[Editor's note: This article is a complement to the October 2009 print article "Health Reform Round-Up."]

Its 17 members hail from different corners of the health care sector. They're physicians, executives, consultants and academics. But does the Medicare Payment Advisory Commission (MedPAC) have the knowledge and resilience to hold its own in an executive post? Some have their doubts.

The Pros
For more than 10 years, MedPAC has been advising Congress on payment rates to providers and private insurers participating in Medicare. The Commission also makes recommendations related to quality measures, coverage and other Medicare issues. Meetings are open to the public, and Congress makes the final decision regarding payment changes, so there are several checks and balances along the way.

Now, that balance of power may shift. Proposals have been made to give MedPAC executive authority to set payment rates. President Obama has repeatedly called for the establishment of an Independent Medicare Advisory Commission, and the concept is included in the Senate Finance Committee's health bill.

Proponents argue that MedPAC's health care experts would be better suited to make payment decisions than Congressional staff. Commission members have direct knowledge and experience in the field, and a pumped-up post would be harder for lobbyists to infiltrate.

"It's time to move MedPAC into the executive branch and away from the influence of special interests," said Sen. Jay Rockefeller in a statement about the MedPAC Reform Act of 2009, which he introduced last May. The legislation would make MedPAC the ultimate decider on reimbursement, with a formal process for vetting public input. By removing Congressional oversight, the Commission could make decisions based on "objective evidence," according to Rockefeller. 

The Cons
Proposals have received vehement backlash from providers and other health care stakeholders. Opponents are leery of giving the Commission unbridled power. Lobbyists could still influence opinions, and without Congress to check the system, decisions could be made that only take certain interests into account.

Hospitals and physicians are concerned that giving MedPAC an executive post would close the door on public input. "As muddy as Congressional hearings can be, it is a much more public, transparent process," said John Gribbin, CEO and president of CentraState Healthcare System and chairman of the New Jersey Hospital Association.

Most recently, Senate Republicans attempted to remove the MedPAC proposal from the Finance Committee's reform bill. Democrats blocked the amendment.

Given the negative outcry, an executive-level MedPAC likely won't end up in the final bill, according to Tom Enders, managing director of CSC Healthcare Group. However, providers can expect to see the Commission gain more clout among lawmakers, with reports being taken more seriously, he said. There could even be new mechanisms to fast-track implementation of MedPAC recommendations. "But who can prognosticate?" he said.

The Alternative
Robert Book, a health care economist with the Heritage Foundation, also doubted the MedPAC measure would take off. But another alarming proposal has been flying under the radar, he said. The House bill includes a section that would establish a Health Choices Commissioner, a position with broad authority to make decisions regarding payment, insurance eligibility and other specifics to be determined. "That's the most underestimated part of the House health bill," Book said.

It's unclear exactly how much power the Commissioner would have, but it could radically change the system. The appointed official could, for example, have the ability to decide what insurance should cover--and what it shouldn't. "There's all sorts of potential for executive branch decisions that's not actually written in the bill," Book said. "This Commissioner would have wide-ranging authority to make these decisions."

According to the bill, the Commissioner would be required to seek input from insurers, state attorney generals and relevant federal agencies. A Health Benefits ombudsman would also be appointed to receive complaints and advise the Commissioner.

The Senate Finance Committee proposal would give similar authority to the Secretary of Health and Human Services, Book added.

Enders also noted legislative references to a health commission, comparing its responsibilities to those of the Federal Reserve Board. But like the MedPAC proposal, the health board concept is "politically unappetizing," according to Enders, so it's unlikely to clear the House floor.

Cheryl McEvoy is an assistant editor with ADVANCE.