Posted On: April 3, 2012 by Patrick A. Malone

Congressional Refusal to Consider Medical Cost Hurts Everyone

As the Supreme Court begins to grapple with the Constitutional challenges to the Obama administration’s health-care reform legislation known as the Patient Safety and Affordable Care Act (ACA), Republicans in the House of Representatives continue to object.

In the words of Fiscal Times correspondent Merrill Goozner, writing on his GoozNews blog, the GOP “took another swipe at the alleged rationing in Obamacare” when they voted to disband the Independent Payment Advisory Board (IPAB). Its purpose is to examine Medicare spending when it grows substantially faster than the economy, and to offer Congress options of how to rein it in. Congress may exercise its suggestions, or enact its own cost-control measures.

That’s a reasonable oversight responsibility for a panel of 15 experts designed to resist political pressure. But Republicans have used fear and loathing to mischaracterize it and, by extension, the rest of health-care reform. They called the IPAB a “death panel,” accusing it of rationing care for the elderly.

Neither party can claim success in moderating Medicare spending, and Goozner indicts the tone of the House debate over the IPAB as the “perennial obsession with the next election, not the next generation.”

The House vote is insignificant because the Senate won’t confirm eliminating the advisory panel, but, Goozner notes, there’s irony in the fact that the vote occurred only a day after a different advisory panel at the Centers for Medicare and Medicaid Services (CMS) convened to discuss coverage issues. That meeting illustrated how wise rationing could save both patients and the government billions of dollars a year without jeopardizing care.

We’ve addressed the issue of cost-effective, appropriate care, by no less a vested interest than the American College of Physicians. The CMS panel, Goozner reports, considered whether there was sufficient scientific evidence to support a Medicare decision to subsidize drug treatments for diabetic macular edema. Caused by diabetes, the disorder compromises vision and can cause blindness.

An expensive drug made by Roche/Genentech called Lucentis is under consideration by the FDA. It costs $1,624 for a monthly shot which diabetics would require for the rest of their lives. Another drug, also made by Roche/Genentech, called Avastin, is equally effective. It’s essentially the same drug, but it’s compounded in larger doses than the newer, pricier version, and was approved by the FDA as a cancer, not diabetes, treatment.

Eye doctors, as Goozner explains, understand that dividing Avastin into smaller doses appropriate for injection into the eye pencils out to $43 per treatment.

If Avastin sounds familiar, that’s because of its recent notoriety over serious side effects, and problems experienced when eye injections are performed improperly.

But that’s not Goozner’s focus here. He’s concerned that the 325,000 Medicare beneficiaries who have diabetic macular edema and might qualify for the treatments must pay 20 percent of the cost as a co-pay. That’s $324.80, every month, for Lucentis, versus $8.60 for Avastin. The seniors get burned, and so do taxpayers.

“If everyone on Medicare who is eligible for the treatment receives Lucentis, it will cost the government $6.3 billion a year,” Goozner says, according to a report submitted to the panel. “If they receive Avastin, the government will pay only $167.7 million.”

The CMS committee, by law, may not consider cost when evaluating whether or not to pay for a treatment. The reform law that Republicans are trying to repeal says comparative effectiveness research paid for by the government—research such as the assessment on diabetic macular edema—cannot be used in making payment decisions.

So the committee’s vote reflected only science, not cost. It decided that both drugs worked about the same.

Currently, both are being used “off-label,” that is, for a purpose other than what they were approved for by the FDA. Still, Medicare contractors in about half the states, Goozner reports, pay for them. Once the FDA approves Lucentis for diabetic macular edema, Roche/Genentech won’t submit an application for Avastin as a treatment because they’re concerned about profit, not price. By law, Medicare must pay for an FDA-approved drug. And doctors, who get a small piece of the price of drugs they use in their offices, will have an incentive to use the more expensive, approved drug.

So, explain to us, again, why the ACA’s Independent Payment Advisory Board should be eliminated?

If you wish to register your opinions on rational rationing or irrational non-rationing and their effect on the public and individual bottom line, contact your Congressional representatives. You can find them here, as well as Congressional leadership.

People interested in learning more about our firm's legal services, including medical malpractice in Washington, D.C., Maryland and Virginia, may ask questions or send us information about a particular case by phone or email. There is no charge for contacting us regarding your inquiry. A malpractice attorney will respond within 24 hours.

All contents copyrighted Patrick Malone & Associates except where copyright held by others. Reproduction in any form prohibited except where expressly granted.

Bookmark and Share