In mid-April, President Obama signed a law that fixed Medicare’s controversial and unpredictable payment formula for physicians. Called the “Doc Fix,” the law puts in place a more stable payment schedule that provides small increases for doctors for the next five years. Notably, physicians who participate in alternative payment models – models that reward quality, value and accountability instead of quantity – will receive a 5% annual bonus between 2019 and 2024.
But the law does not identify what constitutes an eligible alternative payment model. So a new federal advisory committee, called the Physician-Focused Payment Model Technical Advisory Committee, will be established by October 2015 to review and recommend models to the Secretary of the Department of Health and Human Services (DHHS). Recommendations from this federal advisory committee will inform the final decisions about key elements in the law.
This is fairly common. In fact, federal advisory committees are a big part of our legislative process. Other major pieces of domestic legislation, like the “Farm Bill” and the Student Loan Certainty Act, also create these kinds of committees.
And that brings us to the real crux of the issue. Who serves on committees like the one that will recommend models to DHHS, and whose interests do they represent? And by not paying attention to these types of committees, does the public leave the door open for interest groups to push their agendas at the rest of our expense?
Who gets to be on these committees?
The “Doc Fix” law specifies that the 11 members of the committee will be “individuals with national recognition for their expertise in physician-focused payment models and related delivery of care.” In other words, experts. This is normal for advisory committees.
The Comptroller General of the Government Accountability Office is required to solicit nominations and appoint members for the committee. The Comptroller General selects members to ensure that the committee is fairly balanced in terms of points of view represented. The nomination process is open to the public.
There is a federal advisory committee for just about everything
The use of federal advisory committees – also called advisory boards, commissions, task forces or blue ribbon panels – is common. At any given time, there are approximately 1,000 committees in operation with over 60,000 volunteer members.
If there is an important issue – or really any issue at all – chances are there is federal advisory committee for it. Just in the past year, federal advisory committees have been formed on everything from market risk, to the future of the Army, to 21st century policing and even centers that answer calls to emergency phone numbers.
Federal advisory committees are an efficient means to obtain ad hoc expert advice on complex, technical topics, and they can be used to reach consensus on issues that are partisan or divisive. This can relieve members of Congress from having to wrangle over policy details. And that can facilitate legislative deal-making.
Creation of advisory committees also provides political cover – it gives the appearance of action on a topic, even if real movement isn’t happening. Policy makers are mandated to implement these blue ribbon recommendations.
And all of this comes at a relatively modest price tag – US$400 million is spent annually on federal advisory committees, government-wide. To compare, the federal government spends over $580 billion annually on the Medicare program alone.
These committees are transparent…
There are good and bad sides to the use of federal committees.
For instance, one can argue that use of advisory committees is aligned with democratic values. The committees operate under strict rules to promote transparency, including holding meetings open to the public and making all documents publicly accessible. And decision-making power is ultimately retained by policymakers.
These committees make recommendations about what to do and how to do it to the people who have the responsibility to make new policies or legislation. Although research on the influence of committee recommendations is limited, some evidence suggests that policy makers do act upon these recommendations.
So for a modest fee, Congress can access well-considered expert opinion on just about any topic, and the public can watch these committees generate their recommendations. That sounds pretty good, right?
…but the public isn’t paying attention
The danger in deferring issues to a federal advisory committee is that the public just isn’t paying attention to them. Despite the strict transparency requirements, the work of federal advisory committees receives relatively little press, especially compared to Congressional policy making.
The “doc fix” legislation received tremendous press, but the Physician-Focused Payment Model Technical Advisory Committee is likely to operate with little public scrutiny. Like many federal advisory committees, the selection of members, their deliberations, the release of recommendations and the use of those recommendations by policymakers are all likely to receive little attention from the press and the general public.
Medicare covers 54 million Americans and accounts for 14% of federal spending (and 20% of personal health spending) in the US. So a committee that is proposing alternative payment models is well worth paying attention to. If you are a Medicare beneficiary, your care might be affected by the alternative payment models that the Physician-Focused Payment Model Technical Advisory Committee recommends.
But the average Medicare beneficiary probably doesn’t know much about federal advisory committee process. That process is, however, well known to interest groups.
Advisory committees often operate under the watchful eye of interest groups. They attend meetings, submit documents to the committees and lobby policy makers regarding the adoption of those recommendations.
You can imagine how this could pose a problem. The members of the public who are most affected – as well as the taxpayers who ultimately pay the bill – don’t have a good understanding of what is going on. But interest groups that do know what’s going on take pains to make sure their points of view are well represented.
For example, the Wind Turbine Guidelines Advisory Committee was charged with developing recommendations for minimizing wind turbines’ impact on wildlife. The 20-member committee heavily comprised representatives from the wind energy industry, with conservationists claiming that they did not have an equal voice in the deliberation of recommendations.
It does not have to be this way
Greater participation from the public in the federal advisory committee process could balance the influence of interest groups. In fact, the open nomination process and transparency requirements are meant to promote public involvement and interest. We need more members of the public to become involved in this process.
People who are interested in serving on the Physician-Focused Payment Model Technical Advisory Committee or any other advisory committee can use the search function of the Federal Register to identify requests for nominations and nominate themselves or others.
Notices of advisory committee meetings are also published in the Federal Register. People can attend meetings (some of which are accessible via web conference) and submit comments or documents to the committee for consideration.
The “Doc Fix” is an important law with wide, bipartisan support. But let’s not forget that it also leaves important, unanswered questions about future payments for physicians and other medical professionals, and the models in which Medicare beneficiaries will be served. The federal advisory committee process – when it works as it should – offers a pathway for continued public engagement on these issues.