June 20, 2018
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Medicare cost cutting not a job for Congress

By Dr. Erik Steele

If you want to see elected officials in Washington act like you asked them to lick a high-voltage subway rail, ask them to cut waste out of the $450 billion we spend every year in America on Medicare. Most scatter like chickens, which is no surprise, because they get fried every time they try to do that job. Opponents zap them with charges Medicare cost-cutters are harming those insured by Medicare, those insured by Medicare threaten to politically electrocute them at the next election and lobbyists Taser them with claims it’s not waste the politicians are trying to cut out, it’s Medicare’s heart.

Recognizing that few politicians will risk the political electric chair of Medicare cost cutting, the federal health reform law passed last year set up another way to help make difficult decisions to do the job; the Independent Payment Advisory Board. Designed to include physicians, patient representatives, insurance and health care economics experts and modeled on the highly successful commission that has closed many unnecessary military bases over the last 10 years, the advisory board is charged with cutting Medicare costs when those costs grow faster than planned.

Because the board might actually work, many politicians and lobbyists in Washington and elsewhere are trying desperately to cook its goose. The new reform law subjects Medicare costs to spending limits for the first time in its nearly 50 year history, in part by using the Independent Payment Advisory Board. Controlling increases in those costs to taxpayers means someone — drug manufacturers, knee and hip joint manufacturers, physicians, hospitals, etc. — will get less money in the future, and no federal spending ever gets cut without someone whose ox is getting gored trying to repeal the goring.

Repeal of the advisory board, however, would be a mistake in the long haul, because the only thing worse than having a panel of health care experts try to rein in unaffordable Medicare costs is to have Congress — among the least effective health care cost control groups in the world — try to do it.

Tightening our Medicare belt will mean some very difficult decisions about patient care: what surgeries and tests we stop paying for because they are of little real benefit, whether we can afford hospitals everywhere we currently have them, whether some new treatments should be approved for Medicare payment, etc. Leaving that job to people who have to get elected to office is like asking the kids managing a candy store to cut to off their friends from the sweets.

The British knew this when they set up the National Institute of Health and Clinical Effectiveness to study which treatments really do and don’t work well, and, thereby, which would and would not be paid for by government health insurance. They don’t try to make such decisions in the House of Commons.

Here’s an example of the issue: a few months ago an article titled “Four Surgeries to Avoid” appeared in the American Association of Retired Person’s magazine. It was about four common surgeries that are often of marginal benefit to patients but performed on hundreds of thousands of Medicare patients each year nonetheless. Congress could tackle the problem or, under the new law, it might direct the payment advisory board to study the issue and recommend whether Medicare should stop paying for those surgeries.

Which group — Congress or the panel of health care and patient experts — do you think would be most likely to get that decision right? I’m betting on the group that’s not only expert, but is not up for election next November, getting campaign contributions from physicians who do the procedures or getting toasted by political opponents for making tough decisions. I am betting on the group that does not have energy policy, immigration policy and a recession to deal with. So I am betting on the board to do that kind of job best.

Congress should shock us all by putting this rational method of Medicare cost control into effect, tweaking the payment advisory board process over time when needed and letting the board help make Medicare a financially sustainable program for the future.

Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.

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