The Importance of Independence: Affordable Care Act’s Independent Payment Advisory Board Key to Quality Care at Lower Cost
A year ago this week, President Barack Obama signed into law our nation’s first comprehensive health reform law, the Affordable Care Act, which not only extends health insurance protection to tens of millions of Americans but also actually reduces the deficit—in large part because of measures the law takes to responsibly slow the growth in Medicare and overall health spending. Lowering the projected growth of health care costs is a key promise of the law because these ever-escalating costs drain businesses, government coffers, and individuals’ savings. Yet many who criticize the law as a budget buster are aiming to repeal some of its key cost-containment features.
The Independent Payment Advisory Board is a case in point. The Affordable Care Act establishes this board to serve as a guarantor that the law’s cost-containment goals will actually be achieved. If the government’s main health care program for the elderly and disabled Medicare exceeds its per capita cost-growth targets under the new law, then the Independent Payment Advisory Board is empowered to recommend ways to reduce program expenditures by changing the way Medicare pays health care providers.
The secretary of health and human services must implement these recommendations unless Congress passes an alternative proposal or discontinues the cost-containment review process by the Independent Payment Advisory Board. Some legislators propose to eliminate the board. This would be a mistake.
Understanding the purpose of the board—as part of the Affordable Care Act’s cost-containment strategy overall—makes it clear that keeping and strengthening the independent board makes sense. The new health law’s cost-containment strategy includes both reducing excessive payments to providers under Medicare’s current payment mechanisms and moving Medicare—and, by example, the private sector—away from a payment system that rewards volume of services, without regard to health benefits, to payment arrangements that reward effective care, efficiently provided.
The Independent Payment Advisory Board will reinforce this twin focus on quality care at lower cost.
The Affordable Care Act holds hospitals and other institutional health care providers to productivity gains—something every other sector of our economy has achieved over the past several decades. Between 1995 and 2008 average annual productivity growth across the vast majority of U.S. businesses was 2.4 percentage points—just more than 1 percentage point higher than the previous two decades. In contrast, the health care, education, and social services sectors combined have produced average annual productivity growth rates of negative 0.2 percentage points.
The Affordable Care Act’s push for providers to produce productivity gains on par with other sectors promotes the efficiencies needed to reduce health care costs. But to assure that growth rates actually slow, the Affordable Care Act sets a target for Medicare spending growth and requires the Independent Payment Advisory Board to develop and recommend payment changes to achieve it. Both the Congressional Budget Office and the executive branch’s Centers for Medicare and Medicaid Services predict that explicit payment changes will produce most but not all of the savings needed to realize the independent board’s spending-growth targets through 2019 under the new law.
Avoiding excessive increases in the rates Medicare pays historically slows spending growth across the entire health care industry and can do so in the future. But tightening fee-for-service does nothing to improve quality or efficiency in care delivery—a critical goal of health reform. That’s why the Affordable Care Act includes multiple strategies to promote payment and delivery reform.
First, the new law stops rewarding bad behavior. The law authorizes the secretary of health and human services, without seeking congressional action, to review and alter “misvalued” fees, such as paying more for services than they’re worth, and to reduce payments for clearly undesirable behavior, such as hospital-acquired infections or conditions, inappropriate hospital readmissions, and, even more egregious, outright fraud. These new steps will deliver market-based signals to Medicare health care providers—and by example to the entire industry—that the wrong kinds of services that drive up current costs will no longer be rewarded.
Alongside what might be considered these “sticks” to change behavior come a set of essential “carrots,” or rewards to deliver more effective and efficient care. At the most basic level, these rewards are extra payments to providers for doing “good” things—say, meeting a set of efficiency standards while maintaining quality care. But more importantly, these rewards reside in alternative payment mechanisms to replace today’s fee-for-service payment system.
Among the new payment systems the new health law encourages is “bundling” separate fees into a single payment for services associated with a specific condition, such as a hip fracture, which today would include separate fees for diagnosis, surgery, and postoperative care. Another provision of the law promotes the financial and health benefits of primary care and chronic care management through newly created “medical homes,” which coordinate health care for their patients. And yet another new approach to health care promoted by the new law are so-called “accountable care organizations,” which are collaboratives of inpatient and outpatient providers who are rewarded for delivering quality care to a defined set of patients at lower-than-projected costs.
The new law sets a clear timetable for implementing some of these measures and creates the Center for Medicare and Medicaid Payment Innovation to initiate, evaluate, and broadly extend the application of these methods as part of “rapid cycle change.”
