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 A family-practice doctor in Maryland may have received an average
of more than $86,000 per patient that year, according to a Reuters
review of the data. And a California laboratory apparently received
$190 million, the most Medicare paid a single entity in 2012.
After decades of litigation and over the strenuous objections of the
American Medical Association, the leading U.S. doctors group, the
federal Centers for Medicare and Medicaid Services (CMS) on
Wednesday made public for the first time how much Medicare pays
individual doctors.
The massive data release, totaling nearly 10 million lines, also
includes which medical services each of more than 880,000 physicians
and other healthcare providers nationwide billed Medicare for in
2012.
"While the data are not perfect, this is a major milestone in
healthcare transparency," said cancer surgeon Marty Makary of Johns
Hopkins School of Medicine, whose 2012 book, "Unaccountable," argues
for making public more information on doctors and hospitals.
In addition to allowing patients to see which doctors perform a
particular procedure most frequently — often a proxy for expertise
in rare and difficult surgeries such as colon operations — the data
are expected to offer a roadmap to where waste and fraud are most
rampant not only in the Medicare program but throughout the American
healthcare system.
"If you see that a doctor is doing a procedure hundreds or thousands
of times that should be done only on a small number of patients, you
wonder," said Dr. John Santa, medical director of Consumer Reports.
"Are they committing fraud by billing for something they're not
actually doing, doing unnecessary procedures because they're greedy,
or do they practice someplace where so many people need the
procedure?"
Medicare paid physicians, physical therapists, nurse practitioners,
chiropractors and other individual providers $77 billion in 2012.
About two-thirds of Medicare's total $540 billion in payments that
year went to hospitals and most of the rest to prescription drugs.
The providers on the list all participate in Medicare Part B, which
covers services from eye exams and physical therapy to knee
replacements, cataract surgery and CT scans.
Doctors are not required to accept Medicare, which covers some 50
million elderly and disabled Americans, but most do. Excluding
pediatricians, 91 percent of U.S. doctors accept new Medicare
patients, according to a 2013 report from the Kaiser Family
Foundation, and even more continue to see existing Medicare
patients.
"COMPLICATED" CASES
The data released on Wednesday include the names and addresses of
physicians who submitted claims to Medicare in 2012, along with the
codes for the approximately 6,000 services Medicare covers. It lists
the number of times providers billed for each service, the average
submitted charge and how much that deviated from the national norm.
The billing information is expected to indicate which physicians,
therapists or others claim an inordinately high number of
complicated cases. If a case is particularly complex, Medicare
allows them to add a "modifier" to the code they use for billing and
claim higher reimbursement.
"You'll be able to see back surgeons whose average bill is $50,000
because they say almost all of the spinal fusions they do are more
complicated than the usual, and others whose average bill is $5,000"
because they rarely classify the procedures as extra-complicated,
said Santa.
According to the 2012 data, 344 clinicians each received more than
$3 million from Medicare Part B.
That alone is not evidence of fraud, experts warned. But it can
warrant additional scrutiny.
Last December, the inspector general of the Department of Health and
Human Services, CMS's parent agency, found that 303 clinicians each
collected more than $3 million from Medicare Part B in 2009,
triggering "improper payment reviews" for 104. Those reviews
identified $34 million in overpayments. Three of the clinicians had
their medical licenses suspended; two were indicted.
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Although CMS has had the data all along, outside healthcare experts
are eager to scrutinize it, said healthcare analyst and Medicare
expert Cristina Boccuti of the Kaiser Family Foundation. One thing
they will look for is high-volume doctors. If some providers are
billing for many more services per patient than others in the same
community, she said, it could indicate overtreatment. Those
experts will also be looking for regional disparities, Boccuti said.
Since the 1990s, the Dartmouth Atlas of Health Care, a project of
Dartmouth College's health policy institute, has documented vast
differences between cities in the frequency of various medical
procedures.
Doctors in McAllen, Texas, perform five times as many
coronary-bypass surgeries per 1,000 Medicare patients as those in
Pueblo, Colorado, the Dartmouth project has found. Yet patients in
high-volume cities are no sicker.
1979 INJUNCTION
Consumer groups and media outlets have been trying to get the
Medicare physician data since Jimmy Carter was in the White House.
In 1979, after federal officials planned to release it, the AMA and
the Florida Medical Association sought an injunction to stop them on
the grounds that making the information public would violate
physicians' privacy. A federal judge in U.S. District Court in
Jacksonville, Florida, ruled in the medical groups' favor.
Last May, however, a judge in the District Court lifted the ban in
response to a Freedom of Information Act (FOIA) request made by Dow
Jones & Co, publisher of the Wall Street Journal, despite the
continuing opposition of the AMA.
Last week, AMA president Dr. Ardis Dee Hoven said the group "is
concerned that (the government's) broad approach to releasing
physician payment data will mislead the public into making
inappropriate and potentially harmful treatment decisions and will
result in unwarranted bias against physicians that can destroy
careers."
After CMS was deluged with FOIA requests for the data, it invoked a
law that requires federal agencies to openly publish "frequently
requested" information.
The data are not exactly user-friendly. CMS said on Tuesday that it
would post the information on its website, www.cms.gov, but it is
not easily searchable.
Still, a determined patient could see, for instance, that a
particular physician performs an operation only one way. Hopkins'
Makary offers the example of a hysterectomy, which can be done as
open abdominal surgery, vaginally or laparoscopically (through a
tiny incision).
"When discussing your options with a physician," he said, "that's
useful information to know," since it can indicate that the
physician does not tailor procedures to patients' specific
circumstances.
Healthcare watchdogs are optimistic that the data will also reveal
which physicians are abusing the system by billing for medically
unnecessary procedures, which along with fraud are estimated to
account for one-third of the $2.8 trillion in annual U.S. healthcare
spending.
(Reporting by Sharon Begley and M.B. Pell;
editing by Michele Gershberg and Prudence Crowther)
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