Sen. Coburn: for unelected health boards before he was against them

Ezra Klein has an interview with Senator Tom Coburn that focuses on health care reform. Lots could be said about the interview, but I want to focus on what I see as the hypocrisy displayed by Sen. Coburn in his criticism of the Independent Payment Advisory Board (IPAB) that will be created if the Affordable Care Act is implemented. In the interview with Klein, Sen. Coburn says:

The reason I object to IPAB is you’ve got someone between the patient and the physician, and that can never be in the best interest of the patient.

The most shocking thing to me about Sen. Coburn’s consistent demonization of IPAB as a “rationing board”  is the fact that a bill (Patients’ Choice Act) that he co-sponsored and introduced on May 20, 2009 contained two unelected boards (IPAB is also quite weak; another post). That means that key Republicans supported unelected health boards a full month before the first House committee reported out HR3200. I have written tons on this issue specifically, and about Sen. Coburn’s Patients’ Choice Act generally (here, herehere, herehere, here, here, here), including some favorable things. I guess I am just naive, but this level of hypocrisy still shocks me.

Below is a post I wrote in May 2011 that focused on Rep. Paul Ryan, another co-sponsor of the PCA; just insert Sen. Coburn’s name as you read; they have behaved similarly on this issue.

Read more of this post

IPAB repeal effort heating up again

Efforts to repeal the IPAB are heating up again in both the House and Senate (overview from KHN; link to a gated Politico Pro story this morning). I reproduce below a post from last Summer that provides a series of links on the recent history of the idea of boards to improve quality and/or address costs (shorter: boards have experts and they do good things if you appoint them; they are bureaucrats and do bad things if your opponents appoint them).

update: Energy & Commerce health subcommittee voted 17-5 to repeal IPAB (two Democrats joined all Repbulicans in voting for repeal).

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I am pulling together several related posts that I have done suggesting that the Independent Payment Advisory Board (IPAB) is similar to two boards proposed in Title VIII of the Patients’ Choice Act (PCA), the most comprehensive Republican health reform plan offered in the 111th Congress. That doesn’t mean they are exactly the same, but does mean that some of the criticism levelled against IPAB by Republican critics is either uninformed about the advocacy for such boards by leading Republicans in the past, or seems hypocritical to me. It is also possible that Republicans have simply changed their mind, but then I would expect them to say that, and to lay out why they recently supported such boards, but no longer do so.

Both the PCA and the ACA proposed boards that were insulated in some manner from Congress to make health policy decisions. In this way, IPAB is a prime example of a policy idea that ended up in the Affordable Care Act (ACA) that had its genesis in a Republican sponsored bill, or line of policy thought. It is an example of something that appeared to be bipartisan in policy terms (the need for boards insulated from Congress) that became politically toxic once it appeared in the ACA.

Here are the posts I have written on the topic.

  • General argument that IPAB is similar to the boards suggested in the PCA, from May, 2011.
  • Responding to unelected bureaucrats/unconstitutional charges by showing that boards proposed in PCA were similar in structure, Monday July 11.
  • Focus on what IPAB could do in policy terms as compared to what boards in PCA were proposed to be able to do, Tuesday July 12.
  • Reaction from House Budget Committee spokesman to my blogging, and my response, Tuesday July 12.
  • ThinkProgress did a nice table comparing IPAB to boards in the PCA, Wednesday July 13.

Other relevant information.

  • Text of the Patients’ Choice Act, Title VIII p. 206-215 are the portions relevant to this discussion. Introduced on May 20, 2009 and co-sponsored by Ryan and Nunes in House; Burr and Coburn in Senate.
  • Text of the ACA, sec. 3403 p. 982-1,033 lays out the IPAB
  • Kaiser has a comprehensive overview of the IPAB
  • Column I wrote on July 24, 2009 in the Raleigh, N.C. News and Observer on the Patients’ Choice Act

Note: as stated in several posts, there are some Democrats who oppose IPAB as well.

Meme Roundup: IPAB as Similar to Republican-Suggested Boards

I am pulling together several related posts that I have done suggesting that the Independent Payment Advisory Board (IPAB) is similar to two boards proposed in Title VIII of the Patients’ Choice Act (PCA), the most comprehensive Republican health reform plan offered in the 111th Congress. That doesn’t mean they are exactly the same, but does mean that some of the criticism levelled against IPAB by Republican critics is either uninformed about the advocacy for such boards by leading Republicans in the past, or seems hypocritical to me. It is also possible that Republicans have simply changed their mind, but then I would expect them to say that, and to lay out why they recently supported such boards, but no longer do so.

