Independent Payment Advisory Board still in Congress' crosshairs
Since the Affordable Care Act (ACA) passed, the much maligned Independent Payment Advisory Board (IPAB), incorrectly labeled a death panel by the law's opponents, has sat dormant. It has escaped scrutiny during the major debates this summer about repealing and replacing the ACA, but it is certainly not forgotten by all.
IPAB has no members and has never been activated. Opponents are now hoping to make sure the board, which got it's catchy but false moniker from former Alaska Gov. Sarah Palin, never gets put into action as they push Congress to kill the IPAB.
Those who oppose the IPAB, which includes most of the healthcare industry, don’t subscribe to Palin’s over-the-top rhetoric that it will “ration care” and decide who receives medical care. Instead, their concern is what the IPAB would do to physician payments and subsequent patient access to Medicare.
The ACA created the IPAB as a way to contain Medicare costs. The 15-member board would include experts in health finance, economics, health facility management, health plans, prescription drug benefit programs and health professionals, including physicians.
The IPAB has never formed because Medicare spending projections haven’t exceeded a specific limit. If that happens, the government launches the IPAB, and the board looks for ways to curb spending growth and make changes to the Medicare program. It offers cuts without presidential or court review, which would take effect unless Congress found a way to save the same amount of money.
The most recent Medicare Trustees report released in July predicted Medicare projections may reach the level that would trigger the IPAB in 2021. Because Congress hasn't needed the IPAB, neither President Barack Obama nor President Donald Trump has appointed any members.
Currently, the Medicare Payment Advisory Commission (MedPAC) advises Congress on Medicare costs. Created in 1997, MedPAC issues two reports annually with recommendations, as well as provides comments on reports and proposed regulations. MedPAC can only recommend changes, as it doesn't have any power to make decisions. Those changes are put in the hands of Congress.
IPAB supporters say that Congress often ignores MedPAC’s recommendations to save on Medicare, and an independent body like the IPAB would have the ability to make changes and not worry about the politics.
Since the ACA’s passage in 2010, the IPAB has largely fallen into the shadows as other parts of the ACA, like the individual mandate and Medicaid expansion, have risen to the forefront. That doesn't mean opponents have given up. They continue to fight the IPAB idea in Washington, and are still hoping eliminate the board this year.
Health organizations speak out
The Healthcare Leadership Council (HLC) is leading the IPAB repeal campaign and launched a website called Protect My Doctor and Me. The council and nearly 800 organizations that represent patients, seniors, healthcare providers, veterans, employers and Americans with disabilities are pushing Congress to repeal the IPAB this year. The opponents to the IPAB include the American Hospital Association (AHA) and American Medical Association.
AHA Executive Vice President Rick Pollack said the IPAB would remove Congress’ decision-making power over Medicare policy and threatens “the long-time, open and important dialogue between hospital leaders and their elected officials regarding the needs of local hospitals, the patients they serve and how to provide the highest quality of care to patients and communities.”
Opponents like the HLC predict the IPAB would lead to lower physician payments and could cause doctors to stop taking Medicare patients. Private payers already pay more than Medicare, and critics fear that gap may widen if the IPAB implements further reimbursement cuts.
“There are already physicians who won’t see Medicare patients because of the gap between Medicare and private insurance reimbursement, and IPAB will only worsen this access problem,” Kelly Fernandez, director of public affairs at the HLC, told Healthcare Dive.
The ACA included a provision that the IPAB should find Medicare cuts that don’t affect beneficiary health benefits. IPAB foes fear this will leave little room for benefit design reforms and will likely result in physician payment cuts as a way to find savings.
These payment cuts will come without improving healthcare or adding value to the Medicare program, Mary Grealy, president of the Healthcare Leadership Council, told the House Energy and Commerce health subcommittee earlier this year. Grealy suggested Medicare instead find more “value-focused” solutions and not an “indiscriminate approach to healthcare spending cuts.”
Another concern is that the law requires the board to “achieve scorable savings within a one-year time period,” which opponents say could mean huge cuts to achieve immediate savings. Fernandez said the IPAB could make cuts without any “long-term, thoughtful reforms that could strengthen the program’s quality and value.”
One other concern is that the IPAB could give too much power to one person. If the president doesn't appoint IPAB members when it’s activated, the HHS secretary would have the power to curb Medicare spending growth.
Not everyone in healthcare is completely against the IPAB. The American College of Physicians (ACP) liked the idea of having an independent body not influenced by special interests making decisions rather than Congress, who aren't trained in health policy.
The American Academy of Family Physicians (AAFP) also initially backed the IPAB concept, but with caveats that ultimately led to the organization opposing the proposal. Dr. John Meigs Jr., president of the AAFP, told Healthcare Dive the organization supported the IPAB concept because it thought an independent advisory board of experts would lead to better care that’s based on a “primary-care based health system that has appropriate payment for medical services and a financially sustainable business environment.”
Meigs said the AAFP proposed that the board should include at least one primary care physician and consumer representative. AAFP also suggested a public comment period for the IPAB’s recommendations. The group also voiced concerns about the scope of its oversight and transparency issues. These concerns ultimately caused the AAFP to not support the IPAB as proposed.
“Without these elements, the AAFP thought IPAB would not be an effective vehicle for reining in costs. So, in the end, the AAFP opposed the board as it was configured in the final legislation,” said Meigs. Though the AAFP has its concerns, the group has not joined other healthcare organizations in publicly opposing the IPAB.
Where is the IPAB now?
Opponents were hopeful to end the IPAB this year. The ACA included a provision that allows Congress to pass a fast track resolution without any amendments or Senate filibuster that would have killed the IPAB. Both houses needed to pass the fast track legislation by Aug. 15, but that option died when the House went on recess for the summer.
That doesn't mean the IPAB is safe. Reps. Phil Roe (R-Tenn.) and Paul Ruiz (D-Calif.), along with Sens. John Cornyn (R-Texas) and Ron Wyden (D-Oregon), have proposed legislation to end the board. Roe has been especially outspoken about the IPAB and called it “one of the most troubling parts” of the ACA, which would create an “unelected, unaccountable board” with widespread control over Medicare spending.
The idea of ending the IPAB has bipartisan support. Fernandez said more than three-fifths of House members have co-signed the bill to repeal IPAB and a majority of Senators are on IPAB bills.
The House approved ending the IPAB in the last Congress in 2015, but the Senate did not vote on the bill. One hurdle is the Senate’s budget reconciliation rules, which make it harder to add the IPAB to a healthcare bill.
The HLC and its coalition of organizations are disappointed that the fast track option didn't happen, but they are still pushing for Congress to go the regular legislative route. The HLC sent a letter to Congress on Aug. 1 restating its support for repeal of the IPAB.
Fernandez said the Republican leadership plans to include IPAB repeal in other legislation in the fall.
“We believe IPAB will be repealed. Democrats and Republicans in Congress oppose it. No one wants to see seniors and beneficiaries with disabilities lose access to care. We are urging Congress to act expeditiously before it is triggered,” said Fernandez.
- Advisory Board What you should know about IPAB: The ACA tool that could cut provider rates next year
- Healthcare Dive CBO reports show private insurers pay physicians, hospitals far more than Medicare
- Medscape AAFP, ACP Break Ranks With Organized Medicine on IPAB
- Wall Street Journal The Deadline to Kill the Death Panel