Public Meeting of the Medicare Payment Advisory Commission (MedPAC)

January 15, 2015    
From the transcript

MS. [KATHY] BUTO: So, not having been [on the commission in 2008 when MedPAC recommended a] medical home pilot, were we anticipating a large increase in payments to primary care physicians, or just a greater degree … of authority … and status being given to primary care services? [p. 22]

MR. [GLENN] HACKBARTH [COMMISSION CHAIR]: [F]or me, there were two aspects of that recommendation for a medical home pilot. One was a change in the payment method for primary care, and second was an increase in the resources for primary care that might allow for practices to build more infrastructure, both staff and systems, to better coordinate care, especially for complex patients. To be frank, I’ve often thought since the time of that recommendation that it was a mistake to recommend pilots because of how drawn out and, ultimately, inconclusive that process often is, and hopefully, before I’m too far into my own Medicare years, we will get results from those pilots. I wish I were more optimistic that they would be definitive results. So –

MS. BUTO: Glenn, the method –

MR. HACKBARTH: Just a couple more points, Kathy.

So, the notion behind doing a pilot was, would the savings from better management of care be sufficient to offset the higher payment in the form of a per beneficiary lump sum payment to build infrastructure. That’s the – a key notion that’s being tested, as well as what happens to quality of care.

And, my own view … has become that even if the savings from better care management aren’t … large enough to offset the increased payment, the increased payment still makes sense, because we need robust primary care. … [W]e need to shore up the primary care delivery system and make it capable of caring for as many patients as possible … even if it means additional money. So, even if the pilot now comes back and says, well, the savings don’t offset the cost, I don’t think that means we shouldn’t do medical homes.

And, so, that’s why I feel like this was a mistake I made. We should have never recommended pilots. It’s an endless loop that you get into and not necessarily a productive one.
I’m sorry. [pp. 23-24]

In its June 2008 report to Congress, MedPAC jumped on the “medical home” bandwagon which had just begun to pick up steam. MedPAC recommended that Congress “initiate a medical home pilot project in Medicare.” (p. 22)  Glenn Hackbarth was one of two commissioners on MedPAC at that time who are still on the commission. He was one of 16 commission members who voted for that recommendation. (The seventeenth commissioner at that time, Nancy Anne DeParle, was not present.)

At MedPAC’s meeting on January 15, 2015, Hackbarth apologized for his vote. In the excerpt from the transcript of that meeting quoted above, Hackbarth states he wishes he had never endorsed pilot tests of the “medical home” concept. He offers two baffling justifications for this position: (1) he doesn’t like the “inconclusive” results of the tests that have been conducted; (2) he believes the “home” fad has caused more money to flow into primary care, and that outcome alone justifies his support for the fad.

Neither rationale makes sense.

Hackbarth is correct in stating that the research on “homes” has been inconclusive. But his reaction to the research is irrational. The rational response to research that doesn’t support your position is to admit your position was wrong. You don’t cuss out the research and apologize for having supported research.

Hackbarth’s disdain for science may seem irrational to those of us outside the managed care movement, but it is totally consistent with the mores of that movement. Movement leaders and disciples long ago tacitly accepted a double standard: The basic rules of scientific discourse apply to doctors and patients; they don’t apply to health policy analysts who promote managed care.

MedPAC is a leading proponent of the double standard. MedPAC firmly believes that doctors should accept the principles of evidence-based medicine; it does not believe that MedPAC should be governed by an analogous standard – let’s call it evidence-based health policy.

Hackbarth’s apology for having supported pilot tests of “homes” illustrates this double standard.

Hackbarth’s second rationale – that the “home” fad has poured new resources into the primary care sector – is almost certainly backward. If and when health policy analysts ever get around to conducting research on the additional costs incurred by “medical homes,” that research will probably demonstrate that those costs exceed the additional revenues “homes” receive. To date the health policy community has studiously ignored this issue.

What little anecdotal evidence we have indicates clinics that seek to “transform” into “homes” require new resources on the order of 15 to 20 percent of their existing expenditures or revenues.

Not one of Hackbarth’s fellow commissioners took issue with Hackbarth’s argument that MedPAC should ignore research they don’t like. Not one took issue with his claim that the “home” fad has resulted in a net increase in revenues for the primary care sector. MedPAC’s job is to advise Congress on how to improve Medicare. It can’t do that if it continues to promote the double standard: evidence-based medicine for doctors and faith-based health policy for MedPAC.

Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.