By Bill Peckham
Monday I questioned Do MedPAC reimbursement recommendations matter? pointing out that Medicare updates are in HR 6331, the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 which makes the MedPAC recommendations a formality. Today RenalWEB linked to a transcript of last Friday's MedPAC meeting.
MedPAC covers a lot of ground so the transcript is mostly unrelated to dialysis. As RenalWEB warned it's a "398-page pdf file. Updating payments for dialysis services is covered on pages 149-167." (PDF link). MedPAC staffer Nancy Ray's presentation is interesting, it starts on page 149 and goes for nine pages - the transcript is a quick double spaced read. The chair's summary starting on page 158 get's right to it noting that while their numbers show a 1.2% adjustment is warranted they are acknowledging reality, the reality is that current law calls for a 1% update in 2010, so why not call 1% good.
One of the other commission members questions whether they should take the legislation into consideration or just go with their data. I'd summarize the chair's response as: future updates to reimbursement are already legislated and he didn't see a role for MedPAC in "undercutting that agreement that had been worked out in the Congress with the dialysis industry" meaning MIPPA. I thought that was a telling statement. He goes on to say the 1% update is certainly in the range of reasonableness, who's to say what the exact percent should be, so on to skilled nursing facilities. That makes sense to me, under the circumstances it would hard to make the case for 1.2% vs. 1% but the question is raised - who's point of view is MedPAC representing?
The MEdPAC About page is vague:
Independent. Advise Congress on how much Medicare should allow providers to charge. But from who's point of view do they assess the data? Are they taking Congress's point of view? If their priority is to not undercut some deal Congress struck then it sounds like Congress is the contractor not the client. What is Congress's point of view?
DHHS Secretary designate Tom Daschel in his book Critical calls for the creation of a Federal Health Board, a body with the independence and power of the Federal Reserve Board which governs banking (the Fed probably sounded like a better model before the current crisis). I think what Daschel is calling for is something like MedPAC, only with actual statutory power. The Federal Reserve Bank has broad power - intervene in markets, set base line interests rates; the Federal Health Board would have broad power to set reimbursement and treatment standards in healthcare. DHHS working with the Health Board would be like the US Treasury working with the Federal Reserve.
Reading through the MedPAC transcript it really calls into question how something like that could work. How could any Board or Commission sized group of people have the time and depth of knowledge to find the "right" reimbursement rate? There are a lot of dread diseases. It's one thing to have expertise in banking, in money flows but healthcare is not banking. It's a lot more complicated and people's lives are on the line. There are hundreds of specialties. Who could decide what would be the right commitment of resources? Who's to say? What point of view are you taking? At the MedPAC meeting there was no discussion of the negative SDO Medicare margin as something that needs to be addressed. The bias is to reward financial efficiencies which then promotes consolidation. Is consolidation an objective? Or is it a cost? Should we design the system for the people buying the needles or for the people on the sharp end of the needle? There are big changes coming already to the provision of dialysis, with the details of many MIPPA mandated changes still left to be determined. More changes are likely to come.
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