The law also recognizes that these efficiencies and the savings they can deliver will not be realized if changes in payment systems are limited to the public sector, and therefore encourages public-private partnerships. Medicare is a large payer, accounting for 20 percent of our nation’s medical bill in 2009. Private payers have historically followed Medicare payment practices. But that outcome is neither automatic nor immediate.
What’s more, inconsistent payment mechanisms across payers discourage providers from changing behavior, impede efficiency improvements, and create opportunities for offsetting one payer’s spending reductions with increases for others. Indeed, a recent study by the Medicare Payment Advisory Commission, an independent congressional agency, finds that hospitals squeezed by both Medicare and private payers changed their operations to become more efficient, yet hospitals with generous private payments ignored Medicare constraints, took losses on Medicare patients, and continued business as usual. Better quality care at lower costs requires that the public and private sectors work in tandem.
The health reform law encourages common action in different ways. The law gives preference to innovations where providers engage with private payers alongside Medicare in adopting new payment incentives Other provisions in the law further support payment reform in the private sector by extending access to Medicare provider performance data to guide private payers’ payment-reform efforts, and requiring private health plans to regularly report on those efforts. These data will inform the Independent Payment Review Board when it uses its authority to make nonbinding recommendations for private-payer reforms alongside binding recommendations for public programs.
This is a key provision of the new law. From 1970 to 2000 the private sector was less effective than Medicare in promoting efficiency, with an average annual growth rate per enrollee of 11.1 percent compared to Medicare’s rate of 9.6 percent. An effort that addresses public-sector but not private-sector health care spending risks limited access for beneficiaries as well as missed opportunities to encourage health care providers to operate more effectively and efficiently. Therefore, the broader the new board’s authority is to influence not only public but also private spending, the more effective it will be.
A focus on policy tools alone, however, obscures the most important element of the Independent Payment Review Board’s potential impact. Payment improvements in the past were stymied by legislators responding to providers’ resistance to change. Provider payment is rarely a partisan issue but it is a political issue. The new law takes the politics out of the equation by giving the independent board the authority to make Medicare payment recommendations that become law unless explicitly overridden by legislative action. This gives a major boost to policy over politics in containing health care costs.
And it’s precisely this boost that special interest groups want to prevent. Opponents of the new board complain it undermines congressional authority and removes from their control an important budgetary lever at a time when the federal budget deficit is rising at an unsustainable rate. But the real concern of many of these critics, who often are the fiercest advocates of fiscal restraint, is that the board’s authority diminishes their influence and their ability to fashion a Medicare budget that benefits the pharmaceutical industry and other special interest groups that are in a position to lose the most from the board’s future recommendations.
Other critics of the Independent Payment Advisory Board fear the Affordable Care Act did not go far enough in granting it authority, leaving too many loopholes for special interest groups to avoid payment adjustments. In making adjustments the board is prohibited from addressing payments to hospitals, skilled nursing facilities, and other health care providers who are scheduled to receive “productivity adjustments” under the Affordable Care Act. Rather than repeal the board, the more sensible option would be to close these loopholes and extend accountability for unacceptable health care cost increases.
In fact, members of Congress and policymakers in the federal government should be thinking of ways to strengthen the Independent Payment Advisory Board given the fiscal reality facing the federal government today. The new board is one of the Affordable Care Act’s most important cost-containment tools. We can’t afford to lose it.
By: Judy Feder, Senior Fellow, Center For American Progress, March 21, 2011
Tea Party Extremism Run Amok
The success of the Tea Party movement and legitimate concern over the size of the deficit raise a serious question: What does it mean to promote small government?
The pious commitment to keeping big government out of people’s lives—or championing local control—was a common theme among Republican candidates last election season, particularly among those who professed sympathies for the Tea Party element. But local control and small government sound remarkably like pure lawlessness, as Dana Milbank brilliantly reports in Wednesday’s Washington Post.
Milbank—often amusing, always readable—with this most recent and very well-reported column, an absolute must-read, chronicles some of the anti-federal-authority efforts by state legislators:
When Louis Brandeis called state legislatures “laboratories of democracy,” he couldn’t have imagined the curious formulas the Tea Party chemists would be mixing in 2011, including: a bill just passed by the Utah legislature requiring the state to recognize gold and silver as legal tender; a Montana bill declaring global warming “beneficial to the welfare and business climate of Montana”; a plan in Georgia to abolish driver’s licenses because licensing violates the “inalienable right” to drive; legislation in South Dakota that would require every adult to buy a gun; and the Kentucky legislature’s effort to create a “sanctuary state” for coal, safe from environmental laws.
