Does the Independent Payment Advisory Board need physicians?

I was chatting with someone who asked what I did for a living, and I told him I am a doctor. “The kind that helps people?” he joked.

I knew what he meant. The MD is the practical fixer, the PhD the omphalocentric academic. Many believe in this dichotomy, as false as it is. And such a philosophy underlies the opposition to some elements of the PPACA, aka Obamacare.

There’s a board of experts, the Independent Payment Advisory Board, which is tasked to (per Wikipedia  which seems mostly accurate): “… develop specific proposals to bring the net growth in Medicare spending back to target levels if the Medicare Actuary determines that net spending is forecast to exceed target levels, beginning in 2015.

According to official records, the proposals made by IPAB should not include any recommendation to ration health care, raise revenues or increase Medicare beneficiary premiums, increase Medicare beneficiary cost sharing (deductibles, coinsurance, or co-payments), or otherwise restrict benefits or modify eligibility criteria …”

The usual suspects have come out against the board: the AMA (that well known and long term opponent of health care reform, who came out for Obamacare only weakly), Big Pharma, the American Hospital Association. Though I discount most of their concerns out of hand, the AMA does make an interesting point, namely, that working physicians (not eligible per the legislation for board membership) should be included.

But why? The assumption is that only clinicians can know what really helps the individual patient, and bean-counters and economists care only about money.

This is false in so many ways! First, as I have repeated time and again in this space, sometimes doctors don’t know, know only some of what they think, or base a whole practice on precious little evidence.

Second, sometimes population health is the best guide to what is most likely to help the patient in front of you. In fact, most of evidence-based medicine is founded on controlled trials among thousands of people. Now, although these are imperfect at best, we do know something. Beta blockers help after heart attacks. In severe depression, SSRIs can improve matters. And so on.

The clinician is powerless without population health, profligate to no purpose without health economics, and stabbing in the dark without policy and health services research.

Is there a unique perspective that a physician can bring to such a board? Perhaps, but I worry that such a doctor would be the AMA’s (or the specialties’/the RUC’s) Trojan horse to sneak in unsubstantiated overuse. I, for one, accept that a board of experts, tasked with cost-cutting without affecting quality, does not need a token physician.

Zackary Berger is a faculty member of the Johns Hopkins University School of Medicine, where he is an internist and researcher in general internal medicine.  He blogs at his self-titled site, Zackary Sholem Berger.

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  • Docbart

    It’s easy for a salaried physician to take the supposed moral high ground. Those of us in independent practice feel more threatened when the budget ax is being raised. One may hope that the payment cuts will be affect only “cash cows”, but past experience teaches us that not all such cuts are well-directed. Having a physician involved in such decisions may be the difference between financial viability and ruin for those whose pay is not contract-based.

  • southerndoc1

    If the first action of the IPAB isn’t to recommend elimination of facility fees, we’ll know right off they’re another corrupt sham.

    • ninguem

      ^^^what southerndoc said^^^

  • ninguem

    Expanding on southerndoc’s point, here’s example number six bazillion.

    Even Don Berwick points out that hospitals take over physician practices because they can charge twice as much……..that 2X number pops up no matter who looks at it……..twice as much for the same service.

    As the hospitals take over more and more physician clinical practices, they will get monopoly power and the cost of healthcare will rise even worse than it is now. And no, you WON’T get efficiency, the hospitals push the docs to use their more expensive in-house care.

    They have the power of employment AND they impose noncompetes on the docs. So if you’re fired, no you don’t work for the other hospital down the street, you leave town, uproot your spouse and family.

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