I've been an active advocate (some would say agitator) for health care reform for more than 20 years, so I'm thrilled to see the progress we're making now.  It's not all I hoped for, but I've learned that progress comes in small steps.  There is much to be supported, if not applauded, in the current efforts to reform our health services systems, but there is one idea floating around out there that is not just dumb, it's dangerously dumb (well, actually, two dangerously dumb ideas, counting this one).  That is the proposal to beef up the Medicare Payment Advisory Commission (MedPAC) and give it official rate-setting authority for Medicare. Unfortunately, that would be like putting the Village Idiot on steroids.
MedPAC is to health policy what bumper stickers are to philosophy.  For the past 15 years, I have been trying to keep the home health care nurses of Wisconsin safe from MedPAC's well-meant but bumbling efforts to recommend Medicare policy to Congress.  It's often felt as if we're living out "Of Mice and Men" and begging George - Congress -- to protect us from Lennie, his good-hearted but low-IQ friend with impulse control problems.  Lennie - or MedPAC - has been strong enough to do real harm all along, so the notion of pumping him up with steroids is cause for real fear.
Just how handicapped is our Lennie?  MedPAC's memory and vision are severely impaired, as are its abilities to understand and perform basic math and statistics.  MedPAC has extreme problems making associations between related items, often lives in a fantasy world and cannot seem to grasp the gravity of its own shortcomings.
Example:  When MedPAC gathers data on which to base its recommendations, it does not use random sampling to get an accurate picture of what's happening in health care.  Try to explain the concept of garbage-in-garbage-out data to Lennie and you'll get nowhere.  Bad data leads MedPAC to bad recommendations, bad recommendations too often lead to bad policy, and bad policy leads to less than the best health care for Medicare patients.
Example:  MedPAC knowingly neglects to include nearly 1,700 hospital-based home health agencies (21% of the total, but in excess of 60% to 80% in some states) in its analysis of home health margins, and refuses to acknowledge any data that does include them and shows quite different results from their own.  A member MedPAC's own board of directors made MedPAC aware, but that awareness has been fruitless.  In rural areas, such as we have in my home state of Wisconsin, these agencies are often the only provider in the area.
Example:   Medicare's PPS model for paying for home health services is deeply flawed and creates enormous inequities in payment.  Rather than examining the systemic weaknesses and recommending corrective actions, MedPAC simply recommends deep, indiscriminate, across-the-board cuts to address those areas and providers that have "too much" of a margin - never mind what the cuts will do to providers who have little margin, no margin or a negative margin.  In fact, MedPAC's willfully ignorant recommendations only serve to make the problems of PPS all the worse.  They don't address the high margins, they don't address the wide range of margins, and they don't account for the care that will be lost to the cuts.
Currently, 35% of all agencies have negative margins (they're losing money) under Medicare. With the MedPAC recommendations, that will rise to 65%. There will be parts of the country where virtually no agencies will break even with Medicare, and Wisconsin - one of the most frugal of all states with regard to Medicare spending - is one of them.
Example:  When MedPAC recommends policy in response to profit margins among Medicare providers, it uses a national average and fails to examine, understand and account for the wide range of margins.  It fails to account for regional and clinical differences.  In fact, even in arriving at its national average MedPAC specifically excludes provider types that have the lowest, often negative, margins.  Again, garbage-in-garbage-out.  Again, bad data leads to bad health care policy. The MedPAC recommendations will not solve any perceived problems with Medicare margins. Instead, these recommendations will exacerbate any problem with the inaccuracy of the payment model by closing the providers with low-margin and leaving us with only the high margin.
Example:  When home health care moved, in the late '90s and early '00s, from fee-for-service, through the "interim payment system" (IPS) into its current "prospective payment system" (PPS), home care was devastated.  IPS also rewarded agencies with high margins and punished those with low margins.  Thousands of agencies went belly up and a million patients fell from Medicare's home care rolls.  MedPAC, ignoring all available data (as well as reality, experience and logic) celebrated the reduced number of home care visits to the success of the newly created PPS rather than the gutting effect of IPS.
