If Congress Can't Stand the Heat, Could MedPAC?

Call it an admission that Congress simply can't perform one of its most important duties—controlling the purse strings. That's the undertone of what President Obama was saying when he sent a letter to Sens. Max Baucus and Ted Kennedy proposing that MedPAC be empowered to determine Medicare reimbursement to providers. Though the letter covered many areas of the healthcare reform debate, it suggests that MedPAC be elevated to an executive-level agency, under which its recommendations would automatically be adopted unless opposed by a joint resolution of Congress.

While the move would raise troubling questions about the separation of powers under our Constitution, it would not be unprecedented. Obama cites the similarities of the proposal with Defense Base Closure and Realignment Commission, which was charged with determining which military bases to close over the past couple of decades. Under its watch, more than 350 bases have been closed since 1989 to save money on operations and maintenance.

Healthcare and the military don't have much in common on first glance, but the same issues that prevent members from making tough decisions on military bases that bring huge dollars to their congressional districts are also in operation in healthcare. Every member of Congress has a hospital or two in his or her district—not to mention dozens of other businesses that depend on Medicare's largesse. Seeing those hospitals close or seeing other businesses suffer because of payment cuts is politically unpopular.

So even if it no longer makes sense to provide a payment pool that keeps every hospital, physician practice or ancillary provider solvent, Congress has a tough time implementing these decisions. That's why every year they roll back many of MedPAC's toothless recommendations. However you feel about the annual double-digit physician reimbursement cut MedPAC suggests, Congress makes a mockery of the commission not only by rolling back the cut but also by annually increasing payments, generally by a small percentage.

So much for leadership, but aside from that, it seems like a good idea. Congress can police the more draconian of recommendations, but could only overturn MedPAC's recommendations in a fairly blunt way. That power would encourage MedPAC to be more circumspect about its recommendations, because they will have a better chance of actually being enacted. Still, I have my doubts that Congress would willingly give up so much power to the executive branch unless a true crisis is at hand. I think we're there, but despite the rhetoric on healthcare reform, I'm not sure Congress agrees.

What should healthcare leaders take from this? Slowly but surely, government leaders are beginning to treat the healthcare cost problem as seriously as it deserves to be treated. The letter's not the only evidence. Legislation introduced May 20 by Sen. Jay Rockefeller (D-WV), chair of the Senate Finance Health Care Subcommittee, echoes the president's letter in that it calls for MedPAC to have new authority to implement Medicare payment policy. As proposed under the bill, MedPAC would be renamed the Medicare Payment and Access Commission and given new powers, such as determining payment rates for physicians and hospitals.

If this idea has any legs, Congress should change the way MedPAC's board is structured. For one, the commission's 17 members are part-time, and are generally active hospital administrators and physicians. They're appointed for three-year terms by the comptroller general, who himself is appointed by the president to a 15-year term.

In an article by my colleague Janice Simmons, Robert Berenson, MD, who advised Rockefeller on the bill, suggests that full-time officials who no longer have any conflicting interests should staff a new MedPAC, to fully represent the public's interest. Currently, Berenson told Simmons, Congress doesn't get a balanced view of the big picture surrounding the healthcare cost problem.

"You get a concerted effort by affected stakeholders presenting one point of view to Congress—and nobody essentially on the other side," he says.

If the proposal were to be adopted, we should be careful not to consider it a panacea to the unsustainable healthcare cost problem. Never underestimate Congress's ability to undermine any sensible idea about controlling costs and limiting spending. When it comes to lobbyists, Congress continues to demonstrate an inability to say the word "no."