Both the PCA and the ACA proposed boards that were insulated in some manner from Congress to make health policy decisions. In this way, IPAB is a prime example of a policy idea that ended up in the Affordable Care Act (ACA) that had its genesis in a Republican sponsored bill, or line of policy thought. It is an example of something that appeared to be bipartisan in policy terms (the need for boards insulated from Congress) that became politically toxic once it appeared in the ACA.

Here are the posts I have written on the topic.

  • General argument that IPAB is similar to the boards suggested in the PCA, from May, 2011.
  • Responding to unelected bureaucrats/unconstitutional charges by showing that boards proposed in PCA were similar in structure, Monday July 11.
  • Focus on what IPAB could do in policy terms as compared to what boards in PCA were proposed to be able to do, Tuesday July 12.
  • Reaction from House Budget Committee spokesman to my blogging, and my response, Tuesday July 12.
  • ThinkProgress did a nice table comparing IPAB to boards in the PCA, Wednesday July 13.

Other relevant information.

  • Text of the Patients’ Choice Act, Title VIII p. 206-215 are the portions relevant to this discussion. Introduced on May 20, 2009 and co-sponsored by Ryan and Nunes in House; Burr and Coburn in Senate.
  • Text of the ACA, sec. 3403 p. 982-1,033 lays out the IPAB
  • Kaiser has a comprehensive overview of the IPAB
  • Column I wrote on July 24, 2009 in the Raleigh, N.C. News and Observer on the Patients’ Choice Act

Note: as stated in several posts, there are some Democrats who oppose IPAB as well.

 

House Budget Committee Spox Response on IPAB posts

Conor Sweeney, Communications Director of the House Budget Committee that is chaired by Rep. Paul Ryan emailed me the below message (printed verbatim and with his permission) in response to my post last night on the upcoming IPAB hearings. I don’t believe Mr. Sweeney had a chance to see the second post before sending the email based on the timing of the email and the post, but I believe his message to me addresses most of his concerns about what I have written. I appreciate Mr. Sweeney taking the time to contact me. Below his email message I Provide brief responses to his comments.

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Dr. Taylor-

We appreciate your interest in Paul Ryan and his efforts to advance consumer-directed health care reforms. With respect to your concerns:

  • Congressman Paul Ryan believes in providing greater transparency for consumers, not imposing greater control over their lives. The Patients’ Choice Act includes a transparency initiative that empowers beneficiaries to serve as more powerful consumers.  The President’s approach empowers an unconstitutional board to impose price controls, cut provider reimbursements, or make coverage determinations by fiat.
  • The facts about The Patients’ Choice Act’s Health Care Service Commission:
    • No authority to influence Medicare spending;
    • No decision-making authority with respect to provider reimbursements or availability of beneficiary services;
    • Exists solely for the purpose of encouraging transparency and proper metrics with respect to health care services, which will allow consumers to compare on the basis of cost and quality.
  • As Ryan recently argued:“Our plan is to give seniors the power to deny business to inefficient providers. Their plan is to give government the power to deny care to seniors.”
  • For more on The Patients’ Choice Act, please see page 8 of this Section-by-Section document from Senator Coburn’s office: http://coburn.senate.gov/public/index.cfm?a=Files.Serve&File_id=77b590f2-0686-4904-aef8-0866cc47092d

Many thanks,

Conor

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Greater Transparency: I very much like the PCA notion that guidelines and the like be put into language that is understandable. They clearly wanted the information created by the Commission and the Quality Forum (two boards created by the PCA) to be useable by consumers as well as insurers. It is unclear how that would all have worked.

Unconstitutional Board: The PCA creates a 5 member board (who must have this be their full time job) that is nominated by the President and confirmed by the Senate. The 5 member board then creates a 15 member board to carry out the details of guidelines, research and the like. The IPAB is a 15 member board that is nominated by the President and confirmed by the Senate (and IPAB must be their full time job). There is a great deal of similarity. The implication of the boards created in both bills/law is that Congress is unable to do much of the hardest work, and they are turning to experts. How can such a board be unconstitutional when in the ACA but fine when proposed in the PCA?

Price Controls, cut provider reimbursements: IPAB would be required to issue recommendations that would reduce Medicare per capita expenditures if Medicare growth rate targets are not met. This will be done by cutting payments to providers given prohibitions in the ACA against “The proposal shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary costsharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria.” ( Quoting the law (Pub. L. 111-148, § 3403) and what IPAB cannot do.

