Jr., who worked in the Reagan and George H.W. Bush administrations, in a June op-ed in The Wall Street Journal.

Another frequent talking point for critics is that the board would be composed of “unelected and unaccountable government bureaucrats.” As if members of Congress, beholden as they are to lobbyists and the special interests they work for, are somehow more likely to make decisions in the best interests of patients and taxpayers. Yet another talking point is that the board “puts the government right in between you and the decisions made very personally by you and your caregiver,” as Sen. Tom Coburn, R-OK, told reporters last year. It would not do that, either, but it makes for a compelling sound bite.

Despite Dean’s op-ed, support for legislation to kill IPAB seems to be languishing in the Senate, where no Democrats have so far joined the 31 Republican co-sponsors. While a few Democrats have signed on to the House version, it’s not likely to ever make it to President Obama’s desk. Let’s hope it doesn’t. The IPAB is the best hope we have of Washington D.C. following the good lead of Washington state.