Worse, MedPAC ignored the human and financial costs of IPS:  Those million patients had to have either gone to institutional care, which is obscenely more expensive than home care, or gone without care.  When I asked where the lost patients went, state and federal bureaucrats said it wasn't their job to track them.  No one knew what happened to them, but everyone agreed that some of them went without care - and some of them died because of it.  Lennie at his worst.
MedPAC is to health policy what Fox news is to journalism.  Showing a severe memory loss turns MedPAC numbers and recommendations to mush.
Example:  MedPAC is trying now to argue that changes in home health care require changes in its reimbursements and once again failing to deal with reality.  In fact, it fails to account for its own actions.  For instance, it told Congress that the home care reimbursement rate is based on an average of 31 visits when, in reality, MedPAC had already reduced it to 25.3.  MedPAC also failed to account in changes in the delivery of home health that had already reduced the payment rate by more than 28%.
Example:  In its most recent recommendations on Medicare funding for home health, MedPAC failed to account for a series of cost cuts already in effect or already planned: a 1.1% cut in 2002; 15% cut in 2002; 1.1% in 2003; 3.2% in 2006; 2.75% in 2008; 2.75% in 2009; a planned 2.75% cut in 2010 and a proposed 2.71% cut in 2011.  In projecting the savings of the latest round of cuts, MedPAC completely ignored the savings already achieved.   (Thanks to revisions to the PPS, the base payment rate for home care is now less than it was in 2002.  Large changes were made to the system in 2008 - the fourth new payment model for home health in 10 years - and the effect of those changes has not been measured, yet MedPAC is making recommendations based on assumptions about those effects.)
MedPAC is to health policy what Teabaggers and Birthers are to civil discourse.  MedPAC frequently works in a fantasy in which it knowingly ignores reality.
Example:  MedPAC uses data from cost report forms despite knowing full well that more than 20% of the forms contain erroneous data.
Example:  MedPAC recommends bundling home care payments with payments to hospitals, despite knowing that hospitals have no experience in the management of post-acute care and no infrastructure to manage utilization review. MedPAC knows but ignores that hospitals are the highest cost sector, so this is not the place to locate efficiencies in post-acute care.  MedPAC knows but ignores that community-based providers that have a breadth of experience in providing post acute care and avoiding unnecessary hospitalizations.
Example:  To build a meaningful payment model, MedPAC must analyze the causes behind the great disparity in costs - differences in characteristics of patients served, efficiencies, economies of scale, location, size, labor costs, factors outside the control of the home health agency, or happenstance - but, instead, MedPAC makes fantasy-based one-size-fits-all recommendations based on revenue. MedPAC knows that it doesn't know what it needs to know about variations in cost, but it moves ahead in its fantasy that it can build a reasonable payment model without knowing why one home health agency's costs are significantly different than another's.
Example:  MedPAC creates recommendations in the fantasy that all home care agencies are the same, located in the same area, work under the same circumstances, serve the same patients and incur the same costs.
MedPAC is to health policy what Jerry Falwell was to Christianity. MedPAC has trouble seeing how parts of the health care delivery system relate.  MedPAC's vision seems to fall into silos or tunnels and cannot perceive the whole landscape.  MedPAC can't seem to grasp that cutting in one setting may drive up costs in others, or spending here may save there, or other relations within the health system. Unless and until MedPAC's vision and cognitive skills improve to where it can analyze across settings, across patient demographics, and across the spectrum of preventive/acute/post-acute/long-term care, MedPAC will remain a bumbling Village Idiot, leave a wake of pain and destruction.
And putting a creature this dumb on steroids isn't just asking for more trouble, it's begging for it.  The Village Idiot will oblige.  Lennie go be on a rampage, George will be too slow to prevent the damage, and millions will suffer for it.