Monday, July 27, 2009

Balance is the Key to Life (Part II): Politics vs Policy

elephant-balance One of the only specific tenets of health reform that the White House has put its weight behind is an Independent Medicare Advisory Council (IMAC), which is basically the existing “MedPAC on steroids.”

The Medicare Payment Advisory Commission (MedPAC) is an independent advisory body to the U.S. Congress whose thoughtful reports are widely read in policy circles yet summarily ignored by Congress. The basic thinking with this proposal is to model the new IMAC after numerous successful independent commissions that oversee state Medicaid programs and the successful Base Realignment and Closure Commission (BRAC).


Like the BRAC, this new entity would be staffed by knowledgeable nonpartisan experts and would make a set of recommendations to the U.S. Congress that it could either approve or disapprove in their entirety…this way, individual members of Congress could not stand in the way of larger, needed reform efforts. Last Saturday, the Congressional Budget Office (CBO) issued an initial score on the IMAC proposal and confused the policy world by attaching an initial score of a paltry $2B in savings while stating that it really did not know how the IMAC would affect future finances. Additionally, Merrill Goozner at the GoozNews blog points out that the CBO has some concern that the new entity could be dominated by providers. For more discussion on the IMAC, Ezra Klein has two nice posts here and here.

The BRAC has been very successful at taking the unnecessary politics out of difficult equations and MedPAC is universally accepted as an “earnest arbiter” when it comes to Medicare policy - but when one reads the comments submitted after any article on MedPAC, the responses usually go like this:

Just say no to Congress delegating its authority to a bunch of unaccountable and unelected bureaucrats!!!

Truth is, it does not matter whether one is elected or not…bureaucrats (e.g. CMS’ handling of the DME competitive bidding) and members of Congress alike make numerous mistakes on health care policy (e.g. also see DME competitive bidding). For those that think elected representatives are the only ones that can make thoughtful decisions on health policy, I submit as Exhibit 1, Gary Elkins, an eight-term member of the Texas House of Representatives and member of the Health and Human Services Committee. In a committee meeting on 03/24/2009, Rep. Elkins stated,

What's Medicaid? I know I hear it ... I really don't know what it is. I know that's a big shock to everyone in the audience, Okay?

For Exhibit 2, I submit the recent Wall Street Journal article on OMB Director Peter Orszag:

The battle heated up in June, when Mr. Orszag visited Capitol Hill to discuss health care with a small group of House Democrats. The meeting started well, with one lawmaker after another echoing his message that spending controls were critical to any health-care overhaul, according to two administration officials.

Then one member said her top priority was winning higher payments for oxygen suppliers, the officials say. Mr. Orszag was taken aback. Officials had been trying for years to cut payments to suppliers of oxygen and other medical equipment, which critics say are inflated. Yet when a new competitive bidding process was set to take effect last year, industry supporters in Congress were able to delay the plan. They are still fighting to block changes.

"One of the reasons we currently have such disjointed and skewed incentives is that we have an excessively political process," Mr. Orszag said in an interview.

princelogoFor my last exhibit, I submit the Agency formerly known as the Agency for Health Care Policy and Research (AHCPR). In the 1990s, AHCPR was trying to evaluate the evidence behind various medical procedures and summarize this evidence in recommended “practice guidelines” to assist clinical decision-making. The Agency made the mistake of taking on one of the most overutilized services in all of health care…surgery for lower back pain. After its independent panel concluded that there was little evidence to support surgery as a first-line treatment and rather, nonsurgical options should be tried first, back surgeons were enraged and went to the new Speaker of the House, Newt Gingrich. Shannon Brownlee summarizes the history in the Washington Monthly:

Their arguments found a sympathetic ear in Newt Gingrich's newly elected Republican majority in the House. The back surgeons' anger at the AHCPR's efforts to discipline medical practice resonated with the Republican fervor for reducing government, and with the party's ideological antipathy for federal interference in what they imagined as a free market. The agency's name soon appeared on a House Budget Committee "hit list" of 140 federal programs targeted for elimination. (The list also included the congressional Office of Technology Assessment, which evaluated the effectiveness of medical technology.) The Republicans saw the AHCPR as a wasteful government agency, and in 1995 the House voted to eliminate its funding, calling it the "Agency for High Cost Publications and Research."

Eventually, the agency was rescued with the help of a handful of Republican supporters in the Senate, but it suffered a 21 percent cut of its already meager $159 million budget. Sensing the agency was still vulnerable, its director worked with moderate Senate Republicans to protect the agency by downshifting its mission. Now, the AHCPR would merely be a "clearinghouse" for data, which meant it could no longer offer Medicare explicit guidance when it came time to determine which tests, treatments, and procedures to cover. The word "policy," which smacked of the failed Clinton health care plan, was expunged from its name, and the AHCPR became the Agency for Healthcare Research and Quality (AHRQ).

As far as “bureaucrats” go, after experience in both the private and government sectors, I have learned that the 80-20 rule applies in government just like everywhere else in that eighty percent of government employees are professional and committed to improving care. The problem with government decision-making is just like health care at large…the system is way too complex and encourages short-sighted, silo-oriented, political decisions as opposed to thoughtful, broad-based, long-term investments in care. For reference, Health Affairs has recently published two enlightening interviews (here and here) with former Administrators of the Centers for Medicare & Medicaid Services (CMS).

In order to make the difficult, yet necessary changes to improve Medicare and Medicaid, we do need to take some of the politics out of the equation. But we also should not give CMS or other government agencies a “blank check.” Both of these branches of government often mean well but do not always do well.

Some sort of IMAC may provide the balance we need to make better Federal policy but as they say, the devil is in the details. Merrill Goozner over at GoozNews blog, sums up by stating: “If a MedPAC on steroids makes it into the final bill, it will be interesting to see how much money Congress gives the newly empowered agency, not just how much power. It's going to have to become a lot bigger with more expertise than it has now if it is going to do a credible job.”

ultimate-geeks-multi-tool-hammer The IMAC can provide a valuable tool to help improve our health system work but only if it is independent, thoughtful, funded, and supported. It should focus more on aligning current Federal policy with high quality, low cost care and reducing barriers to innovation and teamwork than it does on recommending new policies that often increase the complexity of health care administration. Additionally, it should be given primacy over both Medicare and Medicaid matters and it should meld existing resources and functions as opposed to just adding another layer of bureaucracy and more government.

After all is said and done, this proposal is one of the few under consideration that may actually bend the cost curve and lead to a more simple and sustainable Medicare program. But as usual, it will take some sacrifice, commitment, faith, and a good dose of leadership to make it work. ~BAA