The Independent Payment Advisory Board and Medicare Spending: New Research Suggests a Change in Our Medical Culture

Launch of the ACA’s controversial Independent Advisory Board– a  panel charged with  recommending ways to curb Medicare inflation — has been delayed until 2016. Does this means that the IPAB’s critics have won?

No. IPAB was, from the beginning, only meant to serve as a backstop. The law says that the board will be asked to recommend places where we could pare Medicare spending if—and only if—Medicare inflation begins to outstrip inflation in the rest of the consumer economy.

But over the past three years Medicare spending has decelerated; it is no longer growing faster than the economy as a whole. This is why Medicare’s chief actuary has decided to put IPAB on hold.

Some observers argue that as the economy recovers from the Great Recession, the nation’s health care bill is bound to climb. I disagree. Particularly in the case of Medicare, I don’t think that the economic downturn explains most of the slowdown. 

 I believe that reform is already having  an effect on health care inflation:  Four years of debate over the Affordable Care Act has made us more aware of the waste in our health care system. Patients are asking more questions, and providers know that they are going to be held accountable for that waste.

                                 We Still Need IPAB as a Backstop

That said, in the future, spending could pick up–and we may need IPAB. This is why President Obama has made it clear that he will veto any attempt to eliminate the Board.

It is important to know that IPAB exists, as a reminder to drug companies, device makers, nursing homes and others that, one way or another, we can no longer afford a system that is wasting $1 out of $3 of our health care dollars on over-priced, unnecessary tests and treatments that, too often, put patients at risk without benefits.

If, and when, IPAB is asked to recommend cuts it will use medical evidence to decide where to trim. IPAB is likely to recommend lower payments for certain services and products that medical research tells us are now “overvalued”–based, not on cost-benefit analysis, but on patient outcomes. If patients who fit a particular medical profile are not helped, Medicare should not cover the treatment for those patients.

As I have explained in the past, IPAB is not the panel of bean counting bureaucrats that Obamacare’s opponents suggest.  IPAB will not “ration” care; it is charged with making care more rational by letting Science–rather than lobbyists– decide what Medicare should cover.  Moreover, Congress can veto IPAB’s recommendations, if legislators can agree on  ways to achieve equal savings– without rationing care, or shifting costs to seniors.

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PSA Testing: An About-Face

If you thought U.S. doctors would never accept evidence-based medicine, consider this: Just last week, in a stunning about-face, the American Urological Association(AUA) announced that it no longer recommends routine annual PSA testing for men under 55.   

The organization added that “men ages 55 to 69 who are considering the PSA test” for prostate cancer “should consult their doctors about the test’s benefits and risks.”

The potential “benefit of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade” should be weighed  “against the known potential harms associated with screening and treatment [which include side effects such as incontinence and impotence }  For this reason, ” shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening,”  The AUA stressed that “ patients’ values and preferences” should direct a final decision.

.In addition,  the AUA announced that “to reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening.

I wrote about “shared decison-making” and how it could help patients considering a PSA test make an informed choice  here on HealthBeat back in 2007.(Readers interested in why this protocol is so important to patient-centered medicine may be interested in this story that I wrote for Dartmouth Medicine: “Making Choice An Option.” )  Congratuations to the AUA for having the courage to take this giant step forward into the future of medicine.

“The new guideline is significantly different than previous guidance,” the organization acknowledged, noting that it “was developed using evidence from a systematic literature review rather than consensus opinion.” In other words, urologists didn’t take a vote; they looked at the Science.

Authors of the new guidelines have “learned very quickly that there really was no high-level evidence supporting the use of screening with PSA,” said urologist H. Ballentine Carter, who chaired the panel that wrote the new guidelines.”                         

When I last wrote about PSA testing, in July of 2012, such a radical shift in the AUAs positions would have been unthinkable.  At the time, the U.S. Preventive Services Task Force (USPSTF) had given PSA testing a grade of “D”—suggesting that benefits did not outweigh risks. 

 In response, urologists joined forces with Republicans to threaten the autonomy of the USPSTF by supporting  a House bill (H.R. 5998)  that proposed to mandate “greater role for specialists and advocacy groups” in developing guidelines”  while ”eliminating the Department of Health and Human Services’ secretarial discretion to withhold Medicare funding for interventions that lack convincing evidence for benefit.”      

What a difference a year makes.