Eyeworld

EW NEWS & OPINION 15 O n March 23, 2010, Presi- dent Obama signed the healthcare reform bill, the Patient Protection and Affordable Care Act (PPACA), into law. Congress passed a package of changes to the healthcare reform bill under a process known as "reconciliation" that was then signed by the President on March 30, 2010. ASCRS opposed the final legislation, which was based on the Senate bill, for a myriad of reasons, but one of the major issues was the inclusion of a provision that estab- lishes the Independent Payment Advisory Board (IPAB). Specifically, the provision cre- ates an independent, 15-member Medicare Advisory Board (or as we like to call it—MedPAC on steroids) tasked with presenting Congress with comprehensive proposals to re- duce excess cost growth and im- prove quality of care for Medicare beneficiaries. In years when Medicare costs are projected to be unsustainable, the Board's proposals will take effect unless Congress passes an alternative provision on a fast-track basis. As everyone is aware, under current law, the sustainable growth rate (SGR) formula will re- quire physician payment rates to be reduced by more than 40% over the next decade. Yet IPAB could make cuts on top of those already set to take place. The Board is prohibited from making proposals that ration care, raise taxes or Part B premiums, or change Medicare benefits, eligibil- ity, or cost-sharing standards. ASCRS, along with the Alliance of Specialty Medicine, national med- ical specialty organizations, and con- sumer and patient groups such as the National Committee to Preserve Social Security and Medicare, adamantly opposed the establish- ment of IPAB and urged that it be excluded from the final healthcare reform legislation. It is important to note that the provision was included in the Senate-passed healthcare re- form bill, but not the original House-passed bill. In fact, many members of the House Democratic leadership were opposed to the pro- vision and remain so today. In early January 2010, 75 members of the House of Representatives sent a let- ter to Speaker Nancy Pelosi (D-CA) expressing their opposition to the provision. Congressman Pete Stark (D- CA)—who before the elections was the chairman of the Ways and Means Health Subcommittee—was and still is opposed to the creation of IPAB. He stated the following: "… IPAB is a dangerous provi- sion. By statute, this Commission would be required to hold Medicare spending to an arbitrary and unreal- istic growth rate. It is a mindless rate-cutting machine that sets the program up for unsustainable cuts. That will endanger the health of American's seniors and people with disabilities. It is an unprecedented abrogation of Congressional author- ity to an unelected, unaccountable body of so-called experts. I intend to work tirelessly to mitigate the dam- age that will be caused by IPAB." The creation of IPAB is an inap- propriate delegation of Congress's oversight responsibilities to an arbi- trary board. IPAB undermines Congress's role in providing trans- parency and fairness when making determinations regarding Medicare payments. Medicare payment policy requires a broad, thorough analysis of providers and beneficiaries, and leaving these decisions in the hands of an unelected, unaccountable gov- ernment body with minimal con- gressional oversight will have a negative impact on both providers and beneficiaries. Already Medicare reimbursement rates are well below market rates, and it will likely get worse. The IPAB solution will further ratchet down the costs, without oversight, without care taken to en- sure that Medicare beneficiaries re- ceive the quality healthcare that they need and deserve. Further, the construct of the Board seems to selectively exempt certain providers from its purview— such as hospitals—placing more pressure to cut Medicare in those areas under its jurisdiction. ASCRS does not support allow- ing important healthcare decisions to be made with little clinical expert- ise, resources, or the oversight re- quired to ensure that seniors are not by Nancey McCann ASCRS Director of Government Relations The Independent Payment Advisory Board (IPAB): A dangerous and powerful entity May 2011 Specialty Doctors Criticize President's Proposal on IPAB; More Cuts to Doctors Will Hurt Access for Seniors APRIL 13, 2011 Washington, DC – Today the Alliance of Specialty Medicine offered words of caution for President Obama after the unveiling of his new deficit reduction proposal included plans for an expansion of the Medicare Independent Pay- ment Advisory Board, or IPAB. "The President's proposal to expand IPAB only furthers the largest prob- lem facing Medicare patients, and that is access to physicians," said Alex Valadka, a neurosurgeon from Austin, Texas, and spokesperson for the Al- liance. "Doctors cannot continue to ably treat Medicare patients if they are constantly wondering whether or not the money will be there to reimburse them." As part of the healthcare reform law, the IPAB is responsible for making recommendations on Medicare payment policies. When Medicare growth ex- ceeds the given target, then the IPAB must put forth a proposal to reduce Medicare spending without causing a reduction in patient benefits. This effec- tively means IPAB's focus will be on reductions to physician reimbursements. The IPAB proposal is then sent to Congress under unprecedented fast track procedures, where it would automatically become law unless the Senate blocked it by a 60-vote super-majority. The President's proposal today purports to "strengthen" IPAB through various tools and mechanisms including reducing Medicare's target growth by GDP per capita plus 0.5% as well as giving IPAB the ability to automati- cally sequester Medicare spending. The proposal released today also did not speak to the political deals, which occurred during passage of the health re- form bill, exempting hospitals, hospices and various other Medicare providers from IPAB's reach. If these carve-outs are left unaddressed, that means the entities respon- sible for two-thirds of Medicare spending are exempt from payment cuts until 2019. The end result of this will mean a further reduction in the already below market reimbursement rates for physicians who treat Medicare and Tricare patients and make up less than 10 percent of total Medicare expenditures. The Bipartisan Deficit Commission's report, released last December, called for an end to these carve-outs. In addition to the belief that the IPAB cuts will focus disproportionately on physician reimbursements, the Alliance also has reservations about the cur- rent construction of the IPAB, which lacks the expertise of a single practicing physician, or the same level of accountability offered by Congressional ac- tion. The Alliance believes such sweeping and important changes in the health care delivery system need to be enacted by an affirmative vote of Congress. "If the President and Congress want to address Medicare spending seri- ously, then they should get in the game and work with the entire physician community to do so," said Valadka. "The IPAB will direct billions in Medicare cuts and Congress will let those cuts become law by default. I don't think that fits anyone's definition of accountability." continued on page 16 Chief medical editor's corner For physicians, IPAB is the latest and most distressing four-letter word. Throughout the healthcare reform debate, ASCRS strongly op- posed proposals to create IPAB, which would be disastrous for physician Medicare reimburse- ment. Creation of IPAB was one of several key reasons that ASCRS op- posed the Senate healthcare reform bill, but supported the House bill (which had no IPAB). Based on the President's recent budget-driven proposal to strengthen IPAB, I asked Nancey McCann, ASCRS director of government relations, to summarize why ASCRS has and continues to fight against this dra- conian concept. David Chang, M.D., EyeWorld chief medical editor

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