April 9th 2014 marks the opening of legal hunting of physicians by lawyers, hospitals and insurance companies. The Centers for Medicare and Medicaid Services (CMS) has decided to release 2012 Medicare billing information for individual doctors as part of their “ongoing efforts to increase transparency in health care.” CMS announced its intention in a letter to the American Medical Association (AMA) on Wednesday, saying it plans to release the data as early as April 9.
Jonathan Blum, principal deputy administrator at CMS, stated that CMS plans to publicly release a data set on the types of medical services and procedures furnished by health care professionals as well as payment data related to those services, organized by National Provider Identifier (NPI), Healthcare Common Procedure Coding System (HCPCS) code, and whether the service was furnished in a facility or office setting. For each NPI/HCPCS code/place of service combination, this public data set will include number of services, and the average and standard deviations in submitted charges, allowed amount, Medicare payment, and a count of unique beneficiaries treated.
As a background, last May, a federal judge lifted a 33-year-old injunction that prohibited the Medicare agency from releasing any payment information that could be used to identify individual physicians. In 1979, a Florida federal court granted an injunction in favor of the physicians after finding that the disclosure was covered by Freedom of Information Act (FOIA) Exemption 6, which provides that FOIA “does not apply to matters that are…personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy,” and therefore violated the Privacy Act. The injunction permanently enjoined HHS from disclosing any lists of annual Medicare reimbursement amounts for any years that would individually identify a recertified class of physicians.
Now, although individual patient information will remain off-limits, the files will identify physicians by name. The “privacy interests of physicians” do not outweigh “the public’s interest in shedding light on Government activities,” Blum stated.
“Over the past 30 years, the landscape has changed with respect to physician information that is available to the public,” wrote Blum. “As a result, the health care system is changing from a system dominated by dearth of usable, actionable information to one where care coordination and dramatically enhanced data availability … will power greater innovation, higher quality, increased productivity and lower costs.” “The department concluded that the data to be released would assist the public’s understanding of Medicare fraud, waste and abuse, as well as shed light on payments to physicians for services furnished to Medicare beneficiaries, which are governed by statutory requirements that CMS must follow.”
Supporters of disclosure say the information will help lead consumers to doctors who have the greatest expertise and who get the best results. The data could also be used to spot fraud, such as doctors billing for seeing more patients in a day than they would reasonably be expected to care for.
However, there are some clear downsides with this new practice. The AMA is concerned that the release of Medicare payment information planned will mislead people into making “inappropriate and potentially harmful treatment decisions and will result in unwarranted bias against physicians that can destroy careers,” the association’s president, Dr. Ardis Dee Hoven, said in a statement (Businessweek). The AMA recommends that physicians be allowed to review and correct their information before Medicare releases it. This database could potentially be a treasure chest for malpractice lawyers looking for any shred of evidence to place a claim.
Yahoo News also points out that some physicians could be unfairly singled out. For example, clinicians practicing in economically depressed areas often see patients who “can’t afford medication copays or who don’t follow through with basic self-care. The numbers may not look so good for those doctors, but it may not be because of anything they did wrong.”
The insurance companies and hospitals will use this data to for the first time see what is the actual rate of Medicare reimbursement for the physicians they work with. This has huge implications for driving down the price that physicians will be able to charge in the private sector as well.
We also worry that transparency without proper context will push more doctors into refusing to see Medicare patients and potentially confuse patients. This will serve as a huge database for all malpractice attorneys who can now challenge physicians on their billing and treatment patterns. This program coupled with the Medicare Part D data and the physician payment sunshine data should eventually serve as additional deterrents for young people to go into medicine.