U.S. News’s own Robert Schlesinger also recently questioned the mental stability of some of these local lawmakers.
Setting aside the pure absurdity of some of those ideas, the philosophical underpinnings are pretty disturbing. Where did these local officials get the idea that any community standard—be it a proven ability to make a left turn (if not parallel park) or to avoid poisoning the environment for generations who might come after us—is some egregious infringement on their own rights?
If the anti-big-government, local-control camp wants to prove its sincerity, it can help out right here in the District of Columbia. Still the last place in the country where citizens are denied the right to full representation in Congress, the nation’s capital is again experiencing attempts by members of Congress to make decisions about school vouchers and other matters. The same lawmakers who say they want the federal government to have less control over people’s lives are using Washington as Congress’s personal lab rat. If they really believe in local control, the lawmakers will let the city of Washington alone.
By: Susan Milligan, U.S. News and World Report, March 16, 2011
Sen. Snowe Puts Mainers Out In The Cold To Win Favor From Tea Party
Sen. Olympia Snowe, R-Maine, acted in the best interests of her party's far right, not her constituents, when she voted last week in favor of the federal budget bill. (2009 AP file)
Sen. Olympia Snowe has apparently decided that it is better to bow to political pressure from the tea party movement than to stand up for the interests of Maine.
How else to explain her vote last week for a federal spending measure that would harm Maine’s economy while punishing thousands of Mainers, including seniors, veterans, preschool children, college students and families struggling to keep their oil furnace running?
It turns out that the tea party does not have to defeat U.S. senators to claim their seat. It just has to threaten them. If what Snowe voted for last week becomes law, 700,000 jobs are likely to be lost in Maine and across the country.
This is not according to a Democratic think-tank, but an economic adviser to the presidential campaign of Sen. John McCain, Mark Zandi.
NO TO HEAT ASSISTANCE
Snowe voted to throw tens of thousands of Maine families off of a lifeline that enables them to get through a Maine winter. She voted to cut the emergency energy assistance program — LIHEAP — by 66 percent, literally tossing Maine families out of the program and into the cold.
She voted to undermine services to Maine seniors who benefit from the Medicare program. Payments benefitting seniors who participate in the Medicare Advantage program, for instance, would be suspended, according to Secretary of Health and Human Services Kathleen Sebelius. And Snowe’s vote would create “significant disruption” to providers, suppliers and seniors who use Medicare.
Snowe voted to cut 3,500 positions from the Social Security administration, guaranteeing extended delays in the distribution of basic retirement claims and disability payments. She voted to eliminate 10,000 supportive housing vouchers for homeless veterans.
Sen. Snowe voted to knock 218,000 kids out of the Head Start program and force 16,000 classrooms to close while cutting 1.7 million college students from the Pell Grant program — their lifeline to a college education.
From the seat once held by the environmental champion Sen. Edmund Muskie, Snowe voted to cut land and water conservation, energy efficiency and renewable energy projects, and one-third of the entire Environmental Protection Agency’s budget.
Make no mistake — this was not a vote about doing the difficult but right thing to confront the federal budget deficit.
A sober debate about reining in long-term federal deficits begins by recognizing that the first step to fiscal health is an economy that produces decent-paying jobs.
Jobs fill pockets with money to spend on goods and services that in turn create more jobs. These jobs produce revenue that reduces the federal deficit. You are not serious about fueling a fragile economic recovery when you slash hundreds of thousands of jobs with one vote.
You are not serious about balancing the federal deficit when you support maintaining the Bush tax cuts for the wealthiest of Americans at a price of $2.5 trillion over 10 years — exactly the amount that congressional Republicans want to slash and burn from the federal budget over this same time period.
You are not serious about addressing the federal budget deficit when you repeatedly vote to borrow hundreds of billions of dollars for the war in Afghanistan.
The wars in Iraq and Afghanistan alone account for 23 percent of the federal budget deficit since 2003.
STATE CUTS HURT TOO
The Portland Press Herald’s Bill Nemitz quoted a Portland middle school librarian who drove to the State House in Augusta last week to testify against similar tea party-driven cuts to Maine’s state budget.
Kelley McDaniel described the cuts this way: “It’s not economically sound. It’s not morally sound. And I think you know that. I would be embarrassed to support something so ludicrous — taking from the poor to give to the rich. Maybe you are testing us, checking to see if we, your constituents, are really paying attention, really listening. I hope that’s what’s going on, because the alternative involves me losing faith in representative government, in democracy, and in you, the elected officials.”
