POISON PILLS AND HOT TICKETS  -- IS THE IPAB BOTH?

The Hot Ticket for health care on a national basis is the fate of the Affordable Care Act (ACA), also called Obamacare,  and its controversial arm to keep costs in check, namely, the Independent Payment Review Board (IPAB).  Congressional Representative, Anna Eshoo, D-Ca, in a recent exchange with this writer, said that demands to repeal the IPAB were ill considered because we need to control costs.

Medical historians know that the IPAB began life as the IMAB or Independent Medicare Advisory Board. When the Medicare community learned to what extent it was being targeted, cries of "death panels," exaggerated though they were, brought the IMAB to its knees, well, to one knee anyway, because it's now back on its feet as the IPAB in the ACA (Section 10320 thereof).

Meeting now in New Orleans is the American Academy of Neurology (AAN). In an official publication dated 23 March 2012, the following was stated: "The AAN strongly supports both IPAB repeal and medical malpractice reform ... with the addition of the poison pill (italics added) of liability reform, House Republicans were still able to pass IPAB repeal but lost most of the Democratic support."

For the uninitiated, a poison pill in legislation may be an element added as an amendment to a bill that causes a substantial number of legislators to pull away from the bill though they might otherwise support it. In this case, medical malpractice reform is not what the trial lawyers or their legislative allies want. So to them linking repeal of the IPAB to medical malpractice reform is a poison pill that works for their interests since it'll stop medical malpractice reform just as it's emerging again as a force.

In an earlier publication dated 14 July 2011, "Tell Congress to Eliminate the IPAB," AAN stated that the "IPAB effectively removes Medicare spending decisions from Congress  and leaves them up to an unelected, unaccountable board." Actually, the board members will be responsible to the politicians who get them appointed to the board.

If the name of the game, as Eshoo said, is to control costs, the meaning is clear -- cost control gets priority over the medical care that we as individual patients may actually get. It means that treatments favorably reviewed by professional organizations may not be approved for use by the IPAB because of obeisance to cost-control rules and regulations, not yet even codified.  Political considerations, not medical indications, now govern medical care.

In this instance, all it took to slow down IPAB repeal was to link it to medical malpractice reform. That's how poison pills work. Is there palliation for this poison pill? Yes, there could be.

Requiring Congress to be covered by the ACA and the IPAB should it survive could be palliative. Congress, knowing little about the bill, having passed it "to see what's in it," knew enough about it all along to know that they didn't want to be covered by it. So Congress exempted itself from ACA coverage. We should insist they extend the ACA, if it survives court challenge, so that Congress itself is covered by it -- that's when, and only then, will we  know with reasonable medical probability that the IPAB will either be eliminated or will conduct itself equitably.

Repeal of the IPAB or, at the least, modification of the ACA should be a top priority for any organization purportedly devoted to equitable medical care.

"WHAT WE DON'T WANT IS PEOPLE MAKING ... DECISIONS BASED ON MONEY INSTEAD OF CARE OF THE TROOPS," intoned Representative Norman Dicks, D-Belfair

In our previous column we discussed how insurance companies can twist policies and distort the Affordable Care Act so that denials of care replace rationing. Now we have a situation wherein an actual diagnosis is rationed if not tossed to the winds, i.e., medical treatment for post-traumatic stress disorder (PTSD) in military veterans. This diagnosis can cost from $400,000 to $1.5 million in lifetime benefits.

Rep. Norm Dicks asked Army Surgeon General Lt. Gen. Patricia Horoho to explain how 14 soldiers diagnosed with PTSD had their diagnoses retroactively changed by a forensic psychiatry team in such a manner as to reduce the veterans' disability benefits.

This method replaces actual rationing of care because it allows forensic personnel concerned with costs to overturn a medical diagnosis upon which actual treatment was based. The implication is that the injured soldiers were incorrectly treated and were then awarded excessive benefits.

Keep in mind that the so-called forensic team does not interview and examine the patients -- what they do is a coding audit to determine if the submitted paperwork justifies the diagnosis. Here's an example: post-concussion head syndrome, not a PTSD diagnosis per se, is listed as ICD-9 code 310.2. This diagnosis may include headaches, vertigo and cognitive loss. But if the paperwork reflects headache such that a forensic team can claim with a modicum of reasonable medical probability that the formal diagnosis of 301.2 wasn't fully documented, the diagnosis can be altered to one less remunerative in terms of treatment and disability benefits, e.g., headache, 784.0 -- in this way the payer, whether government or a private insurance company, saves money, increases corporate compensation for the private insuror, and puts the screws to the injured party, a private patient or a wounded soldier.

While we appreciate Rep. Dicks' intervention for the soldiers, we ask where he stands on repeal of the Independent Payment Advisory Board (Section 10320) which is part of the Affordable Care Act for which readers will want to know how Dicks voted. Our expectation is that Rep. Dicks cares as much about Medicare recipients and patients generally as he does about PTSD veterans and their disability remuneration.

If Rep. Dicks wants to stop the deprivation of disabiity benefits to sick and injured soldiers, he just might want to do as much for sick and injured civilians. So might also my own Congressional representantive, Anna Eshoo, D-Ca.

How about it, Norm, Anna, and all other Members of Congress?

References

"Rationing Comes Home to Roost in the Form of Denial of Care," posted originally on www.politicsofhealthcare.com, 2/17/12, reprinted workcompcental, 2/24/12

"Army insists doctors at Madigan aren't discouraged from diagnosing PTSD," The News Tribune, by Adam Ashton, 2/10/12

"Head of Madigan removed from command admid PTSD probe," Seattle Times," 2/20/12, by Hal Bernton