This sounds like a good idea. If the board were empowered to identify (and even fund) potential cost effectiveness research, this would be a powerful tool to responsibly lower costs.

Dr. J

If insurance companies were effectively prohibited from making money by discriminating against sick people, is there a faint chance they would turn to making money by looking for cost-effective treatments?

"Providers can’t stand the government’s meddling, and resent the attempts of know-nothing politicians to set payment rates and dictate treatments."

Providers hate external attempts to limit what they can do and what they can charge, full stop. It doesn't matter whether it is insurers or government. It's hard to see any scenario in Obama's first term in which the AMA and AHA do anything but obstruct, or if they can't do that, water-down any such authority as Daschle recommends.

The absurd part of the objection from the Washington Times is that they backed McCain... and presumably backed McCain's health plan, which was a far more direct end to employer subidized health insurance... Now they have a problem?

That said, Daschle's health board is not such a great idea; much of this idea of "coordination" is already done, if only in reverse: Medicare sets pricing for the private sector as we currently know it. Reversing that with aboard comprised of doctors and hospital types is a recipe for simply a new sort of mischief, one that would leave Congress on the hook for pricing decisions outside their purview. The real Medicare reform, after all, would be the one that started to move away from fee for service, and towards a fee structure better focused on outscomes. An outside board of stakeholders, it seems to me, really doesn't get you there.

Should we be letting Congress politicize the healthcare process? No; but that's really a harder discussion about Medicare more generally, isn't it? If we really want Congress out of Medical procedural discussions we'd need less public intrusion into the healthcare system, not more. Or, like the VA, simply establish a whole outside organization (which, we should note, Congress and the President have balked at fully funding many times) and let it run on its own. But the idea that a Federal Health Board solves something... I don't see it. What I see is a number of people with vested interests getting their hands on the keys to the candy store (a doctor, always in charge? problem #1). Which mostly means... free candy!

Finally, I'd agree that it's been poorly sold... but mostly because it's a bad idea. Likening a Federal Health Board to the Federal Reserve tends to bring up the things people don't like about the Fed - secretive, immune to question or challenge, and capable of making very big, very bad, bets. A more hybrid type proposal - one that focused Medicare, Medicaid, the VA, and private healthcare partners to coordinate efforts (like common "best practice" standards) seems more effective, and better effort aims at what's doable.

The Washington Times is not as far off base as you say. In the US we have a sort of understanding: business provide health care for their employees (which is not the system in other countries) in return for this being tax exempt (subsidized). McCain got lots of flack during the presidential campaign for proposing a change to this agreement.

The Federal Reserve Board works because there is no appeal process - Congress is fully out of the picture.

Not so, with a Health Board. The first time a big ox was bloody, in would come some Senate or House committee, as they should. Medicare reimbursement is set by the Medicare administration, but Congress does intervene, as they should when the system is pushing family practitioners into specialties because of the way rates are set.

Daschle is smart and experienced in the ways of the Senate, but no private insurance company is going to take orders from a
'board' when the Congress (and reelection support funds) is at hand.

This is one of those ideas that sounds good until you think about how it will be gamed, and gamed it will be.

The model that seems to work best given political pressures from the roots and congressional tendency to be alternatingly overinvolved and underinvolved is the Federal Base Closure Commissions. They study, make decisions, and then give Congress (on a take it or leave it basis) a set length of time to approve/disapprove their plan.

Making an MD head of the board is worthless. MDs are bought and sold by insurance companies and drug companies every day, and public/private hospitals are in continued warfare against their own doctors - both being wrong more than right (if that is possible).

If we must have a health board, let it act like the base closure model, and fill it with non-participant wise men/women who take testimony from all the interests and then act in the public interest. Putting the thieves, lawyers, judges and the cops in the same room won't get you a justice system.

Let's see here. There are economists running the federal reserve. There are lawyers throughout government - from the white house to the DOJ - guiding constitutional policy. But several of the commenters are proposing a healthcare authority without any doctors on it.

The real recipe for disaster is designing a broad healthcare reform by empowering a bunch policy whiz kids with no direct experience of how decisions of patient care are actually made. It's the neoconservative version of healthcare reform.

The board - or whatever authority you choose - has to include doctors. They should be well-vetted, with exceptionally high standards of professional ethics, and no conflicts of interest. The authority should also include nurses, patient advocates, and other people with relevant experience.

But the hostility to providers is stupid and counter-productive.

Ezra,

A few thoughts:

As we've seen the last few months and years, the Federal Reserve is not immune to political pressures. Whether it be Greenspan propping up the economy during the Bush years by overly permissive monetary policy to Bernanke working in tight coordination with Treasury and providing sweetheart deals to companies like Citibank (no Rubin influence at all, I'm sure)-- when push comes to shove, the independent barriers come crashing down. Its reasonable to point out that this only happens in moments of crises-- but this is exactly the fallacy of applying this model to health care. When its your disease; your spouse, your child, your parent, your loved one-- there is little difference between health care and the current economic crisis, health is all that matters. Its just naive and unrealistic to not expect similar political pressure for all types of diseases. We see it today with somewhat less-pressing issues such as research funding, drug approvals, reproductive rights, etc.