Our fragile economic recovery, our kids, college students, seniors, veterans, environment and our health all took a hit on the floor of the U.S. Senate from a senator who was once described as independent.
Sen. Snowe might think that she made a prudent political calculation by bowing to the radical right of her party and placing her political interests ahead of the interests of her constituents. But she needs to know that Mainers are paying attention. And that the seat she is holding is Maine’s U.S. Senate seat. Not the tea party’s.
By: Tom Andrews, Former Maine U.S. Congressman, The Portland Press Herald, March 15, 2011
Government by the Week: Is A Government Shutdown The End-Game For The GOP?
Parents have begun arranging alternative child care for their preschoolers, uncertain of whether their Head Start program will be there when they need it. The Social Security Administration is unable to open new hearing offices to handle a backlog of appeals. The Pentagon has had to delay equipment repairs. There is chaos throughout the federal government, as Robert Pear reported in The Times on Tuesday, because a riven Congress has forced agencies to operate on a week-by-week basis.
Yet, on Tuesday, the House passed another short-term spending bill. This one keeps things going for all of three weeks. The Senate will almost certainly join in shortly to avoid an impending shutdown on Friday, the result of the stopgap bill from two weeks ago.
These slipshod exercises in governance were choreographed by House Republicans, who knew that neither the Senate nor President Obama would ever accept their original proposal to gut nonsecurity discretionary spending with $61 billion in cuts through September, including riders to end financing for Planned Parenthood and the health care law. They had hoped to use the pressure of a potential shutdown to achieve much of their goal, but, so far, all they have accomplished is a cut of about $10 billion, mostly from earmarks or programs that the president himself proposed to cut. (The new bill cuts $6 billion.)
House Republican leaders, who say they do not want a government shutdown, have, so far, held off their more fanatical freshmen, who want to slash everything in sight. But the leadership cannot do so forever, and the evidence of that was clear on Tuesday. More than 50 Republicans refused to go along with the three-week resolution because it did not cut enough. Several specifically complained that it allowed financing for Planned Parenthood and the health care law to continue.
This is not a group that cares much for pragmatic compromise, and the three weeks are just a timeout. Representative Mike Pence of Indiana, a Republican who voted no on the new bill, spoke for many of his colleagues when he said the budget could not be resolved without a willingness to shut down government. “By giving liberals in the Senate another three weeks of negotiations,” he said, “we will only delay a confrontation that must come.”
He is absolutely right about that. If Democrats, including the president, do not draw a clear line soon, making their priorities and their limits unmistakable, they will be harried by these kinds of votes for years. Even in the unlikely case that an agreement is reached in three weeks to finance the government through September, a different vote will be necessary just a few weeks from now to raise the debt ceiling. Republicans have already vowed to vote that down — even though it could be financially disastrous — if they do not get their way. And then there is the vote for the fiscal 2012 budget, which begins Oct. 1, and then the year after that.
At some point, Mr. Pence will get his confrontation. If Republicans continue to press for cuts of tens of billions from discretionary spending, setting back the economic recovery largely for ideological purposes, Democrats will have to say no, even if that results in a short-term shutdown. The American people will be able to figure out who is at fault. Responsible governing means agreeing quickly to a deal to finish out the fiscal year, and then starting a serious talk about entitlement programs and taxes — the real causes of a soaring deficit.
By: The New York Times, Editorial, March 15, 2011
The GOP’s Penny-wise, Pound-Foolish Spending Cuts
Let’s say that for every dollar you gave me, I gave you a crisp $10 bill in return. Good deal, right? Almost too good. But before you start to ask questions, I’ll remind you that this is my thought experiment. Perhaps I just love dollar bills. Or perhaps I just love you. At any rate, there are no strings attached, and you can take advantage of it more than once.
Now let’s say that you’re in debt and you need to get your finances in order. Do you start handing me more dollar bills? Or fewer?
If you’ve got any sense, you’ll give me more. Converting dollar bills into $10 bills is an excellent way to pay off your credit card. Except, it seems, if you’re a House Republican.
On March 1, House Republicans voted to cut $600 million from the budget of the Internal Revenue Service for the remainder of 2011, and they want even deeper cuts in 2012. Perhaps that doesn’t surprise you: Republicans don’t like spending — at least when they’re not in power — and they don’t like taxes. Why would they fund the IRS?
