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 A California laboratory received $190 million, the
most Medicare paid a single entity in 2012.
Family physician Tatiana Pavlova Greenfield, who practices in
Maryland, may have received an average of more than $86,000 per
patient that year, according to the Reuters review, and $3.3 million
in total. That compares to an average of $2,200 per Medicare patient
in 2012. Asked for comment, an employee at the office where
Greenfield worked said she "had left the country."
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) made public
for the first time how much Medicare pays individual doctors and
other providers.
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. In a sign of the disproportion in payments, 344 of those
clinicians each received more than $3 million from Medicare Part B.
"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?"
CMS urged the public, press and academics to use the data to answer
such questions. "We want the public to help us, we want the press to
identify outliers in spending," Jonathan Blum, CMS's principal
deputy administrator, told a press conference on Wednesday.
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.
Outpatient office visits were among the most commonly billed
services, accounting for 18 percent of all Part B spending in 2012,
or $14 billion. Part B covers physician, therapist and lab services
ranging from eye exams and physical therapy to knee replacements,
cataract surgery and CT scans for 35 million beneficiaries.
A small number of extremely expensive procedures account for an
outsized fraction of Part B spending. Medicare paid $956 million for
144,000 injections of the Roche drug Lucentis for "wet" age-related
macular degeneration, an eye disease. That works out to 1.2 percent
of total payments for 0.4 percent of beneficiaries. Medicare also
paid $13.6 million for only 530 procedures in which men with
prostate cancer received the controversial treatment Provenge, made
by Dendreon.
"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.
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"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.
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.
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.
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, the AMA and the Florida Medical Association convinced a
judge to keep federal officials from releasing the data on the
grounds that doing so would violate physicians' privacy. Last May,
however, a judge in the District Court lifted the ban.
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 requests for the data under the Freedom
of Information Act, it invoked a law that requires federal agencies
to openly publish "frequently requested" information.
The data are not exactly user-friendly. CMS posted the voluminous
files, which must be downloaded to be read, at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Physician-and-Other-Supplier.html.
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 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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