Identifying and eliminating the roadblocks to comparative-effectiveness research.

105 Medicare Payment Advisory Commission and the Center for Medicare and Medicaid Innovation created by the ACA, will need to be negotiated. Although multiple entities pursuing the same tasks could stumble over each other, there are also real opportunities for synergy. In particular, shared staffing between the IPAB and the innovation center could strengthen both. The legislative requirement that the IPAB submit annual proposals will encourage recommendations for short-term payment fixes rather than long-term changes that might in fact bend the cost curve. If the IPAB is to be truly effective, it must consider not just cuts in provider payments but also changes in how providers are paid, or perhaps even in consumer incentives. Although the statute prohibits reduction in “payment rates” for hospitals before 2020, it does not prohibit the IPAB from recommending changes in payment methods, which might have longer-term effects on cost. But the necessity of making year-to-year cuts will probably focus the IPAB’s attention on short-term cuts in Medicare Advantage plans, which are already slated for deep cuts under the ACA, or on prescription drug prices. The IPAB’s success will also depend on Congress’s reactions to its recommendations. A threefifths Senate vote will be needed to override payment cuts, but Congress could increase Medicare funding through independent legislation. The fact that legislators regularly evade the sustainable growth rate has been cited as proof that Congress cannot cut Medicare costs. On the other hand, Congress left in place the vast majority of the Medicaresavings provisions in the 1990, 1993, 1997, and 2005 budget reconciliation acts.5 And our current fiscal crisis may sharpen lawmakers’ resolve to cut spending. Another major question is whether it is possible to cut Medicare’s provider payments as long as private payers’ rates remain unconstrained. If the gap between private and Medicare rates continues to grow, health care providers may well abandon Medicare. And the IPAB can make only nonbinding recommendations to Congress regarding private payments. In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers, it may well be the most revolutionary innovation of the ACA.