The worst penalty/impact: I wrote in the previous post that the PCA provisions had more teeth than does the IPAB, and a commenter made a good point that while the ultimate penalty in the PCA as I read it (banning someone from participating in Medicare and Medicaid) is a huge penalty, the IPAB could be expected to have a smaller impact on many more providers through reimbursement cuts. This is a fair point. Another important point is that the PCA was never subjected to a hearing, and certainly wasn’t marked in committee, so it would have been clarified and fleshed out had it been. However, the cosponsors made clear the top penalty that could be imposed by these boards in the PCA was the banning of providers from Medicare and Medicaid and/or a civil penalty (again, as I read it). This would happen if providers didn’t follow the guidelines put forth by the committee created in the PCA. That is quite a penalty imposed by a board in conjunction with the Sec. of HHS.

Our plan: Here he is referring to Rep. Ryan’s Medicare proposal in his budget. I didn’t post on this, and am not going to get into it here.The blog has had lots on it, mostly written by Austin.

Sen. Coburn document: The document linked is a summary of the Patients’ Choice Act. As always, the best thing is for you to read the relevant sections of the Patients’ Choice Act for yourself, p. 206-215 are the key sections. You can read the relevant sections of the actual bill in 5 minutes.

Rationing: Not sure where to start. The word rationing has been rendered devoid of meaning by our political discourse. Not rationing is unlimited supply. This is impossible now, and always will be impossible. It is a matter of how, not if.  Watching the morning hearing on IPAB reaffirmed for me a bipartisan blind spot: reducing costs over what they would be by default (and on a per capita basis) can only occur by providing less care and/or paying less for that same care. You can call it what you want, I call it math. It will be hard as hell, but we have no choice but to try. Both sides assume the best for their favorite policy, and the worst for the other guys. Rationing is what ‘they’ (the other side wants); ‘We’ (our side) wants to improve quality, save money and increase value. The country has got to grow up and face limits. We have no hope of doing so if our leaders simply bicker with and talk past one another as they did in this hearing.

House IPAB Hearings-II

Two House Committees will hold hearings today on IPAB. There is a great deal of hypocrisy in the Republican criticism of IPAB, especially that levied by Rep. Paul Ryan, because he co-sponsored legislation in the 111th Congress (The Patients’ Choice Act) that proposed two boards comprised of what he know calls ‘unelected bureaucrats.’ I posted on this last night.

A second line of criticism levied against the IPAB is the tried and true charge of rationing. This criticism is also hypocritical. My reading of the Patients’ Choice Act, Co-sponsored by Rep. Ryan in May, 2009, shows that the two boards he would have created have more power to ‘ration’ and control the practice of medicine than does the IPAB. Don’t take my word for it, read the relevant section of the bill (pages 205-216). You will hear plenty on IPAB at the hearings…as you do, keep the following in mind.

The 15 member board (Forum for Quality and Effectiveness in Health Care) proposed by Rep. Ryan would:

  • Have the goal of promoting transparency in price, quality, appropriateness, and effectiveness of health care (sec. 813, p. 211-12)
  • Will create guidelines to reach this goal (sec. 813, p. 212)
  • Guidelines must follow standards of research and the best evidence and present findings in an understandable format ( sec 813, p. 212)
  • To develop guidelines, the Director of the Commission can contract with outside, private entities to complete research (sec 813, p. 212)
  • The Board was directed to produce their first guidelines by January 1, 2012
  • The Board was to bring forth recommendations each year, and not only when certain cost inflation targets were not met as with IPAB (sec 814, p. 213-14)
  • The Board has more teeth than the IPAB. Here I will simply reproduce the text of the Patients’ Choice Act, sec. 814(a)(b)(1)-(2) p. (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]

When you listen to the hearings today, think of these facts. Especially in the case of Rep. Ryan, who has put himself forward as a truth teller who is helping our nation address our fiscal woes. He needs to explain how he could propose the use of unelected boards to promulgate guidelines, and grant them the authority to ban providers who don’t follow such guidelines from participating in Medicare and Medicaid and/or impose a civil penalty, and then say what he has said about the IPAB.

It is possible to change ones mind. Rep. Ryan and others may have thoughtful reasons for changing their mind, but they have so far offered no thoughtful discourse on IPAB. And if you do change your mind with a track record like that noted above, I would expect you to say something like “I used to support boards similar in concept to IPAB, that actually had more power to shape the health care system than does IPAB. I no longer do so because”….

Maybe the hearings today will fill in the blank.

House IPAB Hearings

The House will have two hearings (Budget Committee and Commerce Committee) on the Independent Payment Advisory Board (IPAB) July 12 (text of law sec. 3403; and nice overview of IPAB from Kaiser).

