Health Reform Built to Fail

Editor’s Note:  The WSJ’s analysis and conclusions regarding CMS’ fatally-flawed competitive bidding progam with respect to negative pressure wound therapy also apply to the other home medical equipment and related services procured under the program.

From: Wall Street Journal

How Medicare rigs competitive bidding and hurts patients.

Americans may not be familiar with the medical innovation called negative pressure wound therapy, though it has helped hundreds of thousands of patients with complex or chronic injuries like burns or diabetic ulcer complications that could never heal on their own. Now President Obama’s Medicare team is about to severely damage this field, and many others too—all in the name of reforming how the entitlement pays for care.

Last week a Medicare competitive-bidding program went live in 91 metro regions—nearly all the U.S. population—for what’s known as durable medical equipment. That bureaucratic jargon covers advanced devices like wound therapy, respiratory assist equipment for people who can’t breathe, and feeding tube systems for people who can’t eat. It also lumps in things like walkers, scooters and “support surfaces.” Those would be beds.

The good intentions of this saga date to 2003, when Congress in a fit of sanity ended Medicare’s price controls in favor of auctions. Both political parties soon rebelled when oxygen tank suppliers, scooter stores and such in their home districts started whining about being asked to compete on market prices, rather than plod along with the guaranteed revenue of the fee schedule. But the much deeper problem is that Medicare cooked up an auction process that defies all economic sense.

Normally when the government wants to buy something, it asks companies how much they can provide and to name their price. Winners are selected from the lowest bid up until the government has what it needs at the lowest possible cost, and thereby finds competitive equilibrium prices.

Under Medicare’s highly unusual version of competitive bidding, it will pay the winners the median price of all the winning bids, rather than using the clearing price. Bids are also for some reason nonbinding.

This matters because it creates incentives for unscrupulous third-party companies to make low-ball “suicide bids.” If the median price shakes out high enough, they automatically win the contract, buy the medical products from manufacturers and turn a profit. If it isn’t, they can dump the contract since bidding involves no commitment.

Medicare will then offer the contract at the median price to the honest companies that have made bids aligned with their true costs, and they can take it or leave it. Medicare benefits because the median prices will be biased below the clearing price—in other words, the “auction” is merely another way of generating arbitrary below-cost price controls.

The Bush Administration road-tested this scheme in 2008 with pilot projects in nine cities. For illustration let’s return to negative pressure wound therapy, a technique that involves a sealed dressing attached to a vacuum pump to prevent infection and improve recovery. Patients can recuperate at home but require 24/7 clinical and safety support, typically provided by the device’s maker. Advanced wound treatment is far more complex than, say, a cane.

In 2008, only 17 of the 88 winning bidders bothered to supply wound therapy devices. Only 10 of them had any actual expertise in how the technology is used or in patient support. The supply crisis was so deep that for several weeks no Medicare patients in two of the cities could receive this treatment at home, and the government threw out the entire program and said it would retool competitive bidding.

Yet by one estimate, a 2011 reprise had roughly one-fifth of the bids going to companies that were on credit hold with device manufacturers—i.e., they couldn’t buy if they wanted to. Medicare, meanwhile, boasts that it will reduce prices for durable medical equipment by 35% and “save” taxpayers $28 billion. All it is really doing is rewarding the fly-by-night operators while harming innovative companies and ultimately patients.

The current nationwide rollout has no substantive revisions from the failed pilots, despite the objections of 244 economists and auction scientists led by the University of Maryland’s Peter Cramton. The consensus of basically everyone who knows anything about auctions is that the no-risk bids and median pricing are idiotic and designed for failure.

At a December meeting, a coalition of device makers and professional clinical groups even accepted these flaws but begged Medicare deputy administrator Jonathan Blum merely to accredit wound therapy bidders. He refused to apply any such basic quality control standards. The Administration does not care.

The larger tragedy is that market methods like auctions are the only way to rationalize the entitlement state. They’re at the core of the reform ambitions of Paul Ryan and Ron Wyden—and they’re already tough enough to achieve given the resistance of the providers that want more of Medicare’s money. This fiasco turns on 1.4% of Medicare’s annual spending, yet it risks discrediting competitive bidding for good.

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