AAOS Now

Published 2/1/2010
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Lauren Bates; Nick Piatek

Don’t write-off an IMAC

Brown victory doesn’t eliminate possibility

With the election of Republican Scott Brown as U.S. Senator from Massachusetts, Democrats have lost their 60-vote super-majority in the Senate. This loss of filibuster-proof numbers puts the future of healthcare reform in doubt. To complicate matters, Speaker of the House Nancy Pelosi (D-Calif.) has said that the House will not pass the Senate’s healthcare reform legislation.

The Senate bill contained provisions for an independent payment advisory board, one of the many reasons why the American Association of Orthopaedic Surgeons (AAOS) opposed the bill. But the shift in the balance of power doesn’t mean that the physician community has seen the last of this concept.

The idea of an independent Medicare payment advisory board has been around since the early 1990s. In the past year alone, lawmakers have proposed at least four different variants, including the Independent Medicare Advisory Commission (IMAC), the Independent Medicare Advisory Board (IMAB), and the most recent version, the Independent Payment Advisory Board (IPAB).

Familiar concept, new application
Independent advisory commissions are not new and have been used by Congress for a variety of issues. Both the Defense Base Closure and Realignment Commission and the Medicare Payment Advisory Commission (MedPAC) are independent advisory boards.

The rationale behind these commissions is that they can conduct an independent analysis, gather the most relevant and comprehensive data, and develop in-depth solutions to specific problems. By design, these advisory committees operate in isolation while making their recommendations. Congress then uses the recommendations, but also takes into account the larger impact of the issue.

Recent healthcare reform proposals have taken this “advisory board” model and reinvented it to help control Medicare costs. Although this idea has had many iterations, the result would be an unelected board with Congressional authority over the Medicare program.

For example, the board would have the ability to make payment and coverage decisions for millions of the nation’s elderly without the input of elected officials. Proponents of independent commission cite the fact that Medicare is on an unsustainable path and blame Congress for not making difficult cost-cutting decisions under the weight of special interest groups.

Opponents, however, note that an independent board will not reduce pressure on Congress, because interest groups will continue to lobby their representatives for a final vote. In addition, they note that the public will not have the opportunity to voice concerns over decisions made to one of the nation’s largest healthcare programs.

A presidential idea
As Congress was drafting healthcare reform legislation, President Obama mentioned the idea of providing MedPAC with authority to make cost-cutting decisions. He described it as “an independent medical advisory committee modeled on the kind of committee that is called MedPAC right now.”

As the President was ramping up support for this idea, Sen. John D. Rockefeller IV (D-W.Va.) introduced two bills that would expand MedPAC’s authority by making it a new agency within the executive branch. With this standing, any reimbursement and cost reduction recommendations from the board would go into effect without Congressional oversight.

With strong pressure from the White House, the House and Senate both considered including a variation of an independent advisory commission in healthcare reform. Many representatives opposed the idea, forcing it out of the final legislation passed by the House. The concept gained traction in the Senate, however, where Sen. Rockefeller continued to press for a board, citing it as a cost-saving mechanism. The concept—strengthened by a variety of amendments—was part of the final Senate bill.

What’s next?
Whether an independent advisory board will ultimately be part of a health care reform bill is not yet known. The AAOS strongly opposes the inclusion of this type of independent board in healthcare reform, believing that decisions regarding the Medicare program should remain under Congressional oversight.

“The creation of an IMAC-like entity would severely limit Congressional oversight of the Medicare program and replace the transparency of Congressional hearings and debate with a more opaque process with, at best, minimal accountability for the healthcare decisions it makes,” said Joseph D. Zuckerman, MD, AAOS president.

The AAOS also joined 15 other surgical organizations, including the American College of Surgeons, writing to Speaker Pelosi. The organizations noted that “Medicare payment policy requires a broad and thorough analysis of providers and beneficiaries, and leaving these decisions…in the hands of an unelected, unaccountable governmental body with minimal Congressional input will negatively impact the availability of quality, efficient health care to Americans. Should provisions to place the authority for Medicare payment policy in an unelected executive agency be included in any legislation at any point, the surgical community would vigorously oppose this legislation, regardless of any other provisions that may be included.”

The AAOS has also argued that the composition of this body would limit its ability to grasp the impact of decisions on the delivery of care, in part because physicians would not be able to “continue their careers while serving on such a policy-setting body at the executive branch level. As a result, such important perspectives that appreciate the patient-provider relationship would be lost.”

The AAOS office of government relations will continue to monitor legislation and provide updates to members through articles in AAOS Now and Advocacy Now.

Lauren Bates is government relations specialist in the AAOS office of government relations. She can be reached at bates@aaos.org

Nick Piatek is communications specialist in the AAOS office of government relations. He can be reached at piatek@aaos.org