Dermatologists oppose healthcare reform's IPAB panel, lack of Medicare fix

April 1, 2010

Dermatologists say they will vigorously oppose many portions of the newly passed healthcare reform bill, although they say it's too soon to determine exactly how. Chief objections are the bill's creation of an independent payment advisory board (IPAB) for Medicare and lack of a fix for Medicare's sustainable growth rate (SGR), sources say.

Key Points

Chief objections are the bill's creation of an independent payment advisory board (IPAB) for Medicare and lack of a fix for Medicare's sustainable growth rate (SGR) formula, sources say.

"With all the backroom deals cut with the health insurance industry and the hospital associations, among others, I'm not surprised" that the bill passed, says Daniel M. Siegel, M.D., clinical professor of dermatology and procedural dermatology fellowship director, SUNY Downstate, Brooklyn.

Bruce Deitchman, M.D., says that while he applauds the bill's attempts to corral insurance-industry excesses, the PPACA provides "no mechanisms to prevent overcharging, to prevent denial of care through the straw men of preauthorization and preapproval, and to return the practice of medicine from the tyranny of insurance companies to doctors."

He is clinical associate professor of dermatology, New York University Medical Center.

"The legislation does provide coverage for more Americans who were previously uninsured, eliminates (denials for) pre-existing conditions and strengthens wellness efforts," adds William D. James, M.D., American Academy of Dermatology (AAD) president.

Lone bright spot?

Regarding wellness, he says that the PPACA's 10 percent tax on indoor tanning will "discourage all individuals, especially young people, from this dangerous practice." This tax, championed by groups including the AAD, replaced a proposed 5 percent tax on cosmetic procedures contained in an earlier Senate healthcare bill.

However, Dr. Siegel says the tanning tax is the bill's only bright spot. The creation of the president-appointed IPAB for setting Medicare rates is "probably the worst nightmare of all," he says. "That lets Congress abrogate its power to legislate to an appointed committee that will be able to create policy that, if not specifically overridden by Congress, will become law."

Unlike the Relative Value Update Committee (RUC) system now used, Dr. Siegel says the IPAB could slash any specialty's Medicare reimbursements without input from the specialists affected. Additionally, he says that with no permanent SGR solution, "We'll be in the same boat every year - begging Congress to correct that. And we shouldn't be asking to stop the Medicare reductions. We should be asking for cost-of-living increases."

Furthermore, instead of a public option, the bill creates state-run exchanges where lower-income Americans can purchase health insurance, sometimes with government subsidies.

"Since Medicare runs a 2.5 to 3 percent overhead and is the least-hated insurance program out there," Dr. Siegel says, "if healthcare is a privilege, the status quo is fine. If it is a right, and President Obama wanted true reform, Medicare for all should have been the way to go."

More objections

Dermatologists also worry that patient care could be impacted. Under the PPACA, Dr. Lebwohl says, "We are going to cover 30 million extra people with the same number of doctors. Care will suffer somewhere."

Dr. Deitchman adds, "The expansion of Medicare, while well-intentioned, is a time bomb which will explode on the states two or three years after it begins," when states must take over payment for increased fees that the PPACA sets for primary-care doctors.

The bill also states that doctors will be reviewed based on claims data, "and those that use more (services) and code with higher complexity will be penalized with decreased reimbursement," says Margaret E. Parsons Sander, M.D., a Sacramento, Calif., dermatologist in private practice and president of the Sierra Sacramento Valley Medical Society.

Dr. Deitchman says that if he orders more biopsies than a colleague does, it might simply reflect that he sees more potential skin cancers.

Dr. Siegel and Ronald Wheeland, M.D., chief of dermatologic surgery, department of dermatology, University of Missouri, Columbia, Mo., add that the bill's 2,470 pages obscure as-yet-unseen problems.

"We will eventually find many loopholes and carve-outs done for the purpose of obtaining support," Dr. Wheeland says.

Dr. Siegel says most of organized medicine probably will object to the PPACA, "but how they will object is still up in the air." Possibilities include legal challenges and dumping Medicare, which many doctors already have done, Drs. Siegel and Lebwohl say.

AAD to seek changes

Dr. James says the AAD will "continue to strongly advocate for changes including a permanent fix to the SGR formula that threatens access to care for seniors and military families, and correcting problems with the IPAB, which as currently written could result in changes that will undermine access to care and destabilize healthcare delivery." American Medical Association (AMA) President J. James Rohack, M.D., echoes these sentiments in a March 21 statement.

At press time, 14 state attorneys general had joined in a lawsuit challenging the PPACA's constitutionality.

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