Medicare Advisory Panel ‘Changes the Debate': Outgoing Director

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By Mindy Yochelson

Congress may not act on every recommendation from its top Medicare advisers, but MedPAC has changed the direction of the debate on the country’s top health-care entitlement program, the panel’s outgoing director told Bloomberg Law.

Issues such as developing a unified payment system to cover different post-acute settings, like nursing homes, captured the attention of the relevant Senate and House committees after they appeared on the Medicare Payment Advisory Commission’s meeting agendas, Mark E. Miller said. He leaves his post Dec. 1 after 15 years of supervising the policy agenda of Congress’s Medicare advisory commission.

MedPAC keeps no formal record of which of its semiannual recommendations is acted upon by Congress. Lawmakers might not pass MedPAC’s recommendations intact as legislation. But at the same time, issues are brought to their attention because of MedPAC’s work, Miller said.

Physician Payment

One policy issue on which the MedPAC commissioners left their fingerprints was the repeal of the sustainable growth rate formula, which was used to reimburse doctors under Medicare. The SGR caused Medicare doctor reimbursements to become an annual merry-go-round of double digit cuts—and congressional repeal of those cuts.

Congressional legislation changing the physician payment system was broadly consistent with MedPAC’s recommendations.

Others issues influenced by MedPAC’s work included changing the Medicare Advantage payment system to ensure that managed care payments are closer to fee-for-service payments, establishing the Part D outpatient drug benefit, and reforming graduate medical education, Miller said.

But as he leaves, costs for both the Part D outpatient drug benefit and the Part B office-administered drug benefit remain outstanding problems. “The cost of drugs is something that the Congress is going to have to face,” he said.

Also looming is the problem of spending by beneficiaries dually eligible for Medicare and Medicaid. Dual eligibles make up a disproportionate percentage of Medicare beneficiary costs. But they aren’t a monolithic population so it’s difficult to tailor an appropriate delivery system to accommodate all their needs, he said.

Another Look

And, like the proverbial bad penny, the physician reimbursement system is back on the MedPAC agenda in 2017. The commissioners are taking another look at the doctor payment system that replaced the SGR this year.

Miller defended expected draft recommendations on the topic so soon after repeal of the SGR.

The replacement law, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), created a two-track doctor payment system. One of the tracks, the Merit-based Incentive Payment System (MIPS), requires doctors to report quality measures to Medicare. Their reimbursements are based on those measures. The commissioners have been discussing a replacement system for the MIPS track. They say MIPS is complex, pricey, and won’t help doctors improve their performance or help beneficiaries choose a quality professional.

Miller defended expected recommendations to repeal MIPS just months after it began, with some professionals calling the move premature. Although MIPS was implemented Jan. 1, MACRA, the legislation that created it, was around before that, he said. MedPAC’s job description is to refine and redirect legislation, particularly laws like MACRA that cost billions of dollars and affect millions of professionals, he said.

Building a Consensus

The 17 commissioners are from varied backgrounds and don’t think in lockstep. MedPAC staff helps the chairman develop a consensus as recommendations ripen to a vote.

“We listen very carefully to their questions and concerns,” then respond with evidence to back up the recommendations, he said. The recommendations are designed to accommodate the broadest of commissioner viewpoints, he said.

During the past 15 years, the Medicare program has evolved from one based less on government-administered pricing to one based more on managed care and pay-for-performance. Beneficiaries are now urged to choose providers based on quality, he said.

As the second person to hold the job of executive director and the first to hold it for a long time, Miller said he built MedPAC’s reputation in part by maintaining cordial relationships with the relevant congressional committees.

As a result, when there’s a question about Medicare, “the first phone call is to MedPAC,” he said.

Moving On

But now it’s time to move on.

Miller will become vice president of health care for the Laura and John Arnold Foundation, a private philanthropy.

The new post he said could impact health-care policy beyond Medicare and the halls of Congress. As an example, the foundation gave $5.2 million in 2015 to the Institute for Clinical and Economic Review, an independent nonprofit health-care research organization. The money was for a program to produce reports on new drugs approved by the FDA that will show the drug’s comparative effectiveness and cost effectiveness. The reports are intended to potentially affect health system budgets and change patient care.

“I think this new position is a real opportunity to try to effect positive change through a variety of channels,” Miller said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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