The breadth of scope for something like this is (should be) awe inspiring. The complexity for every disease and treatment-- there are thousands of them-- is astounding. You linked to an example on prostate cancer several months ago, and I made this point then-- the article provided an excellent look at the level of complexity involved in determining appropriate levels of benefits that should be covered. The data is messy and not clear cut-- and this is in an article focused exclusively on urologists that have spent their careers in this field. In what model of this Fed Board does this omniscient board have the ability to do this competently across thousands of diseases and procedures? The FDA is chronically understaffed, with a budget of $2 billion that most people think should be at least doubled. Their task is solely focused on safety of food and drugs, and making risk-benefit decisions on drugs. In other words, the FDA's scope is significantly easier that a Health Board's would be-- yet the FDA can't find enough qualified people or get sufficient funding from Congress. How about Congress fixes the FDA before taking on tougher challenges? Seriously? I sometimes honestly wonder-- is there just no humility in DC? Or do folks not really understand what a Board of this sort would involve to be successful?

Max Baucus's health care plan has a variant on the idea in its Independent Health Coverage Council staffed by experts in "insurance, health benefit design, actuarial science, medicine, business, and consumer protections."

Medical literacy should be an absolute requirement. Period. We don't have economists as one of several groups deciding monetary policy. The analogy doesn't hold 100%, but fortunately the requirement doesn't need to be that difficult-- there are MDs (or even RNs) that have a medical background andexpertise in each of the areas listed above. These people exist, we should be insisting the truly top-flight people are involved in any type of decision-making here. These people frankly are much more qualified than the "experts" coming up with the plan. They are folks that hate the politics, haven't come close to engaging the DC scene, so unfortunately DC doesn't know about them. Hopefully, people in DC will be humble enough (ha) to know that there are very, very few people in government or policy right now that would be qualified for this monumental task. Just like the expectations we'd have for someone heading up the Fed.

The Massachusetts health reforms have something similar in the "Connector Board."

No, they don't. They have guidelines that list 10-15 broad buckets of coverage for insurance plans. I suspect there is a little more behind the scenes that haven't been made public, but the "qualification of benefits" being used in Massachusetts is not scalable on a federal level. Its too high-level and not transparent. At the federal level this will be much more complicated-- look at Medicare guidelines for a similar example.

Among the problems currently bedeviling health care is that few of the decision-makers are actually trusted to work towards the public good. Insurers, who make money by denying care, are broadly loathed, and they lack the public trust to make hard decisions. Providers can’t stand the government’s meddling, and resent the attempts of know-nothing politicians to set payment rates and dictate treatments. And patients are increasingly skeptical of hospitals and providers, who they know make money each time they order a test. What Daschle is offering is a decision-making body insulated from political pressures and profit considerations, imbued with the power and funding to gather real evidence, and run by trusted authorities, and thus able to lay claim to real legitimacy. But they're making it sound secretive and bureaucratic. The Federal Reserve is trusted, but very poorly understood. And health care feels much more personal than monetary policy. And Alan Greenspan ain't looking too good right now.

So this is where I'll end. This sounds great. It really does. But its just not based in reality, at least enough of it. Its true that people don't trust insurance companies or the government. But as jd pointed out earlier, physiciansaren't going to take crap from this board, either. They don't care that the chair is a doctor, because unless they are they same typeof doctor that they are, then most docs won't feel they are qualified to oversee their specialty. So nothing solved there. To work effectively, it will have to be bureaucratic, because there's just a tremendous amount of data and detail that need to be digested, reviewed and decided. Again, its the FDA on steroids-- a lot of steroids. That organization is as weak and mistrusted as we have in government right now. The Fed is trusted because no one knows what they do. But folks know about the FDA, and they will hear even more about the Health Board, and there's just not a good reason to think they'll gain any more trust than the FDA. And your last line here touches on my first point-- the independence and success of the Fed isn't looking so good right now in a crisis, and in health care, every decision is the crisis of at least one patient group. Altogether, it leaves me in a bad, sad place-- I'm concerned that this concept can be sold with the hopes you've ascribed to in this post, which just aren't based in enough reality.

This post is where our policy ideas diverge, and I think that your and other supporters of this concept lack the first-hand experience with health care is a gaping hole. I hate pulling this card-- and called out another commenter a week ago for making the same point, but thinking that putting a "doctor" as chair of the board makes everything OK just sounds so silly. Silly really is the word. And this is where I'm frustrated with Obama's health policy team-- which person am I supposed to be satisfied really gets half of what I'm saying here?

why did the Moonie Times become someone we should listen to for anything? Seriously, a week ago they were claiming Obama was abandoning the plan to repeal DADT for the forseeable future, and then only after the gay press contacted the future adminstration did we learn that its actually going to happen in late 2009 or sometime in 2010 after he gets a game plan together. So- again- since the Moonie's make stuff up- why do we listen to them? If they can't even bother to talk directly to the source?

It's a very bad idea, he said to me, to have congressmen setting Medicare's pay rates for specific medical services. But that's the world in which we currently live.

The reimbursement rates for specific services aren't set by Congress right now, they're set by the RUC, which is a board comprised of doctors.

The reimbursement rates for specific services aren't set by Congress right now, they're set by the RUC, which is a board comprised of doctors.

Yup, I meant to make that point as well, but it got lost in the others.

But that's sort of the point-- this commenter is a medical student (no disrespect, I'm impressed that you know this) and he's pointing out another mistake... this one by Daschle.

really good post. thank you

we need to get government out of health care and all other private sector functions. the only thing that government does will is related to the military. there is absolutely zero that government can do that would not be better and more efficiently done by the private sector. if this health board is ruled by liberal bureaucrats, then i know exactly how i'm going to be screwed from day one.

I'm in favor of the
Federal Health Board and of getting Congress out of the details, but I'm not sure I agree that always having a doctor in charge woudl be so reassuring. Doctors are wonderful, but they are also businessmen, and many of them have taken undue advantage of the rules in the past.

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controversial.