I realize that politicians change their position on issues as their political needs and circumstances change, but I have found the degree of animus and rhetoric thrown against the IPAB by Rep. Paul Ryan and many other Republicans* to be shocking because Rep. Ryan (along with Devin Nunes, and Sens. Coburn and Burr) introduced a bill in the last Congress (the Patients’ Choice Act [PCA]) that created two similar boards that actually were to have more power than is granted to IPAB. Here is a comprehensive post I wrote  looking at the IPAB through the lens of what Rep. Ryan previously proposed in terms of unelected boards, including detailed references to Ryan’s PCA with links.

Much of the rhetoric against the IPAB levied by Rep. Ryan (and others) has focused on the narrative that it empowers unelected bureaucrats. The Patients’ Choice Act proposed by Rep. Ryan in the 111th Congress created two boards:

  • Health Services Commission. 5 members appointed by the President and Confirmed by the Senate. The PCA stipulates that these 5 people cannot have another job, but must serve in this role full time. [page 206-210]
  • The Office of the Forum for Quality and Effectiveness in Health Care, a 15 member board appointed by the 5 members of the Commission noted above. [page 210-215]

The IPAB, created in the ACA, creates:

  • 15 member board (IPAB) appointed by the President and confirmed by the Senate, with the 15 members having to serve on a full time basis (cannot have another job). [page 1019-1021]

The Patients’ Choice Act was introduced on May 20, 2009, about 1 month before the first House Committee passed HR3200. The IPAB is an example of an idea initially put forth by Republicans ending up in the ACA. The rhetoric used against IPAB about unelected bureaucrats, especially when made by Rep. Ryan, seems blatantly hypocritical to me given what he and his 3 Republican colleagues had previously co-sponsored in this area. I think Rep. Ryan owes the country an answer as to why he used to be for boards appointed by the President, confirmed by the Senate, and who gave up their job in order to work on important health policy issues for the federal government, while he is now adamantly opposed.

*There are some Democrats opposed to IPAB as well.

Three questions on the road to sustainability

If we ever slow health care cost inflation to a sustainable pace, it will be because we learn how to ask 3 simple questions when thinking about a medical treatment:

  • Does it improve quality of life for the patient?
  • Does it extend the patient’s life?
  • How much does it cost?

Asking the questions are of course much simpler than figuring out the answer, and far far simpler than deciding what to do with the answer.

The first step is not demonizing even the asking of the questions. This would represent a profound shift in our culture, and is needed. We need to grow up and learn how to talk about limits in medicine. Then we will have to learn how to give practical answers to these questions, and the answers will have to be knowable and usable at the bed side as doctors and nurses are caring for actual people–you, me, my parents, grand parents and kids. These are not just technical policy questions, but need to become cultural ones as well, asked by all of us, no matter what type of insurance we have.

Then we will have to decide what to do with the answers. None of this will be easy.

The good bad news is that there is a good deal of care that is non-productive, which I would define as care that does not improve quality of life or extend life. We should start there. I don’t know how much health care spending could be reduced by stopping care that didn’t improve quality of life or extend life, but this is the correct way to think about our attempts to slow health care cost inflation. We might have to get into the very hard business of deciding that some care that was productive but very expensive shouldn’t be done. But, we might not; we won’t know until we start asking these 3 questions. Matt Miller and Austin and Aaron have been talking about this today.

The Independent Payment Advisory Committee (IPAB) is a vehicle that could be used to begin to ask these questions. I have been amazed at the level of vitriol against IPAB given past Republican support of similar boards with far more proposed power than what IPAB has. However, if we are forgetting about the past, lets forget about it and reach a bipartisan way to ask these questions, using IPAB as the vehicle since it has the advantage of having been enacted into law.

One practical solution would be for the President to say he is going to name one of the Republican members of Congress who is a physician to be the chair of IPAB. I believe Tom Coburn is retiring in 2012, and he co-sponsored the Patients’ Choice Act that proposed IPAB-like boards. And he uttered the most profound statement of the entire Blair House health policy summit in February 2010 when he said that 30% of medical care is non productive (I don’t know if this figure is correct, but IPAB could start figuring it out). Senator Coburn could even say exactly how the boards he proposed in the PCA were good policy ideas, but the current structure of IPAB is not, and we could enact a bipartisan tweak of IPAB.

I am being totally serious. Anything that moves us in the direction of beginning to ask these questions, to begin to depoliticize the recognition of limits, and to get to the policy. I am not sure I can take another election based on ‘I am not as bad as the other guy’ while serious problems go unaddressed.