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The Pros And Cons Of IPAB And Why It Shouldn’t Be Repealed

ipab21 IPAB: Fix It, Dont Repeal It

In recent weeks, several Democrats and some health reform advocates including the AMA have joined Republicans in calling for a repeal of provisions in the new health law that create the Independent Payment Advisory Board (IPAB). For these people, IPAB represents the worst aspects of the new law–an unelected, centralized planning authority empowered by government to make decisions about the peoples’ health care. Arbitrary cuts to providers, short-sighted decisions that stifle innovation and rationing of care are sure to follow, they claim.

While it’s true that the rules governing IPAB are flawed and should be fixed, eliminating IPAB altogether would be a mistake.

Created by the Affordable Care Act, IPAB is a fundamental part of the law’s plan to control health care cost escalations. The law contemplates that each of the Board’s 15 members would be appointed to a 6-year term by the president. Members are to include providers, health policy and public health experts, and consumer representatives. Each would have to be confirmed by Congress, much like Supreme Court justices. And unlike a frightening, wizard-like bureaucrat operating behind a curtain-as critics would have you believe-the IPAB chairperson would be required to appear before any committee of Congress that desires a hearing, just as the President’s cabinet members are required to do.

IPAB’s mandate would be to recommend ways to prevent excessive escalations in per capita Medicare expenditures. Specifically, whenever these costs grow faster than targets established by the Affordable Care Act, IPAB would propose ways to reduce Medicare spending by up to 1.5%. When that happens, Congress can either approve those recommendations, develop alternatives with the same impact, or simply allow Medicare costs to accelerate. In the last instance, a 60% majority of the Senate would be required to overrule the IPAB recommendation.

ipab11 IPAB: Fix It, Dont Repeal ItSome sort of cost-governing approach is mandatory, because we want to offer comprehensive coverage to Medicare beneficiaries within some reasonable cost structure, and because Congress has shown no inclination to do so, for example by enacting quality- and efficiency-based payment models. As Jonathan Cohn points out, Congress is unlikely to do this going forward, either, because its members are heavily influenced by lobbyists whose job it is to maintain the lucrative status quo. IPAB members, shielded as they should be from such influences but still wholly accountable to Congress, may well succeed where lawmakers have not.

Some of those who are now calling for a repeal of IPAB predict it will release “treatment edicts” that prevent folks from gaining access to expensive procedures, cancer drugs and so forth. These predictions are unlikely. The Affordable Care Act prohibits IPAB from modifying Medicare benefit schemes or any other behavior that could be construed as “rationing.” It also prohibits IPAB from raising premiums, restricting benefits or modifying eligibility.

So What Will IPAB Do?
When medical research suggests that certain treatments are more effective, or cost-effective (I provide an example involving coronary stenting here), IPAB is authorized to recommend changing reimbursement rates under Medicare to promote such treatments. These recommendations do not ration care. Providers can practice medicine as they see fit. The new reimbursement scheme will incent providers, however, to heed the research sooner, and more comprehensively than would otherwise be the case.

Let’s not forget that all payers, private and public, already routinely decide what procedures to cover. In effect, IPAB can increase input by scientists and cuts down input by lobbyists when it comes to coverage decisions.

Critics have also charged that by cutting reimbursement to providers, IPAB might indirectly foster rationing. According to this argument, cash-strapped providers will begin turning-away Medicare beneficiaries if their payment is reduced too far. As Cohn points out however, these criticisms have never raised above the anecdotal stage. Most doctors still see Medicare patients; in fact they are more open to seeing such patients than to many of those insured through private carriers.

Is there room to improve current legislation governing IPAB? Yes, there is. According to Henry Aaron, IPAB can’t make recommendations governing acute and long-term care hospitals, psychiatric facilities and inpatient rehabilitation until 2020. It can’t do that for clinical labs until 2016. In their current form, IPAB rules also prevent recommendations that drive up costs in the short run, even though they might save money in the long run. These rules should be fixed, for obvious reasons. But repeal IPAB altogether? Heavens no!

It is ironic that the loudest critics of health reform–the ones who claimed it didn’t have enough teeth to control Medicare cost escalation–are the same ones who now demand that IPAB, a key element of the law’s cost-control strategy, be repealed.

If none of this is persuasive, consider the alternative proposed by Paul Ryan and supported by Republicans in the House. Rather than empowering a commission to improve Medicare efficiency, it severely reduces the scale of the entitlement program altogether. It offers seniors a voucher that provides less comprehensive coverage than today’s Medicare, and forces seniors to fend for themselves in the private insurance market, just as they did before LBJ created Medicare in the first place.

Few if any seniors want to revisit those days.

*This blog post was originally published at Pizaazz*


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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

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