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Who's Afraid of IPAB?

By Dr. Christopher Hughes

Yesterday, 20 physicians' organizations, largely representing procedure based specialists and sub-specialists, sent a letter to the "Super-Committee" asking them to recommend repeal of the PPACA's Independent Payment Advisory Board (IPAB). It is a sad and disappointing letter. In the debate over the passage of the PPACA in 2009 and 2010, we at Doctors for America took pride in the fact that the ten largest physician organizations supported the House version of health reform (which even included the public option). Even after the Senate version removed the "doc fix" or "SGR Fix," all but two of those organizations stuck with their support. And I am pleased to say, that of these ten, only three signed on to this letter.

I grant that, even back then, many of these organizations expressed concern about resolving the SGR problem and expressed reservations about the future IPAB, so their support of the PPACA was and is greatly appreciated by many (I think it is fair to say most) physicians. The support was an acknowledgement that health reform was about our patients, and not just about us.

But the letter is disappointing on several levels. Straight out of the gate, it asks the Super Committee, the committee charged with reducing the deficit, to toss out a major feature (not a bug!) of the PPACA that can bend the cost curve in the right direction - and reduce the deficit! Although the Congressional Budget Office only estimates small savings due to restrictions in analysis, small across-the-board reductions are not what is concerning these organizations. They are concerned with the fact that, in all likelihood, the IPAB will finally address two things that desperately need addressing: first, increasing reimbursement for primary care services, and reducing reimbursement for procedure based specialties, and, second, taking the process for setting reimbursement out of the hands of a hand picked committee of the AMA.

The first issue has been coming to a slow boil for quite some time, and many primary care physicians are now on board for a little revolution. In a gross over simplification, reimbursements are determined by a committee selected through the AMA, essentially controlled by the higher paid specialties, called the RUC (for more details, read "The Primary Care Revolt") and we have seen steadily increased reimbursement for procedure based specialties and devaluing of primary care. The idea that this immense power will be no longer subject to domination by specialists has led to both fear and loathing.

The second issue addressed by the letter is the concern over "unelected and largely unaccountable individuals," meaning, presumably, unelected and unaccountable to them. The "unelected" part, as with the other cost control mechanisms within the PPACA, is a feature, not a bug. As Professor Henry Aaron noted in a recent piece in the New England Journal of Medicine, this is "self-abnegation — the willingness of legislators to abstain from meddling in matters they are poorly equipped to manage." A feature, not a bug. He goes on to quote our own Harold Pollack: “Every Democratic and Republican policy expert knows that we must reduce congressional micromanagement of Medicare policy." Aaron calls it Congress's "Good Deed."

A final thought about "unelected" and "unaccountable." Some physician specialty organizations have influence in Washington and state capitols larger than their membership numbers would suggest. I give them credit for their involvement in the political process, but I would urge them to remember that health reform, in the PPACA, and in our ongoing efforts to do better, it is ultimately about our patients, our entire population's, well being, and not our own. We'll be OK. Really.

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