The Medicare Payment Advisory Commission (MedPAC) held a two-day public meeting September 17-18, 2009 in Washington, DC. The Commission meets publicly on a regular basis to discuss Medicare issues and policy questions and to develop and approve its reports and recommendations to the Congress. At these meetings, commission staff present research and policy options for the Commissioners to discuss, and time for public comment is provided.
     » View agenda and presentations for the September 17-18 meeting.

Context for Medicare Payment Policy

MedPAC’s March 2010 Report to the Congress will include an introductory chapter that puts the Commission’s recommendations within the broader budget, policy, and health care delivery context in which the Medicare program operates. The chapter will address the challenges the program will face in the future, and how the program fits within the broader U.S. health care system, along with factors driving increasing costs. MedPAC staff presented topics for consideration that addressed Medicare expenditures and health care spending in the United States compared to other countries.

Factors identified as major contributors to the growth of health care spending include technology, income, insurance, prices, changes in longevity and demographics, health status and organization of the delivery system. Other topics focused on price accuracy and equity, quality and coordination of care, information for patients and providers, as well as cost issues for Medicare beneficiaries and policymakers.

The Commission commended staff on the framework thus far and suggested the chapter accomplish two broad goals. The first goal is to provide updated information on cost trends and the status of the Medicare trust fund. The second goal is to provide MedPAC’s perspective on policy issues and how Medicare ought to evolve in the future.

Comparative Effectiveness: Physician Perspectives and On-going Initiatives

For this presentation, MedPAC staff reviewed the Commission’s previous work and recommendation on comparative effectiveness research (CER) and presented findings from recent physician focus groups describing physician perspectives on CER.

In July and August of this year, the MedPAC conducted six physician focus groups in Baltimore, Chicago and Seattle. Participants included a mix of primary care physicians and specialists. These focus group discussions revealed that physicians had a very diverse range of opinions about comparative effectiveness. In general, CER initiatives are not well understood by practicing physicians, and while the majority welcomed more data on comparative effectiveness, there was concern about the aspects of research. Very few participants had little access to head-to-head comparisons of drugs, devices, or procedures. Several felt that current guidelines from their specialty societies were consensus-based because evidence did not exist. Though specialty societies seemed to be a generally trusted source of evidence, there was concern that consensus-based guidelines could be shaped by professional biases and conflicts of interest. The National Institutes of Health (NIH), U.S. Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) were also cited as trusted sources.

Participants also mentioned that CER studies should take into account not only outcomes, but also side effects of treatment, quality of life and differences among groups. This opinion is consistent with the Heart Rhythm Society’s position stated in a June 1 letter to Congressmen Schrader in support of the Comparative Effectiveness Research Act of 2009 (H.R. 2508). The Society wrote that “CER should not encourage a generalized, 'one-size fits all' approach. Rather, it is necessary to design studies and communicate results in ways that reflect variation in individual patient needs and account for differences among patients, including co-morbidities, sex, race and ethnicity.”

The focus group participants felt that CER findings should be concise, easy to read, and easily accessible. This opinion is also consistent with the Society’s position. We agree that “comparative effectiveness programs should include transparent decision-making procedures and broad stakeholder representation to enhance the credibility and usefulness of such studies.” Some also worried about the effect CER will have on innovation. Manufacturers of drugs and devices that proved less effective than alternatives could be driven out of business. A number of participants linked CER to liability reform and that it could make them vulnerable to lawsuits if they used alternative treatments.

Some focus group participants were opposed. Those who were most opposed felt that they got all the information they needed from annual conferences, journals, drug company representatives, and their own experience. They worried that CER would lead to mandatory guidelines from both the government and private payers. They also worried that the research would only show the most effective treatment, on average, and ignore sub-populations.

The Commission broadly discussed how to address the concerns raised by the focus group participants, specifically how to ensure CER studies are credible and unbiased, and development of effective dissemination system, such as a clearing house or a designated web site.

Greatest Total Medicare Spending And Fast Growing Episodes

MedPAC staff presented a cross-silo perspective on levels, growth and variation in Medicare spending for certain episodes of care. The data was retrieved using a data tool developed by Ingenix, Inc. that captures episode treatment groups (ETG). The ETG software groups Medicare claims into approximately 500 clinically distinct episodes of care. The base classes are further split into more granular ETGs. Of the possible episodes, the presentation focused on the 20 fastest growing clinical episodes that accounted for the greatest share of total Medicare spending in 2005.

Atrial fibrillation and atrial flutter were identified within the 20 fastest growing episodes between 2002 and 2005. The episodes were then ranked according to geographic areas (Boston, Greenville, Houston, Indianapolis, Las Vegas, Miami, Minneapolis, Orange County, Phoenix and Portland). The data showed variations in spending for the same episode in different locations.

The Commission discussed focused on the underlying incidence of diseases that account for the fast-growing episodes and different ways to analyze growth contributors. There was also mention of the RUC’s implementation of a number of screens to identify services with high utilization and how to link the two sources together.