Release of Medicare pay data raises questions

In April, the Centers for Medicare and Medicaid Services (CMS) revealed to the public how much the agency had paid Medicare providers in 2012—a total of $77 billion to more than 880,000 clinicians. While federal officials described the data's release as a key step forward in terms of price transparency, several physician groups, including ACP and the American Medical Association, questioned its usefulness.

In letters sent to CMS (available online here or here) the organizations outlined several concerns. Payment data should be released in a more user-friendly format with greater explanation of its limitations, and doctors should have the opportunity to review and correct their numbers before public release, among other issues, the groups said.

ACP President David Fleming, MD, MA, FACP, said that ACP “is very supportive of transparency.” But April's massive download of information posed potential problems, he added. “One of the concerns that we do have is that this is raw data that was sort of dumped out there with no true context as to what the data means or clear guidance as to how it can be used,” Dr. Fleming said.

The data release is part of a general effort by CMS to be more transparent about health care costs, inspired by provisions in the Affordable Care Act as well as a 2013 order from the president calling for an open-data policy in all federal departments.

Already, the Hospital Compare website provides information about hospitals' quality and cost. Federal officials also are in the process of developing another website, Open Payments, to document transactions between health care manufacturers and doctors or teaching hospitals. As of August, those data were scheduled to be publicly released on Sept. 30.

Raising concerns

The initial data release drew some dramatic headlines, such as “Medicare Data Shines Light on Billions Paid to TX Doctors,” in the April 14 Texas Tribune.

A box that accompanied the article listed the state's 20 top Medicare recipients, who together accounted for $79.5 million in 2012 payments. Of these, 7 were oncologists, 7 were ophthalmologists, and 2 were internists.

Being at the top of the list doesn't necessarily mean a physician was taking home millions from Medicare, however. A doctor might be recouping the costs of expensive specialty medications, or billing for a group of physicians under his own name.

On the University of Michigan Health System's website, the academic center made this point prominently, noting that one family medicine physician was listed with more than $7.58 million in Medicare payments for 207,000-plus patients. The figure was so high because the doctor was leading a federally funded primary care demonstration project, with payments falling under her name first before being paid out to the treating physicians, the health system said.

Even to some doctors who didn't top the list, the data release is displeasing in principle.

“I wonder how many other professions have their income laid bare without explanation,” said Ulrike Sujansky, MD, ACP Member, an internist practicing in San Mateo, Calif., who estimates that roughly 70% of her visits involve Medicare patients.

“This data does not allow the average health care consumer to make meaningful decisions about their own health and wellbeing. So it takes away my privacy without really providing any benefit to the patient,” she said.

Patient vs. policy benefit

It's true that the billing data don't contain distinctions, such as quality differences, that would be useful to consumers, agreed Gail Wilensky, PhD, a senior fellow at the international health foundation Project HOPE and a former Medicare administrator who wrote an opinion piece on the data release from the policymaker perspective that was published online June 10 in the Annals of Internal Medicine.

But Dr. Wilensky also noted that physician groups have historically resisted any release of data. Doctors can play a pivotal role in improving the quality and context of health data moving forward, she said. “My advice to the physicians is, ‘Your complaints about the misleading nature of this data are justified. So work to make it better and more useful.’ It's not going to go away.”

In the near term, the billing data are likely most useful for broad analysis, looking for trends that might signal fraud or abuse, Dr. Wilensky said. “It doesn't mean that because someone is a high biller, even an extraordinarily high biller, that they're committing fraud,” she said. “It may be that they are perfectly appropriate and legitimate reasons. But I think it is certainly worth a further exploration,” similar to how the IRS audits outliers, she noted.

The data also might help unravel geographic spending differences, Dr. Wilensky said. She served on a committee that produced a 2013 Institute of Medicine report finding that doctors and hospitals are key drivers of significant spending variations within geographic regions.

Regional variations in the cost of care are “rampant,” according to an opinion piece in the June 10 Annals by Eric Horwitz, MD, chair of the department of radiation oncology and David Weinberg, MD, chair of the department of medicine at the Fox Chase Cancer Center in Philadelphia. For example, Dr. Horwitz and his coauthor found that Medicare reimbursement for individual radiation oncologists ranged from $206,788 to $802,627 in Des Moines, Iowa, and from $7,437 to $33,177 in San Francisco.

Spending also differs based on practice type, the authors noted. In Philadelphia, one doctor at an urban academic medical center was billing $63 for a procedure and getting reimbursed $15 per treatment. Meanwhile, a suburban colleague in private practice was billing $300 on average and getting reimbursed $69. Dr. Horwitz said that the Medicare data release provides a level of detail that doctors themselves have not previously been able to access, as well as the ability to look at patterns.

Differences in coding patterns have been revealed by the April data release, according to Robert Berenson, MD, FACP, a fellow at the Urban Institute. As one example, he cited a ProPublica article published in May, which found that while only 4% of Medicare office visits in the country are classified as the most complex level of “5,” more than 1,800 clinicians billed at that level at least 90% of the time. About 20,000 clinicians only billed at levels 4 or 5, the analysis found.

“I don't believe for a second that there are doctors that only do level 5 patients,” said Dr. Berenson, who also was quoted as a critic of such billing practices in the ProPublica article.

Solutions

In their letters to CMS, leaders at ACP and the AMA advocated for doctors to be provided the opportunity to review their data for accuracy prior to release. The ACP letter, noting that errors already have been identified, strongly recommended “the inclusion of such a ‘review and correction’ period prior to its public release.”

But as of late summer, CMS administrators have resisted allowing physicians prior review of individual billing data. In a piece published July 10 in the New England Journal of Medicine, Ms. Tavenner and several colleagues acknowledged the concern but noted that, based on paid claims, “We remain confident that the data are accurate.” Any physicians concerned that their volume is too high might consider that their National Provider Identifier numbers have been compromised and pursue the CMS procedures to report suspected fraud, they wrote.

Allowing 880,000-plus doctors and other clinicians to review their data in advance could also have a stifling effect, Dr. Berenson said, given the additional time and work involved for the ensuing challenges to the data.

“It would be nice,” he said. “But it seems to me completely unreasonable. Basically that says ‘We're not going to have public release, because operationally it's impossible.’”

As such data releases continue, Dr. Wilensky hopes that the individual billing data and other details, such as risk adjustment and quality measures, will be added to existing sites like Physician Compare, providing policymakers, patients, and physicians themselves with a more complete picture. “The fact that some patients don't use quality data that's available is no excuse for not making it available,” she said.

Anecdotally, physicians are finding that patients don't use the new payment data much either. Dr. Fleming doesn't recall any questions from patients about his own data, although there were some comments about the overall release, and Dr. Sujansky said that she didn't field any questions.

Although there's been “a little bit of sensationalism” about the Medicare payment statistics in the media, Dr. Fleming said that he's been generally comfortable with what's been written and doesn't think most doctors are too worried about the data release.

“I think robust, well-informed, well-balanced discussions in the media and in both the public and professional press can be very useful in fostering greater understanding. It can also be very informative for ACP and its membership,” he said.