Well, as the Associated Press reported, “every dollar the Internal Revenue Service spends for audits, liens and seizing property from tax cheats brings in more than $10, a rate of return so good the Obama administration wants to boost the agency’s budget.” It’s an easy way to reduce the deficit: You don’t have to cut heating oil for the poor or Pell grants for students. You just have to make people pay what they owe.
But deficit reduction is not the GOP’s top priority. It’s a bit lower on the list, somewhere between “get Styrofoam cups back into Congress” — an actual push the Republicans took up to thumb their nose at Nancy Pelosi’s environmental policies — and make “Sesame Street” beg for money. In fact, if you listen to Speaker John Boehner, he’ll tell you himself. “The American people want us to focus on creating jobs and cutting spending,” he has said. And that comment wasn’t a one-off: “Our goal is to cut spending,” he said in another speech.
Cutting spending is related to, but in important ways different from, cutting deficits. For one, it rules out tax increases. That’s how Republicans can lobby to make the Bush tax cuts permanent, at a cost of $4 trillion over 10 years, and yet say they’re fulfilling their campaign promises by making much smaller cuts to non-defense discretionary spending. If you add up what Republicans have offered since the election, the policies they’ve endorsed would increase deficits but also decrease spending, at least in the short term. The IRS example shows that spending cuts don’t always reduce the deficit. But it’s worse even than that: Spending cuts don’t always reduce government spending.
There are three categories of spending in which cuts lead to more, rather than less, spending down the line, says Alice Rivlin, former director of both the Congressional Budget Office and the Office of Management and Budget. Inspection, enforcement and maintenance. The GOP is trying to cut all three.
Let’s begin with the costs of cutting inspection — for example, the Food and Drug Administration and the Agriculture Department. Together, the agencies are charged with ensuring that the nation’s food is safe. That’s increasingly crucial as our interconnected, industrialized system makes contaminated food a national crisis rather than a local problem. In recent years, we’ve seen massive recalls stemming from E. coli in spinach, salmonella in peanut butter and melamine in pet food. Each required the recall of thousands of tons of food and alerts to consumers who, in many cases, were screened or treated.
The problem was bad enough — and the people and pets sick enough— that Congress passed a bipartisan food-safety bill during last year’s lame-duck session. But now Republicans want big cuts in the agencies’ budgets, meaning fewer inspectors and a higher chance of outbreaks and food-borne illness. And those don’t come cheap. They show up in our health-care costs, disability insurance and tax revenue, not to mention in the pain and suffering and even death they cause.
Next up: enforcement. As any budget wonk will tell you, cracking down on “waste, fraud and abuse” won’t cure all our fiscal ills. But waste, fraud and abuse do happen, particularly in Medicare and Medicaid, where they can be costly. Republicans are looking for big reductions in the Department of Health and Human Services, meaning fewer agents to conduct due diligence on health-care transactions. Costs will go up, not down.
Then there’s deferred maintenance. In 2009, the Society of Civil Engineers gave America’s existing infrastructure a grade of D. They estimated that simply maintaining America’s existing stock would require up to $2.2 trillion in investment. But Republicans have been cool to Obama’s calls to increase infrastructure investment. Just “another tax-and-spend proposal,” Rep. John Mica (R-Fla.) said when the initiative was announced. But a dollar in maintenance delayed — or cut — isn’t a dollar saved. It’s a dollar that needs to be spent later. And waiting can be costly. It’s cheaper to strengthen a bridge that’s standing than repair one that’s fallen down.
And there are plenty of examples beyond that. Republicans have proposed massive cuts to the Securities and Exchange Commission, which would make another financial crisis that much likelier. They’ve proposed cuts to the National Oceanic and Atmospheric Administration, which conducts tsunami monitoring. In their zeal to cut spending, they’re also cutting the spending that’s there to prevent overspending. Just as you have to spend money to make money, you also have to spend money to save money — at least sometimes.
There are all sorts of reasons Republicans are being penny-wise and pound-foolish. Cutting $100 billion in spending in one year sounded good on the campaign trail but turned out to be tough in practice. Curtailing the IRS and cutting the Department of Health and Human Services — and, particularly, its ability to implement health-care reform — is a long-term ideological objective for Republicans.
Whatever the reason, the effect will be the same: a higher likelihood of pricey disasters, an easier time for fraudsters, and bigger price tags when we have to rebuild what we could’ve just repaired.
By: Ezra Klein, The Washington Post, March 15, 2011
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