The federal health care reform law establishes a new body, called the Independent Payment Advisory Board (IPAB), responsible for enforcing the annual spending cap in Medicare. The IPAB will consist of 15 presidential appointees and will start making changes to Medicare in 2015. The fundamental problem with this system is there is little recourse in the event IPAB makes a bad decision.
The panel's recommendations automatically become law unless Congress overrides them through a three-fifths vote or passes an alternative set of cuts that hit the same spending targets. Neither patients nor doctors can appeal an IPAB decision. The primary cost-cutting tool available to IPAB is broad reductions to reimbursement rates of select providers that participate in Medicare — chiefly, physicians. The IPAB's powers also include the ability to cut reimbursements in the Medicare drug benefit. This power is cause for concern, as it could result in critical medical decisions falling into the hands of nonphysicians.
IPAB isn't able to look to benefits, deductibles or co-payments for savings, so one of the more likely targets becomes reimbursement rates. Reductions in Medicaid reimbursements over the years have made it impossible for many physicians to break even on patients enrolled in that program, and they've reacted by simply leaving Medicaid entirely. Such cuts will have a similar effect in Medicare. Patients will face a shortage of doctors and compromised quality of care — making a bad situation even worse.
Many Maryland patients currently lack a physician. According to a recent study by MedChi (the Maryland State Medical Society) and the Maryland Hospital Association, Maryland is 16 percent below the national per-capita average in the total number of local physicians in clinical practice. Shortages are most acute in rural parts of the state and among primary-care physicians and medical specialists. Statewide, there are shortages in primary care, dermatology, hematology/oncology, psychiatry, anesthesiology, emergency medicine, thoracic surgery and vascular surgery. Retirement levels are also of concern, as physicians 65 or older make up about 10 percent of the clinical full-time equivalent and physicians 55 or older constitute one-third of the total.
Ultimately, treatment decisions should remain between a patient and her physician. That treatment should not be influenced by the decisions of some unelected board. During last year's debate over health care reform, President Barack Obama promised that if you like the doctor you have, you can keep your doctor. We need to change the IPAB to keep the president's promise so that this unaccountable board doesn't interfere with the relationship Medicare patients have with their physicians.
Congress should address the problems with IPAB before their own power over the board is significantly diminished. Once IPAB is implemented in a few years, and its recommendations are offered to Congress, lawmakers will be on deadline to pass the recommendations or substitute them at the same savings level. Once that deadline passes, the secretary of the Department of Health and Human Services must carry out the recommendations, even if Congress does not act.
If we don't fix this well-intentioned but flawed component of health care reform, IPAB could seriously undermine the quality and availability of the treatments available in Medicare. There are more than 714,000 Marylanders enrolled in the Medicare program. Even minor damage to Medicare could have a significant effect on our state's health care system.
Maryland has a history and tradition as a leader in health care. Our state also has a history and tradition of promoting access to medical care and of preserving and protecting the doctor-patient relationship. Maryland needs to continue the tradition and take a leadership role to reform the IPAB, making the changes necessary to sustain the Medicare program while guaranteeing patients' continued access to treatment.
Gene M. Ransom III, is the CEO of MedChi, the Maryland State Medical Society. His email is firstname.lastname@example.org.
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